JMH: Multidisciplinary stroke clinics improve care at comparable costs

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Implementing a multidisciplinary stroke clinic model into practice can improve care for high-risk cerebrovascular disease patients at almost the same cost as discharge to home, according to a study published in the April 26 issue of the Journal of Multidisciplinary Healthcare.

“Stroke is a leading cause of serious disability and is the third leading cause of death,” Arlene A. Schmid, PhD, of the Richard L. Roudebush Veterans Affairs (VA) Medical Center in Indianapolis, and colleagues wrote. “The majority of stroke survivors are discharged from the acute care setting, and return to home with mild or moderate physical, cognitive or emotional deficits that require ongoing care and medical attention.”

To evaluate the success of an outpatient multidisciplinary stroke clinic model for veterans with cerebrovascular disease and risk factors, Schmid et al assessed 162 patients cared for in the clinic.

The researchers reported clinical care outcomes, patient satisfaction, provider satisfaction and VA costs. And while the authors wrote that multidisciplinary outpatient clinical programs have been shown to improve patient outcomes, they noted that research outlining their effectiveness is sparse.

Standards for Quality Improvement Reporting Excellence (SQUIRE) guidelines were used to explore program evaluation; and most patients were treated at the VA Connecticut Healthcare System between 2002 and 2005.

The average age of the 162 patients was 69 years, 97 percent were male, 72 percent were white and 68 percent had a history of stroke. Forty-three percent of patients had six or more comorbidities. While the number of clinical visits for patients ranged from one to six, most (58 percent) only visited the clinic once.

The authors reported that patients who visited the clinic more than once had blood pressure (BP) improvement over time. Mean systolic BPs decreased from the first visit to the last visit, 137.21 mm Hg to 128.60 mm Hg. Mean diastolic BP decreased from the first visit to the last visit, 77.88 mm Hg to 71.98 mm Hg. LDL-C levels also improved from between the first and last visit, 101.91 mg/dL to 80.61 mg/dL.

Seventy-two percent of patients reported an increase in physical exercise regimens, 40 percent had a decrease in smoking and 75 percent attempted to quit smoking, the authors reported.

As for costs, among the 36 patients seen in the clinic in 2003 who had healthcare cost data for the two years prior and two years after the visit, the trends in total VA healthcare costs before the first clinic visit was $4,950 and the trend after the clinic visit was $743. Median post-discharge total VA costs for veterans hospitalized for ischemic stroke at the clinic was $13,876 compared with $18,169 for patients who did not receive care in the clinic.

“While costs were not significantly different, we are able to see that the veterans in the Clinic had better care with improved outcomes at comparable costs,” the authors wrote.

Fifty patients completed patient satisfaction surveys and all of the respondents rated their overall experience as “good” or “excellent.” Ninety percent of respondents said that they liked being seen by multiple specialists during the same appointment. Average appointment time was reported to be 2.5 hours, and 75 percent of respondents said this was a reasonable amount of time.

The researchers concluded that improvements in care may have been due to the fact that standard screening procedures were implemented to identify problems in patients.

“Although the Multidisciplinary Clinic demonstrated improvements in several domains, responses to the patient education questions indicated that either our patient education program was not effective or the questions we used asking about stroke risk factors and stroke signs and symptoms were not well-understood by our patients,” the authors wrote.

Schmid and colleagues noted that limitations of the study could have stemmed from the fact that the sample size was relatively small and the number of survey responses by both providers and patients was poor.

However, the authors noted that the multidisciplinary outpatient stroke program can “fill critical gaps in care” for veterans with cerebrovascular disease without an added cost burden. Additionally, they offered that implementing this model at VA medical centers across the country would be feasible.