The Establishment And Application Of The Organized Stroke Management Based On The Clinical Pathway Of The Acute Ischemic Stroke

BackgroundStroke has been the first cause for death and disability and the incidence of acute ischemic stroke, the main type of stroke, is increasing year by year. There are 7 million stroke patients in china, among which 70% are ischemic stroke. Meanwhile, the annual cost on stroke is more than 10 billion yuan while the total cost would be close the 20 billion yuan which was a big burden to the country and the families. However, the treatment of stroke is still not normative, for example the basic treatment pattern is still medicine which will lead to the waste of the health service resource. Therefore, improving the prevention and treatment ability to control the medical cost has become an important project in the health management area.Some professors suggested that we should not pin our hope of the future treatment of stoke on a detailed treatment method, instead it should be the establishment of a new system. China has developed its own unique medical history, and stroke disease has been one of four ancient stubborn illnesses. Thousands of years the TCM doctors accumulated many methods of treatment for the stroke, which offers the valuable basis for the modern physicians to apply the Integrative treatment to the stroke patients. The Cerebrovascular Disease Center of Guangdong provincial hospital is the earliest established senior stroke center which has the ability to apply the organized management of stroke combining TCM and western medicine. In this condition, we do the exploratory study on the establishment and application of the organized stroke management based on the clinical pathway of the acute ischemic stroke.ObjectiveThe study constructed the treatment program based on the clinical pathway of the acute ischemic stroke through literature study and experts consulting. Then, we use the historical control to evaluate the clinical effect and the health and economic effect of the program in order to provide a organized treatment pattern of stroke which can decrease the hospital stays, decrease the medical cost and improve the medical quality.MethodRaising the key issues, finding evidence to support the key issues through literature study, combining the experiences of the famous TCM doctors, using Delphi method to do the expert consultation, based on all of which establish the treatment program of the clinical pathways of acute ischemic stroke. At last, apply the organized management based on the clinical pathway of the acute ischemic stroke in the senior stroke center of and use the historical control to analyze the length of stay, hospital cost, complication rates between two groups and do the initial evaluation of its health economics effect and clinical efficacy.Results1. The raising of the key issues of the acute ischemic stroke and literature study:The key issues on diagnosis:Western diagnosis of stroke is definite, its problem is whether to use the subtype diagnosis or not. However, the TCM syndrome differentiation (using the yin yang syndrome differentiation of not) is not clear.The key issues on treatment:①The general principles and determination of treatment;②which Western medicine guidelines to be choosed;③the determination of the specific principles in TCM treatment;④time point the TCM intervention during the treatment;⑤whether or not to use acupuncture and rehabilitation;⑥management of complications:such as pneumonia, urinary tract infections.According to the name of the disease, syndrome, principles of the treatment, acupuncture and the herbs we did the ancient literature study and provided the corresponding evidence of the key issues. Finally, we got 63 articles providing evidence to the key issues in the modern literature. As to the experiences of famous TCM doctors, although the specific focus of treatment is different, most of the experts believed that activating the blood stasis, Tongfu, resuscitation and refreshment, are the main principle in the treatment of stroke, which provided the evidence to the this conclusion.2. The application of Delphi in the construction of clinical pathway in the acute ischemic strokeHigh positive coefficient of two rounds of experts consultation are separately 100% and 91% which showed that the experts are well cooperated. The overall experts authority coefficient Cr=0.84 showed that the expert authority on the content is of high degree of assessment. All the coordination factor of the two rounds of consultation in this study are statistically significant (P<0.05) whose W value is 0.151～0.329 and 0.187～0.412 except the coordination factor "treatment dimension" (P>0.05) which demonstrates that the results of the evaluation is believable. The reliability testing showed that the activity of the experts is high and its authority of the content is also high.as to the indicators, the anticipated results of the rest 4 indicators are reliable except the "treatment dimension"With previous literature study and famous TCM doctors' experiences, the professional group has reached the agreement in the diagnosis and treatment:Diagnosis:the clear diagnosis of acute ischemic stroke must be combined with CT, MR and other means, the name of disease use the standard in the "Chinese stroke diagnosis and evaluation standard", also adopted the subtype of channel and network strike and organ strike, for the syndromes, we decided to use the combination of the 9 syndromes differentiation and the yin-yang differentiation.Treatment:treat the acute ischemic stroke patients with western medicine and TCM including the antiplatelet drugs, etc. All the western treatment measures are made according to the "Guidelines for the early Management of Adults with ischemic stroke(2007) ". The TCM treatment are made according to the principle of yin-yang syndrome differentiation.The establishment and application of the stroke organized management based on the clinical pathway of the acute ischemic stroke in the senior stroke center of Guangdong provincial hospital.We enrolled 108 consecutive patients during the January 2010 ~ August 2010 in the of Guangdong Provincial Hospital as the treatment group(pathway group). Meanwhile,133 consecutive patients during January 2008 ~ August 2008 in the Senior Stroke center(cerebrovascular Center) of Guangdong Provincial Hospital were the control group (non-path group).As to the health and economic indicators, the average hospital stay was 14.25 days,7 days less than the non-path group and the Median hospital stay was 14 days,6 days less than the non-path group. The average hospitalization cost of the pathway group is 17584 yuan less than the non-path group and the median hospital cost is 3821 yuan less than the non-path group. The difference of hospital stays and the cost between the two groups were statistically significant (P<0.05).As to the clinical efficacy, the incidence of lung infection in pathway group and non-pathway group were separately was 6% and 14% of, of which the difference was statistically significant (P<0.05). Progressive stroke in pathway group and non-pathway group were separately 9% and 11%, of which its incidence of two groups has no significant difference (P> 0.05) but still much lower than the international rate reported 19% or 37%. The evaluation of the short-term effect using the change of NIHSS score showed that the effective rate of the path group was increased by 19% than the non-path group whose difference was statistically significant (P<0.05).The application of the key issues showed that in the path way group, the application rate of aspirin within 48 hours is 99%, rehabilitation application rate is 99%, swallowing assessment application rate was 98%, Tongfu treatment application rate is 96%, activating blood stasis application rate was 100% and the application rate of a acupuncture is 98%, all of which the application rate were higher than the non-pathway group and the difference was statistically significant (P<0.05).ConclusionThe stroke organized management based on the clinical pathway of the acute ischemic stroke can decrease the hospital stays, cut down the hospitalization cost, avoid the occurrence of the lung infection and improve the clinical efficacy.