Health Policy and Health Services Delivery in the Era of COVID-19

HomeStrokeVol. 52, No. 6Health Policy and Health Services Delivery in the Era of COVID-19 Free AccessReview ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessReview ArticlePDF/EPUBHealth Policy and Health Services Delivery in the Era of COVID-19 Dominique A. Cadilhac and Janet Prvu Bettger Dominique A. CadilhacDominique A. Cadilhac Correspondence to: Dominique A. Cadilhac, PhD, Level 3 Hudson Institute Bldg, 27-31 Wright St, Clayton, VIC 3168, Australia. Email E-mail Address: [email protected] https://orcid.org/0000-0001-8162-682X Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria Australia (D.A.C.). Stroke Division, Florey Institute of Neuroscience and Mental Health, The University of Melbourne Heidelberg, Victoria Australia (D.A.C.). and Janet Prvu BettgerJanet Prvu Bettger Duke Roybal Center on Aging, Margolis Center for Health Policy, and Department of Orthopaedics, Duke University, Durham, NC (J.P.B.). Originally published18 May 2021https://doi.org/10.1161/STROKEAHA.121.033292Stroke. 2021;52:2177–2179Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: May 18, 2021: Ahead of Print Advances in stroke care policy during 2020 were largely influenced by the coronavirus disease 2019 (COVID-19) pandemic (over 765 articles in web-of-science, 57 in the journal Stroke, 17 with keyword policy). People with COVID-19 have a 1.5% increased chance of stroke1; those with stroke and COVID-19 have worse outcomes compared with those without a history of stroke.2,3 It is essential to prevent transmission to patients with stroke and maintain standards of stroke care to avoid unnecessary death and disability.4,5 Several regions released guidance early in the pandemic and may still be responding.6–9 As examples of rapidly evolving policy, the current European stroke action plan was adapted to cover COVID-19,10 and the Canadian stroke best practice recommendations were modified to provide a virtual (telestroke) health care management toolkit for individuals with stroke.11 In this article, we summarize the main themes that emerged based on the different phases of care (Figure) and provide future considerations for policies that could protect the integrity of evidence-based stroke care. Essential to realizing the impact of new policy is having standardized data to assess whether the intended outcomes have been achieved.Download figureDownload PowerPointFigure. Policies to maintain the integrity of stroke care during the coronavirus disease 2019 (COVID-19) pandemic.Public Awareness and Acute StrokeThere were concerns among the stroke community that people with suspected stroke have been avoiding the hospital. Delays in arriving to hospital, coupled with new infection control screening procedures, have meant some people with stroke miss out on time critical treatments.6 Emergency medical services were to have protocols in place for safe and timely transport of suspected pandemic-infected patients and prenotify hospitals to launch code stroke.11 Emergency department triage protocols and workflows changed including overcoming logistical issues for imaging and telemedicine access.11 Examples also included modifying standard poststroke treatment monitoring procedures to reduce the frequency of patient assessments that require repeated donning and doffing of personal protection equipment over short intervals of time.12 The impact of these protocol changes remains unclear.To increase capacity for the management of patients with COVID-19, hospitals repurposed wards and redeployed staff from different disciplines or specialties.7 To minimize the impacts on care quality, acute stroke care protocols were adapted so that hospital staff unfamiliar with stroke care required minimal training.13 In countries where stroke unit staffing and beds were protected, the quality of stroke care remained unchanged during the pandemic.14 Therefore, hospital executives have been encouraged to maintain and protect the integrity of stroke services to avoid unnecessary disability, complications, or deaths after stroke.15Rehabilitation and Community-Based CareThe shifts in acute care bed availability and staffing had a cascading effect on inpatient rehabilitation, the transition home after stroke, outpatient rehabilitation, and specialty care follow-up. During periods of pandemic surge when the demands for acute care beds were increased, several regions reported fewer rehabilitation admissions, and shorter lengths of inpatient stays for patients who receive rehabilitation.16 This had implications for being able to adequately assess and treat patients, adhere