Diagnostic Imaging of Ischemic Stroke in the Emergency Room Setting: Implementation Considerations - CADTH ENVIRONMENTAL SCAN REPORT
←
→
Page content transcription
If your browser does not render page correctly, please read the page content below
1 2 3 4 5 6 7 CADTH ENVIRONMENTAL SCAN REPORT 8 Diagnostic Imaging of 9 Ischemic Stroke in the 10 Emergency Room Setting: 11 Implementation 12 Considerations 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
31 Authors: Michael Raj, Charlotte Wells, Melissa Severn
32 Cite As: Diagnostic Imaging of Ischemic Stroke in the Emergency Room Setting: Implementation Considerations.
33 Ottawa: CADTH; 2018 May. (Environmental Scan; Issue XX).
34
35 Disclaimer: The Environmental Scanning Service is an information service for those involved in planning and
36 providing health care in Canada. Environmental Scanning Service responses are based on a limited literature
37 search and are not comprehensive, systematic reviews. The intent is to provide information on a topic that
38 CADTH could identify using all reasonable efforts within the time allowed. Environmental Scanning Service
39 responses should be considered along with other types of information and health care considerations. The
40 information included in this response is not intended to replace professional medical advice nor should it be
41 construed as a recommendation for or against the use of a particular health technology. Readers are also
42 cautioned that a lack of good quality evidence does not necessarily mean a lack of effectiveness, particularly in
43 the case of new and emerging health technologies for which little information can be found but that may in future
44 prove to be effective. While CADTH has taken care in the preparation of the report to ensure that its contents are
45 accurate, complete, and up to date, CADTH does not make any guarantee to that effect. CADTH is not liable for
46 any loss or damages resulting from use of the information in the report. Copyright: This report contains CADTH
47 copyright material. It may be copied and used for non-commercial purposes, provided that attribution is given to
48 CADTH. Links: This report may contain links to other information available on the websites of third parties on the
49 Internet.
50
51 Canadian Agency for Drugs and Technologies in Health (CADTH)
52 600-865 Carling Avenue,
53 Ottawa, Ontario K1S 5S8
54
55
CADTH ENVIRONMENTAL SCAN: Diagnostic Imaging of Ischemic Stroke in the Emergency Room
Setting: Implementation Considerations
256 Context
57
58 Stroke is the third leading cause of death and the main cause of adult disability in Canada.1
59 The average patient irretrievably loses 1.9 million brain cells each minute in which stroke is
60 untreated.1 To halt the progression of irreversible brain tissue damage, swift treatment is
61 required. The goal of neuroimaging is to improve the outcome of stroke by quickly making
62 the correct diagnosis and enabling immediate treatment. Since patients cannot be treated
63 until they are imaged, the rapid acquisition and interpretation of imaging studies is critical for
64 improved outcomes.2
65
66 There are four main types of stroke: ischemic, hemorrhagic, covert, and transient ischemic
67 attack.3 The most common is ischemic,3 accounting for approximately 80% of acute strokes.4
68 The purpose of the first imaging procedure performed in patients with suspected stroke is to
69 distinguish between hemorrhagic and ischemic stroke, which is needed for the appropriate
70 management of acute stroke. 4 Imaging can also contribute to efficiencies in stroke systems
71 of care by assisting physicians in making decisions regarding the transfer of patients with
72 acute ischemic stroke from primary stroke centers to centers capable of performing
73 endovascular procedures.5
74
75 Non-contrast computed tomography (CT) is the most widely used first line imaging modality
76 for the diagnosis of suspected acute stroke.6 The test rules out hemorrhage and other
77 conditions that mimic stroke.7 However, there are many other imaging modalities that can be
78 used to investigate acute stroke.
79
80 Other factors that determine optimal use of imaging modalities include availability of skilled
81 technicians and specialist physicians, access, physician preferences, and costs.8
82 Geographical dispersion is also a barrier to the successful outcome of timely diagnosis of
83 ischemic stroke.9,10 There is uncertainty as to which implementation strategies for optimal
84 imaging have been used in the Canadian emergency care setting, and which have been the
85 most successful.
86
87 Objectives
88
89 The objective of this Environmental Scan is to identify and summarize information regarding
90 the implementation considerations for diagnostic imaging of acute ischemic stroke in the
91 Canadian emergency care setting. The following questions are addressed:
92
93 1. What are the current diagnostic imaging modalities used for ischemic stroke
94 diagnosis in the emergency setting in Canadian jurisdictions?
95
96 2. What types of ischemic stroke imaging modalities are accessible in Canadian
97 jurisdictions across urban, rural, and remote health care settings?
98
CADTH ENVIRONMENTAL SCAN: Diagnostic Imaging of Ischemic Stroke in the Emergency Room
Setting: Implementation Considerations
399 3. What are the main challenges and enablers of diagnosing ischemic stroke in the
100 emergency setting in Canadian jurisdictions?
