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Biomedical subjects

Lee Schwamm

Publications and source records attributed to Lee Schwamm.

7 recordsLinked to original sources
PubMed2006

Designing a sustainable national registry for stroke quality improvement.

Several studies have shown wide variations in the delivery of hospital-based care to patients with acute ischemic stroke. The findings of these studies suggest that recommendations drawn from published evidence-based or consensus-based guidelines are implemented inconsistently. Although rates of adherence to stroke quality indicators can be increased through the use of targeted quality improvement (QI) efforts, stroke QI programs are still in their infancy. Current stroke QI programs are often highly variable and poorly coordinated, rely on differing definitions of key data elements and/or indicators, and are challenging to implement and sustain in resource-constrained healthcare environments. Key barriers to long-term success of these programs include inadequate funding at the local and national level, lack of infrastructure to support electronic data capture for QI as part of the process of patient care, lack of a single clearinghouse for uniform data definitions and performance indicator descriptions, competing survey instruments to monitor hospitalized stroke care, and constraints on inpatient and post-discharge data collection imposed by the new Federal Health Insurance Portability and Accountability Act Privacy Rule. In addition, the competing needs of registry activities (e.g., complete case ascertainment) versus QI efforts (e.g., incremental tests of change) must be balanced. Potential solutions include: (1) financial incentives to healthcare providers and institutions for participation in QI initiatives; (2) financial incentives to healthcare providers and institutions for measurable improvements in care; (3) mandatory data reporting on key measures of stroke care; and (4) promotion of active and sustainable collaborations among key stakeholders including healthcare providers (e.g., physicians, nurses), healthcare organizations (e.g., hospitals, physicians' groups), quality improvement organizations, health payers and insurers, public health departments, and state and federal health agencies to create a single national stroke registry for stroke QI.

Acute Disease↗
PubMed2006

The Paul Coverdell National Acute Stroke Registry: initial results from four prototypes.

BACKGROUND: This paper summarizes the experiences of the Paul Coverdell National Acute Stroke Registry first four prototype registries in Georgia (GA), Massachusetts (MA), Michigan (MI), and Ohio (OH), and includes information on their sampling design, case ascertainment, and data collection methods, as well as some key findings. METHODS: Using a combination of different sampling methods, each prototype obtained a representative statewide sample of hospitals. Acute stroke admissions were identified through prospective (MA, MI) or retrospective (GA, OH) methods. A common set of case definitions and data elements were used by each registry. Weighted site-specific frequencies and 95% confidence intervals were generated for each outcome. A summary estimate, representing a weighted average of the four site-specific estimates, was also calculated. RESULTS: Of the total 6867 admissions, 1487 (21.6%) were from the GA registry, 1206 (17.6%) from MA, 2566 (37.4%) from MI, and 1608 (23.4%) from the OH prototype. Just less than 60% of admissions were ischemic strokes (site-specific estimates ranged from 52% to 70%), with transient ischemic attack (18.5%) and intracerebral hemorrhage (8.8%) making up most of the remainder. Twenty-one percent of patients admitted were younger than 60 years of age, and 55.3% were women. The proportion of black subjects varied from 7.1% (MI) to 30.6% (GA). Twenty-three percent of admissions arrived at the emergency department within 3 hours of onset. Overall 4.5% of ischemic stroke admissions were treated with recombinant tissue plasminogen activator; site-specific treatment rates were 3.0% (GA), 3.2% (OH), 3.4% (MI), and 8.5% (MA). Only a small minority of treated patients (range, 10.8% [OH] to 19.6% [MI]) received recombinant tissue plasminogen activator within the recommended 1 hour door-to-needle time. A minority of eligible subjects were screened for dysphagia (45.4%), underwent lipid testing (33.6%), or received smoking-cessation counseling (21.4%). In contrast, compliance with antithrombotic treatments at discharge was high (91.5%). CONCLUSIONS: A minority of acute stroke patients are treated according to established guidelines. Quality improvement interventions, targeted primarily at the healthcare systems level, are needed to improve acute stroke care in the United States.

Acute Disease↗
PubMed2005

Acute stroke care in the US: results from 4 pilot prototypes of the Paul Coverdell National Acute Stroke Registry.