to stroke rehabilitation guidelines, secure equipment, arrange follow-up appointments, and train family.17,18 Caregivers for patients with stroke have reported being unsure of prognosis and being unprepared for discharge. Visitor restriction policies and lack of video conferencing to connect patients and therapists with family caregivers were major barriers to their readiness to continue care at home.19 Some countries approved new or emergency policies to provide additional funds to informal caregivers taking on additional responsibilities due to the decreased access to home and community-based services. It is unclear if these policies have improved the circumstances for caregivers of stroke survivors.Pivoting to Virtual Stroke CareSafety and effectiveness of adapted models of care is uncertain, especially regarding telehealth for rehabilitation services. Funding arrangements, protocols, and policy to support such initiatives were lacking or imperfect.20 Many nations with telehealth infrastructure and governing laws for cybersecurity had not fully deployed reimbursement policies for providers, particularly for outpatient specialty or rehabilitation services.21 In the United States and Belgium, laws changed quickly and reimbursement for outpatient rehabilitation provided by therapists was made possible. There were steep learning curves for rehabilitation therapists who have not used telehealth as part of their standard practice for stroke. For most nations, it remains unclear whether patients requiring rehabilitation were adequately reached and treated.Complicating use of telehealth was digital equity for stroke survivors. Even in well-resourced regions, there were marked disparities in access to telehealth after stroke associated with individuals' lower incomes and economic instability, or being from underserved geographies or historically marginalized communities including those with disabilities.22Reducing Inequities, Adapting Actions Plans, and Measuring ImpactBeyond the health disparities known in stroke incidence and outcomes further exacerbated by the pandemic, more upstream policies need higher prioritization.23 It is imperative that the stroke community contribute to data-driven policy solutions that eliminate inequities in access to healthy food, stable housing, safe neighborhoods, high quality education and health care, and employment with a livable wage. Establishing policies that address these social determinants of health is essential.24 In the field of stroke, national scientific societies, stroke support organizations, and governmental agencies need to be engaged in adapting action plans to include virtual approaches to care, and creating educational resources for clinicians and survivors/caregivers.10 It is essential that we ensure accessible and trustworthy information and support for survivors and caregivers particularly when direct access to health care professionals is constrained or limited.10ConclusionsThe unintended consequences of COVID-19 and the implications of health system and public health policy changes to deal with the pandemic for stroke are yet to be fully determined. The stroke community needs to work together to address these new challenges and measure the impact. We encourage researchers to generate evidence to support policy and planning for stroke to ensure patients are not further disadvantaged. We need to be able to learn from these events in how to respond and make appropriate and timely policies.Nonstandard Abbreviations and AcronymsCOVID-19coronavirus disease 2019Sources of FundingNo specific funding to complete this article was obtained. Professor Cadilhac acknowledges research fellowship support from the National Health and Medical Research Council (Australia, #1154273).Disclosures None.FootnotesThe opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.For Sources of Funding and Disclosures, see page 2179.Correspondence to: Dominique A. Cadilhac, PhD, Level 3 Hudson Institute Bldg, 27-31 Wright St, Clayton, VIC 3168, Australia. Email dominique.cadilhac@monash.eduReferences1. Merkler AE, Parikh NS, Mir S, Gupta A, Kamel H, Lin E, Lantos J, Schenck EJ, Goyal P, Bruce SS, et al. Risk of ischemic stroke in patients with covid-19 versus patients with influenza [preprint].medRxiv. 2020. Preprint posted online May 21, 2020. doi: 10.1101/2020.05.18.20105494Google Scholar2. Payus AO, Liew Sat Lin C, Mohd Noh M, Jeffree MS, Ali RA. SARS-CoV-2 infection of the nervous system: a review of the literature on neurological involvement in novel coronavirus disease-(COVID-19).Bosn J Basic Med Sci. 2020; 20:283–292. doi: 10.17305/bjbms.2020.4860Google Scholar3. Kummer BR, Klang E, Stein LK, Dhamoon MS, Jetté N. History of stroke is independently associated with in-hospital death in patients with COVID-19.Stroke. 