101
102 Methods
103 Approach
104 To understand implementation issues associated with diagnosing ischemic stroke in
105 Canadian emergency care settings, a dual-stage, sequential research protocol was followed.
106 The two stages included 1) consultation with targeted key stakeholders (informants), and 2)
107 a review of the published and grey literature. Findings from the literature search were used
108 to supplement the information retrieved during the consultations.
109
110 Data Collection
111 Stage 1: Consultations
112 Consultations were conducted with targeted key informants identified through the clinician
113 networks managed by the CADTH Implementation Support and Knowledge Mobilization
114 team or referred through other informants during consultations. These key informants were
115 consulted in order to provide a general overview of policy, practice and implementation
116 issues related to imaging modalities in diagnosing ischemic stroke in Canadian emergency
117 care settings as well as to identify relevant literature. To guide the consultations, a semi-
118 structured interview guide was developed (Appendix 2). Interview questions were developed
119 based on research questions and were related to the general approach to diagnosing
120 ischemic stroke in the emergency room, challenges and supports to the diagnosis of
121 ischemic stroke, the implementation of strategies, as well as gaps in the literature.
122 Consultations took place between August and November of 2017 and consent to publish
123 comments and names were obtained from key informants.
124
125 Stakeholder feedback will be solicited by posting a draft version of the report on CADTH’s
126 website and by emails to subscribers to CADTH’s mailing lists. Key informants involved in
127 the consultations will also be asked to provide feedback.
128
129 Stage 2: Literature Search
130
131 Search Methods
132 The literature search was performed by an information specialist, using a peer-reviewed
133 search strategy.
134 Implementation-related information was identified by searching the following bibliographic
135 databases: MEDLINE (1946–) with in-process records and daily updates, Embase (1974–)
136 via Ovid; CINAHL (1981–) via EBSCO; and PubMed. The search strategy is comprised both
137 controlled vocabulary, such as the National Library of Medicine’s MeSH (Medical Subject
138 Headings), and keywords. The main search concepts were stroke, diagnostic imaging,
CADTH ENVIRONMENTAL SCAN: Diagnostic Imaging of Ischemic Stroke in the Emergency Room
Setting: Implementation Considerations
4139 Canada, and key terms for implementation issues. No methodological filters were applied to
140 limit retrieval by study design. Retrieval was limited to documents published since January 1,
141 2007. Results were limited to English- and French-language publications.
142
143 Grey literature (literature that is not commercially published) was identified by searching the
144 Grey Matters checklist (https://www.cadth.ca/grey-matters), which includes the websites of
145 HTA agencies, clinical guideline repositories, SR repositories, economics-related resources,
146 public perspective groups, and professional associations. Google and other Internet search
147 engines will be used to search for additional Web-based materials.
148
149 Selection Criteria
150 English- or French-language reports that described implementation and context issues,
151 including barriers (or challenges) and facilitators (or enablers) associated with diagnosis and
152 imaging of ischemic stroke in the emergency department were eligible for inclusion.
153 Screening and Selecting Articles for Inclusion and Data Extraction
154 Citations arising from the literature searches were screened independently by one reviewer
155 for information related to implementation issues in Canada. From each potentially relevant
156 article, one reviewer extracted the bibliographic details (i.e., the authors, the year of
157 publication, and the country of origin), and data, which was organized under the
158 INTEGRATE-HTA framework.11 The information from the identified literature supplemented
159 the information provided by the consultations, and attempted to address potential information
160 gaps.
161 Descriptive analysis and synthesis
162 Responses from consultations were used to address Questions 1 and 3. Data from CADTH’s
163 Canadian Medical Imaging Inventory report (2017)12 was used to address Question 2. All
164 research questions were supplemented with information obtained through the literature
165 search. Additionally, stakeholder feedback will be used to supplement information received
166 from the consultations and literature search.
167
168 Information from consultations and findings from the literature were sorted into categories
169 based on the domains identified by the Context and Implementation of Complex
170 Interventions (CICI) framework from INTEGRATE-HTA11 to identify themes related to the
171 strategies used to improve timely access to the diagnosis of ischemic stroke in the Canadian
172 emergency setting.
173 The framework helps to examine the influence of context and implementation issues as
174 modifiers in an HTA, and factors enabling or limiting intervention uptake.
175
176 The concept of context within the framework is considered to be a set of characteristics or
177 circumstances that interact, influence, modify, facilitate, or constrain the intervention and its
178 implementation. Implementation, for the purposes of the framework, is considered to be an
179 actively planned and deliberately initiated effort with the intention of to bring a given object
180 into policy and/or practice.11
CADTH ENVIRONMENTAL SCAN: Diagnostic Imaging of Ischemic Stroke in the Emergency Room
Setting: Implementation Considerations
5181
182 Using this framework, the domains of context, socio-economic, socio-cultural, setting,
183 political, legal, geographical, ethical, and epidemiological, were used to guide the
184 categorization of information on challenges and enablers of diagnosing ischemic stroke in
185 the emergency setting in Canadian jurisdictions. The four domains of implementation,
186 provider, organization and structure, policy, and funding, as well as the additional domain of
187 patient were used to further guide the categorization of identified strategies, barriers, or
188 supports as they relate to the implementation of diagnostic strategies across the various
189 levels of health care service delivery.
