This is the moment of compression: the work of managing the program must be redistributed in order to create a sustainable CSC. There are several characteristics of organizations that have created a sustainable CSC model:. Medicare bundled payments represent a single payment usually to the hospital for services provided during an episode of care for a defined period of time. It is up to the hospital to pay physicians and rehabilitation facilities for their services.
Medicare uses their claims database to find areas where there is unexplained variation in patient level cost across hospitals. They identify types of care and more specifically, episodes of care where they feel there is opportunity, given the right incentives, to reduce variation, reduce cost and improve quality of care.
While stroke has been one of 48 episodes of care offered to hospitals for several years, few hospitals have chosen stroke for bundled payments. But that may change. Stroke represents a hyper-acute stage of hospital care followed by a transition to rehabilitation or skilled nursing home and, with more tightly coordinated care in certified stroke centers, stroke may be viewed as an ideal episode of care for bundled payments. Objectives To review existing data on prehospital stroke treatment, especially relevant to MSU technology, to identify gaps in our understanding of MSU feasibility, especially relevant to applying the MSU strategy in the United States, and to describe the Houston MSU program and clinical trial.
Evidence Review Published data from English-language journals in PubMed from to present reviewing early treatment with tPA and prehospital stroke evaluation and treatment. Findings The MSU may result in an overall shift toward earlier evaluation and treatment with tPA, particularly into the first hour after symptom onset, leading to substantially better outcomes.
As a result of improved clinical outcomes owing to earlier treatment, the costs of an MSU program may be offset by a reduction in the costs of long-term stroke care and an increase in quality-adjusted life-years, thereby supporting more widespread use of this technology. To make MSU deployment more practical, the vascular neurologist aboard the MSU must be replaced by a remote vascular neurologist connected to the MSU by telemedicine, reducing manpower requirements and costs.
A prospective study evaluating the logistics, outcomes, and cost-effectiveness of this approach is needed and under way. JAMA Neurol. Coronavirus Resource Center. Our website uses cookies to enhance your experience. Conclusions: This study provides initial insight into the potential barriers and facilitators needed to develop and implement stroke caregiver programs.
Further exploration of these topics can inform caregiver program development and their implementation into stroke systems of care. Rehabilitation research needs to contribute to the evidence that caregiver programs can improve patient, caregiver, and health system outcomes.
State D also did not use any in-kind contributions for program implementation Table 2. These extremes highlight alternative forms of implementation and their cost implications.
Showing a range of implementation possibilities can help encourage and support future program decisions. Additionally, 4 of the 6 grantees that participated in the cost study received PCNASP funds before the — program, and programmatic costs might vary by stage of program implementation. The composition of grant-funded expenditures should be documented to gain a better understanding of how implementation of the PCNASP supports health system-level QI to improve patient outcomes.
State health departments are positioned to serve as a keystone for supporting statewide stroke systems of care, and it is not surprising that findings from this study show that most program costs were incurred to support staff and QI. In-kind contributions are key to define because program planners might underestimate the importance of these costs Our study found that in-kind contributions from health departments varied from negligible to substantial.
This lack of funding from in-kind contributions underscores the importance of providing PCNASP funding to health departments for establishing stroke systems of care and implementing QI; without PCNASP funding, these 4 health departments would not have been able to leverage the internal resources needed to implement components of stroke systems of care.
Most of these in-kind contributions were for nonlabor costs, which indicates that these health departments used funds for large purchases of materials, equipment, or contracted services that were above and beyond CDC PCNASP funding.
However, the other 2 previously funded grantees used similar amounts of in-kind contributions to those of grantees that had not participated before the — program. Overall, in-kind contributions are an essential point for planners to consider when designing program implementation. That some state health departments made large in-kind contributions to meet their goals demonstrates that the diversity of programs across states might require health departments to leverage PCNASP funds to obtain additional resources to achieve their goals.
Comparing cost estimates to the published estimates of the impact of PCNASP can help policy makers and planners estimate the potential return on investments in this type of stroke QI program. A study assessing the progress of PCNASP on selected stroke quality of care measures between and demonstrated an increase in the percentage of stroke patients receiving IV alteplase by 9 percentage points; the percentage of stroke patients with a door-to-needle time less than 60 minutes by 40 percentage points; and the percentage of stroke patients with a door-to-needle time less than 45 minutes by 30 percentage points Across a broader body of stroke literature, IV alteplase is reported to be more effective in treating stroke patients when it is administered as close as possible to the time of onset Furthermore, the timely use of IV alteplase among acute stroke patients is considered a cost-effective treatment for stroke 40 and is associated with improved long-term stroke outcomes Although the literature demonstrates improvements in quality of stroke care among the PCNASP, it is vital to understand the value of the full program investment by assessing programmatic costs intended to catalyze improvements in stroke quality of care.
Future studies should investigate the association between improved health care processes and outcome measures relative to the value of resources invested by the PCNASP through state health department—funded programs.
Although these resources were devoted to implementing stroke systems of care as part of the partnership with PCNASP, organizations might have allocated these resources to improving stroke systems of care independent of PCNASP. These estimates are likely not representative of the full sample of partners. Therefore, it is reasonable to think that the cost of resources involved in implementation would represent a large portion of the total program costs.
Accordingly, it is crucial that partners and state health departments are aware of and have appropriate expectations for the estimated value of resources, time, and costs of program implementation to assess their ability to participate in the program and to confirm that their participation is worth the investment. In addition, program planners at the state health department might be able to craft recruitment materials and partnership agreements that communicate an estimated range of in-kind contributions that partners are likely to bring to the collaborative effort.
This study has 3 main limitations. First, data were collected retrospectively for the entire funding period, which might have contributed to recall errors and prohibited the ability to accurately determine how costs were distributed during the 3 years. In future evaluations, it would be ideal to include ongoing cost data reporting requirements. Second, data were obtained from a convenience sample subset of PCNASP-funded state health departments and, similarly, state health department—reported costs for a subset of their partners.
Lastly, the parameters defining types of resources and efforts, which should be included or excluded when reporting in-kind contributions from partners, were not specified in the instructions for the data collection tool.
Furthermore, we were not able to validate what was reported as in-kind and whether it was directly associated with achieving the aims and objectives of PCNASP and not associated with other non-PCNASP stroke initiatives. This study highlights the costs of implementing components of stroke systems of care at the state level among 6 states. Past implementation literature is limited and reflects only selected interventions, rather than comprehensive QI initiatives Our study is the first to document the costs incurred by state health departments implementing stroke systems of care across multiple programs.
Results can guide future program budgets, strategies, and focused interventions; improve planning for sustainability; and increase the potential scale and adoption of programs across the country.
On a small scale, identifying the estimated costs for public health and the health care sector to establish and implement components of statewide systems of care can help policy makers, public health, and medical officials of the potential cost effectiveness to implement and sustain efforts, such as the PCNASP, that aim to reduce the burden of stroke.
This study was funded under contract from the Centers for Disease Control and Prevention. The findings and conclusions of this manuscript are those of the authors and do not represent the official position of the Centers for Disease Control and Prevention.
No copyrighted material, surveys, instruments, or tools were used in this article.
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