2020; 51:3112–3114. doi: 10.1161/STROKEAHA.120.030685LinkGoogle Scholar4. Zhang L, Sun W, Wang Y, Wang X, Liu Y, Zhao S, Long D, Chen L, Yu L. Clinical course and mortality of stroke patients with coronavirus disease 2019 in Wuhan, China.Stroke. 2020; 51:2674–2682. doi: 10.1161/STROKEAHA.120.030642LinkGoogle Scholar5. Aguiar de Sousa D, van der Worp HB, Caso V, Cordonnier C, Strbian D, Ntaios G, Schellinger PD, Sandset EC, Organisation ES. Maintaining stroke care in Europe during the COVID-19 pandemic: results from an international survey of stroke professionals and practice recommendations from the European Stroke Organisation.Eur Stroke J. 2020; 5:230–236.Google Scholar6. Markus HS, Brainin M. COVID-19 and stroke-A global World Stroke Organization perspective.Int J Stroke. 2020; 15:361–364. doi: 10.1177/1747493020923472Google Scholar7. Wira CR, Goyal M, Southerland AM, Sheth KN, McNair ND, Khosravani H, Leonard A, Panagos P; AHA/ASA Stroke Council Science Subcommittees: Emergency Neurovascular Care (ENCC), Telestroke and the Neurovascular Intervention Committees; and on behalf of the Stroke Nursing Science Subcommittee of the AHA/ASA Cardiovascular and Stroke Nursing Council. Pandemic guidance for stroke centers aiding COVID-19 treatment teams.Stroke. 2020; 51:2587–2592. doi: 10.1161/STROKEAHA.120.030749LinkGoogle Scholar8. Sylaja PN, Srivastava MVP, Shah S, Bhatia R, Khurana D, Sharma A, Pandian JD, Kalia K, Sarmah D, Nair SS, et al. The SARS-CoV-2/COVID-19 pandemic and challenges in stroke care in India.Ann N Y Acad Sci. 2020; 1473:3–10. doi: 10.1111/nyas.14379CrossrefGoogle Scholar9. AHA/ASA Stroke Council Leadership. Temporary emergency guidance to US stroke centers during the Coronavirus Disease 2019 (COVID-19) Pandemic: on behalf of the American Heart Association/American Stroke Association Stroke Council Leadership.Stroke. 2020; 51:1910–1912. doi: 10.1161/STROKEAHA.120.030023Google Scholar10. Christensen H, Pezzella FR; Action Plan for Stroke in Europe Implementation Steering Committee. Implementation of the Stroke Action Plan for Europe 2018–2030 during coronavirus disease-2019.Curr Opin Neurol. 2021; 34:55–60. doi: 10.1097/WCO.0000000000000893Google Scholar11. Blacquiere D, Gubitz G, Yu AY, Wein T, McGuff R, Pollard J, Smith EE, Mountain A, Lindsay P. Canadian Stroke Best Practice Recommendations 7th Edition: Virtual Healthcare (Telestroke) Implementation Toolkit.2020: 34. Heart and Stroke Foundation of Canada. Accessed May 6, 2021. https://www.heartandstroke.ca/-/media/1-stroke-best-practices/csbpr7-virtualcaretools-13may2020.Google Scholar12. Gioia LC, Poppe AY, Laroche R, Dacier-Falque T, Sévigny I, Daneault N, Deschaintre Y, Jacquin G, Stapf C, Odier C. Streamlined poststroke treatment order sets during the SARS-CoV-2 Pandemic: simplifying while not compromising care.Stroke. 2020; 51:3115–3118. doi: 10.1161/STROKEAHA.120.031008LinkGoogle Scholar13. De Silva DA, Fan TI, Shamala D, Thilarajah O. A protocol for acute stroke unit care during the COVID-19 pandemic: acute stroke unit care during COVID-19.J Stroke Cerebrovasc Dis. 2020; 29:105009.Google Scholar14. Rudilosso S, Laredo C, Vera V, Vargas M, Renú A, Llull L, Obach V, Amaro S, Urra X, Torres F, et al. Acute stroke care is at risk in the era of COVID-19: experience at a comprehensive stroke center in Barcelona.Stroke. 2020; 51:1991–1995. doi: 10.1161/STROKEAHA.120.030329LinkGoogle Scholar15. Coote S, Cadilhac DA, O'Brien E, Middleton S; Acute Stroke Nurses Education Network (ASNEN) Steering Committee. Letter to the Editor regarding: Critical considerations for stroke management during COVID-19 pandemic in response to Inglis et al., Heart Lung Circ. 2020;29(9): 1263-1267.Heart Lung Circ. 2020; 29:1895–1896. doi: 10.1016/j.hlc.2020.09.925Google Scholar16. Prvu Bettger J, Thoumi A, Marquevich V, De Groote W, Rizzo Battistella L, Imamura M, Delgado Ramos V, Wang N, Dreinhoefer KE, Mangar A, et al. COVID-19: maintaining essential rehabilitation services across the care continuum.BMJ Glob Health. 2020; 5:e002670.Google Scholar17. Lindsay P, Furie KL, Davis SM, Donnan GA, Norrving B. World Stroke Organization global stroke services guidelines and action plan.Int J Stroke. 2014; 9(Suppl A100):4–13. doi: 10.1111/ijs.12371CrossrefMedlineGoogle Scholar18. Winstein CJ, Stein J, Arena R, Bates B, Cherney LR, Cramer SC, Deruyter F, Eng JJ, Fisher B, Harvey RL, et al; American Heart Association Stroke Council, Council on Cardiovascular and Stroke Nursing, Council on Clinical Cardiology, and Council on Quality of Care and Outcomes Research. Guidelines for adult stroke rehabilitation and recovery: a guideline for healthcare professionals from the American Heart Association/American Stroke Association.Stroke. 