BACKGROUND AND PURPOSE: The Paul Coverdell National Acute Stroke Registry is being developed to improve the quality of acute stroke care. This article describes key features of acute stroke care from 4 prototype registries in Georgia (Ga), Massachusetts (Mass), Michigan (Mich), and Ohio. METHODS: Each prototype developed its own sampling scheme to obtain a representative sample of hospitals. Acute stroke admissions were identified using prospective (Mass, Mich) or retrospective (Ga, Ohio) methods. All prototypes used a common set of case definitions and data elements. Weighted site-specific frequencies were generated for each outcome. RESULTS: A total of 6867 admissions from 98 hospitals were included; the majority were ischemic strokes (range, 52% to 70%) with transient ischemic attack and intracerebral hemorrhage comprising the bulk of the remainder. Between 19% and 26% of admissions were younger than age 60 years, and between 52% and 58% were female. Black subjects varied from 7.1% (Mich) to 30.6% (Ga). Between 20% and 25% of admissions arrived at the emergency department within 3 hours of onset. Treatment with recombinant tissue plasminogen activator (rtPA) was administered to between 3.0% (Ga) and 8.5% (Mass) of ischemic stroke admissions. Of 118 subjects treated with intravenous rtPA, <20% received it within 60 minutes of arrival. Compliance with secondary prevention practices was poorest for smoking cessation counseling and best for antithrombotics. CONCLUSIONS: A minority of acute stroke patients are treated according to established guidelines. Quality improvement interventions, targeted primarily at the health care systems level, are needed to improve acute stroke care in the United States.

Adolescent↗
PubMed2003

Interatrial septal mobility predicts larger shunts across patent foramen ovales: an analysis with transmitral Doppler scanning.

BACKGROUND: The association of patent foramen ovale (PFO) with cryptogenic stroke is strongest in patients with larger shunts and patients with atrial septal aneurysms (ASAs). We postulated that the potency of ASA as a risk factor for stroke relates to the size of shunt across PFOs associated with mobile atrial septae. The purpose of this study was to investigate the relationship between atrial septal mobility and the degree of right-to-left shunting with a transthoracic transmitral Doppler scanning (TMD) contrast technique. METHODS: In 165 consecutive patients, transthoracic TMD recordings were made during a saline contrast study with the patient at rest and after a maneuver to increase right atrial pressure. Bubble transit corresponded to high intensity signals in the velocity envelope of the mitral inflow profile and was quantified by a bubble score. RESULTS: A PFO was diagnosed in 59 patients (36%). In 50 patients with PFO and adequate echocardiography images, the incidence of ASA was 52%. In this group, both total septal mobility and leftward deviation predicted the TMD bubble score at rest (Spearman rho 0.64, 0.64, respectively, P <.001) and after the maneuver (Spearman rho 0.74, 0.73, P <.001). In 28 patients with cerebral ischemic events, the maneuver bubble score was predictive for cryptogenic stroke (P =.02, odds ratio 7.58). There was a trend toward significance between total septal motion and cryptogenic stroke (P =.06). CONCLUSION: Atrial septal mobility predicts the degree of right-to-left shunts across PFOs. The role of excessive septal mobility in the etiology of stroke may therefore be caused by the greater opportunity for paradoxical embolism because of the size of the associated trans-PFO shunt.

Adult↗
PubMedDate not supplied

Characterization and evolution of diffusion MR imaging abnormalities in stroke patients undergoing intra-arterial thrombolysis.

BACKGROUND AND PURPOSE: Lesions revealed by pretreatment diffusion-weighted imaging (DWI) may not progress to infarction, and apparent diffusion coefficient (ADC) or DWI thresholds for tissue viability may exist. We evaluated the evolution of abnormal DWI findings in patients with acute stroke who underwent thrombolysis. METHODS: Sixteen patients with acute occlusion of the anterior circulation underwent DWI followed by intra-arterial thrombolysis; follow-up CT or MR imaging was performed after reperfusion therapy. Lesion volumes were measured on all images. In three patients with abnormal DWI findings that appeared normal at follow-up, ADC values, ADC ratios, and DWI ratios were obtained on a section-by-section basis in the DWI-hyperintense regions that were either abnormal or normal at follow-up. RESULTS: In three patients, part of the DWI-hyperintense tissue appeared normal and part appeared abnormal at follow-up imaging. In one of these patients, the lesion decreased by -35.6%. In the other two, lesion growth appeared in regions that appeared normal at initial DWI: in one, the overall change in size was -2.4%, and in the other, the lesion increased by 89.8%. Respective mean changes at follow-up in normal-appearing and abnormal-appearing regions were: ADC, 731.7 x 10(-6) mm(2)/s and 650.4 x 10(-6) mm (2)/s; ADC ratio, 0.92 and 0.78; and DWI ratio, 1.16 and 1.32 (P <.001 for all measures). CONCLUSION: In patients with acute stroke who undergo intra-arterial thrombolysis, most abnormal, pretreatment DWI findings indicate eventual infarction. In 19% of the patients described herein, DWI-hyperintense regions appeared normal at follow-up. ADC values, ADC ratios, and DWI ratios may be useful in identifying the portion of abnormal tissue that is potentially salvageable after reperfusion therapy.

Acute Disease↗