Project: Identifying organisational barriers and resolutions in thrombolytic therapy for acute ischemic stroke in the North of the Netherlands. A simulation model study.

Identifying organisational barriers and resolutions in thrombolytic therapy for acute ischemic stroke in the North of the Netherlands. A simulation model study.

Dit is de samenvatting van de aanvraag.

Objective(s) /research question(s): The goal is to identify optimal organisational structures in care for patients with acute ischemic stroke. Also, local redesign of acute care for this category of patients is foreseen. It is (inter-)nationally widely recognised that in case of an acute stroke thrombolysis is presently administered too little. Current Dutch stroke care only partially or locally complies with existing guidelines and treatment standards. Several apparent bottlenecks or constraint such as awareness among patients, spouses, public service professionals, but also immediate access to general practioners' care, (ambulance) transportation, and lack of capacity and expertise in secondary care have been identified. To improve on this situation it is essential to identify those possibilities for improvement that will yield the highest return, and to present the pertaining stakeholders with information on the potential impact thereof in terms of numbers of patients adequately treated, decreased burden of disease, and additional resource requirements. The latter will prove vital information for redesign of care and drawing up unambiguous strategies for implementation. This will be achieved in close collaboration with the stakeholders/participating professionals once the results have been presented and discussed.

Design: Pooled cohort data (from various cohorts in the Northern OOR region) and a Discrete Event Simulation (DES) model, incorporating estimates on, e.g., incidence, resource use and administration of rTPA.

Study population(s)/ datasets: Patients with stroke in 3 Northern provinces, GP consults, GP acute care database (doktersdiensten), ambulance transport database, hospital admissions, national demographics and incidence data, and the data from the PRACTISE study from Dippel et al., supplemented with additional data and parameters from literature and Dutch cost data.

Intervention: Thrombolysis in acute ischaemic stroke Implementation strategy: Assessment and comparison of current and alternative care scenarios in the Northern region in terms of resources and capacity, and identification of potential deficits thereof to deliver rTPA timely. Subsequently, draw up concrete plans for improvement together with stakeholders/participants.

Outcome measures and process indicators: Resources required per additional patient treated optimally. Also, the costs per (QA)LY gained according to various implementation scenarios will be compared, i.e., a hypothetical iCER of implementation of thrombolyses for stroke according to guidelines compared to current care. Notably, various organisational configurations may be conceived, i.e., from an entirely centralized service to largely decentralized, which will have considerable effects on the (cost-)effectiveness.

Power/data analysis: NA for modelling and simulation studies. The study will however provide robust estimates with narrow ranges (credibility intervals) of global and specific costs and effects according to the various scenarios.

Economic evaluation: Estimating iCERs of alternative delivery scenarios.

Time schedule: 9 months: Development acute stroke DES model. In parallel model parameters will be determined and obtained. 3 months: analyse data obtained and perform simulations. Last (6 month) phase: analyses of output, presentation of results and proces re-design

Beknopte Nederlandstalige samenvatting

Implementatiedoelstelling / onderzoeksvraagstelling: Identificeren van optima ten aanzien van de organisatie van zorg rondom trombolyse behandeling na acuut hersen infarct, en conform bevindingen herontwerpen van zorg.

Studie opzet: Simulatie model gebruik makend van onder andere cohort data Noordelijke provincies en de PRACTISE studie van Dippel et al.

Studiepopulatie / databronnen: Patiënten met een acuut CVA in database van dokterdiensten, ambulance zorg en alle ziekenhuizen in Noord-Nederland, alsmede div landelijk datasets en bronnen en de PRACTISE data.

Te implementeren interventie: Trombolyse na beroerte

Implementatie activiteiten/strategieën: Identificeren van efficiente scenarios met behulp van simulatie.

Uitkomstmaten en procesindicatoren: kosten per op tijd behandelde patient en kosten per (kwaliteitsgecorrigeerd) levensjaar van geoptimeerde zorg (volgens diverse scenario's) in vergelijking met huidige zorg.

Sample size berekening/data analyse: nvt

Economische evaluatie: incrementele kosteneffectiviteit ten opzichte van diverse implementatie vormen.

Tijdpad: 9 maanden model ontwikkeling en data vergaring 3 maanden scenario analyses en 6 maanden analyse, rapportage en herontwerp CVA zorg.