2016; 47:e98–e169. doi: 10.1161/STR.0000000000000098LinkGoogle Scholar19. Sutter-Leve R, Passint E, Ness D, Rindflesch A. The caregiver experience after stroke in a COVID-19 environment: a qualitative study in inpatient rehabilitation.J Neurol Phys Ther. 2021; 45:14–20. doi: 10.1097/NPT.0000000000000336Google Scholar20. Bersano A, Kraemer M, Touzé E, Weber R, Alamowitch S, Sibon I, Pantoni L. Stroke care during the COVID-19 pandemic: experience from three large European countries.Eur J Neurol. 2020; 27:1794–1800. doi: 10.1111/ene.14375Google Scholar21. Klein BC, Busis NA. COVID-19 is catalyzing the adoption of teleneurology.Neurology. 2020; 94:903–904. doi: 10.1212/WNL.0000000000009494Google Scholar22. Al Rifai M, Shapiro MD, Sayani S, Gulati M, Levine G, Rodriguez F, Mahtta D, Khera A, Petersen LA, Virani SS. Racial and geographic disparities in internet use in the United States among patients with atherosclerotic cardiovascular disease.Am J Cardiol. 2020; 134:146–147. doi: 10.1016/j.amjcard.2020.08.001Google Scholar23. Churchwell K, Elkind MSV, Benjamin RM, Carson AP, Chang EK, Lawrence W, Mills A, Odom TM, Rodriguez CJ, Rodriguez F, et al; American Heart Association. Call to action: structural racism as a fundamental driver of health disparities: a presidential advisory from the American Heart Association.Circulation. 2020; 142:e454–e468. doi: 10.1161/CIR.0000000000000936LinkGoogle Scholar24. Marmot M. Health equity in England: the Marmot review 10 years on.BMJ. 2020; 368:m693. doi: 10.1136/bmj.m693Google Scholar eLetters(0)eLetters should relate to an article recently published in the journal and are not a forum for providing unpublished data. Comments are reviewed for appropriate use of tone and language. Comments are not peer-reviewed. Acceptable comments are posted to the journal website only. Comments are not published in an issue and are not indexed in PubMed. Comments should be no longer than 500 words and will only be posted online. References are limited to 10. Authors of the article cited in the comment will be invited to reply, as appropriate.Comments and feedback on AHA/ASA Scientific Statements and Guidelines should be directed to the AHA/ASA Manuscript Oversight Committee via its Correspondence page.Sign In to Submit a Response to This Article Previous Back to top Next FiguresReferencesRelatedDetailsCited By Scheper M, van Velzen M and L U van Meeteren N (2023) Towards responsible use of artificial intelligence in daily practice: what do physiotherapists need to know, consider and do?, Journal of Physiotherapy, 10.1016/j.jphys.2023.07.012, Online publication date: 1-Nov-2023. Burns S, Fleming T, Webb S, Kam A, Fielder J, Kim G, Hu X, Hill M and Kringle E (2022) Stroke Recovery During the COVID-19 Pandemic: A Position Paper on Recommendations for Rehabilitation, Archives of Physical Medicine and Rehabilitation, 10.1016/j.apmr.2022.04.004, 103:9, (1874-1882), Online publication date: 1-Sep-2022. Furlepa K, Śliwczyński A, Kamecka K, Kozłowski R, Gołębiak I, Cichońska-Rzeźnicka D, Marczak M and Glinkowski W (2022) The COVID-19 Pandemic as an Impulse for the Development of Telemedicine in Primary Care in Poland, Journal of Personalized Medicine, 10.3390/jpm12071165, 12:7, (1165) Glinkowski W (2022) Orthopedic Telemedicine Outpatient Practice Diagnoses Set during the First COVID-19 Pandemic Lockdown—Individual Observation, International Journal of Environmental Research and Public Health, 10.3390/ijerph19095418, 19:9, (5418) Srivastava A, Swaminathan A, Chockalingam M, Srinivasan M, Surya N, Ray P, Hegde P, Akkunje P, Kamble S, Chitnis S, Kamalakannan S, Ganvir S and Shah U (2021) Tele-Neurorehabilitation During the COVID-19 Pandemic: Implications for Practice in Low- and Middle-Income Countries, Frontiers in Neurology, 10.3389/fneur.2021.667925, 12 June 2021Vol 52, Issue 6 Advertisement Article InformationMetrics © 2021 American Heart Association, Inc.https://doi.org/10.1161/STROKEAHA.121.033292PMID: 34000827 Originally publishedMay 18, 2021 KeywordshospitalpandemictelemedicinetriageworkflowPDF download Advertisement SubjectsCerebrovascular Disease/StrokeEthics and PolicyQuality and OutcomesSocial Determinants of Health

Récupéré en direct depuis OpenAlex et désinversé. Les résumés ne sont pas conservés dans cette base de données : les index inversés représentent 8,6 Go des 9,3 Go de texte de la base, et le serveur dispose de 13 Go libres.