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Stroke services, stroke networks: is there an ideal model?
  1. T Moulin1,
  2. M Hommel2
  1. 1Stroke Unit, Dept of Neurology, Jean Minjoz University Hospital, Besançon Cedex, France
  2. 2Stroke Unit, Dept of Neurology, La Tronche University Hospital, Grenoble Cedex, France
  1. Correspondence to:
 Dr Thierry Moulin
 Stroke Unit, Dept of Neurology, Jean Minjoz University Hospital, 25030 B Besançon Cedex, France; thierry.moulinuniv-fcomte.fr

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Stroke programmes have a vital role to play in educating the public and primary physicians

Since their first development in the 1970s, the clinical effectiveness of stroke units has been demonstrated in many randomised controlled studies and meta-analyses. The rapid broad-scale implementation of stroke units and structured stroke care in general, has been hindered by many factors of a medical and economic nature. This suggests a missed opportunity for patients in medical terms since almost all stroke patients are hospitalised and it also represents an inappropriate allocation of financial resources.

Different models have been proffered to improve the quality of stroke care and rationalise patient management. The Calgary Stroke Programme1 (this issue, pp 863) is a good example of a North-American stroke centre. It is a centralised model, concentrating stroke medical expertise and material resources in a single acute unit. All patients presenting with suspected stroke are dealt with according to specific management guidelines and flow charts. Another tangible benefit for patients is rapid and direct access to a specialised care system allowing them to “bypass” their local hospital or GP.

While there are clear benefits in the North-American model, should such a centralised model be simply transposed to European countries? It is unlikely that this would work in practice, due to this diverse nature of European health systems.

If the Calgary stroke model could be beneficial for patients and financially efficient for the hospital, it describes the course of individual patients and represents just one link in the “vertical” healthcare network. The global aim of this “vertical” part of the network is to provide emergency care while optimising medical management, reducing patient length-of-stay, as well as the prevention of recurrent stroke to minimise the impact of stroke (the right management, at the right time for the right patient).

A geographically-based structure, providing equal access to stroke expertise for all citizens wherever they live, constitutes the “horizontal” part of the network. These public health care objectives have to be shared by doctors and the appropriate health authority representatives in the framework of a long term medico-social project.2 The two parts of the network mandate state-of-the-art IT supports as well as telemedicine (telestroke) videoconferencing and image transfer technology. The networks must also be coordinated by a stroke specialist based in the stroke unit—the cornerstone of the networks.3,4 Perhaps combining European and North-American pieces of the jigsaw could be an effective model, as highlighted by the Project for Integrative Stroke Care (TEMPiS) in Munich, Germany.3

What can be agreed upon by both American and European stroke teams is that stroke programmes have a vital role to play in educating the public and primary physicians about risk factors, symptom management, and stroke prevention. There is also a consensus on the need to establish emergency admission procedures, and to organise stroke rehabilitation and long term care to minimise the medico-social impact of stroke.

A firm European endeavour from the healthcare providers and political decision makers will be necessary to achieve this crucial goal.

Stroke programmes have a vital role to play in educating the public and primary physicians

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