190
191 Findings
192 Consultations
193 In total, nine key stakeholders were interviewed for the purposes of this environmental scan
194 (Appendix 1). This included three physicians (two emergency room physicians and one
195 stroke neurologist); four health system administrators including provincial Ministry of Health
196 representatives tasked with management or coordination of stroke services for their
197 jurisdiction; one paramedic with considerable involvement with stroke services in his
198 province; and one researcher representing a national special interest group in the stroke
199 community.
200 Through these consultations, there was representation for the following provinces: British
201 Columbia (BC), Alberta, Saskatchewan, Ontario, Nova Scotia and Prince Edward Island
202 (PEI). While all stakeholders represented were based in urban environments, all were
203 knowledgeable in the issues related to rural and remote settings as related to stroke care or
204 served populations in these settings as well.
205 Efforts were made to contact stakeholders in other Canadian jurisdictions. No response was
206 received from Manitoba, Nunavut, the Northwest Territories (NWT), Yukon, Quebec, New
207 Brunswick, or Newfoundland and Labradorby by the deadline for consultation.
208
209 Literature Search
210 The literature search yielded 410 citations, of which 18 studies were determined to be
211 eligible to address the research question. Twelve articles were published in Canada,8-10,13-21
212 three articles were published in the United States (US),22-24 one article was from
213 Switzerland,25 and one article was from both the US and Canada (an international
214 collaboration).26 Additionally, a Rapid Response report was authored by CADTH which was
215 not specific to the Canadian context.27 Three articles focused on imaging or best practice
216 recommendations,10,20,24 three articles focused on telestroke,13,18,20 three articles focused on
217 access to stroke care,8,9,26 and one article focused on stroke education in emergency
218 medical residency programs.21 The remaining articles pertained to quality of stroke care,
219 experiences with portable CT scanners, stroke protocols, field recognition and accuracy of
220 stroke diagnoses, and other related neuroimaging articles.14-17,22,23,25,27
221 Findings below are presented by research question.
222
CADTH ENVIRONMENTAL SCAN: Diagnostic Imaging of Ischemic Stroke in the Emergency Room
Setting: Implementation Considerations
6223 What are the current diagnostic imaging modalities used for ischemic stroke
224 diagnosis in the emergency setting in Canadian jurisdictions?
225
226 Non-contrast computed tomography (NCCT) is considered by many to be useful in its ability
227 to address imaging requirements for stroke assessment.6 Other imaging modalities are also
228 used, including CT angiography (CTA), multiphase CTA, CT perfusion (CTP), multimodal
229 MRI, MR perfusion (MRP), MR angiography (MRA), and ultrasound. Magnetic resonance
230 imaging (MRI) is also used, although less frequently and contingent on availability, suitability
231 and time.25
232
233 CT is the imaging modality available in most hospitals on a round-the-clock basis. While CT
234 is more widely available, MRI can provide additional information compared with CT, and is
235 more sensitive to small infarctions. 25 However, MRI may not be suitable for all patients as
236 some patients are contraindicated for MRI scanning (e.g., are claustrophobic, have
237 pacemakers, or have metal in the body), thus CT scanning is recommended.27
238
239 The choice of CT or MRI imaging is based on the available infrastructure and staff, as well
240 as the experience of the stroke team. The choice of modality depends on the infrastructure,
241 the logistics, the expertise of the stroke team.25 It also may depend on physician preferences
242 and logistical factors such as whether advanced imaging, especially MRI, can be performed
243 quickly and on a 24/7 basis.24 The choice of modality is also dependent on other factors
244 which are described below.
245
246 Access to imaging modalities can be an enabler to timely stroke diagnosis. The
247 consultations conducted with informants working in either urban, rural, or remote settings or
248 with knowledge of the imaging capabilities across jurisdictions, indicated that CT is the
249 primary diagnostic imaging strategy used to diagnose ischemic stroke across all Canadian
250 jurisdictions consulted with. While most of these modalities are available in urban, acute care
251 centers, rural facilities tend to have on-site access to CT and ultrasound while some may
252 also have CTA capabilities. Conversely, access to imaging modalities can be a barrier to
253 timely stroke diagnosis. The consultations also highlighted that remote health care facilities
254 generally do not have these services available and will send patients to the nearest, most
255 appropriate site that can offer access to these modalities. Further information regarding the
256 accessibility and availability of imaging modalities across Canada and in various Canadian
257 jurisdictions is outlined below.
258
259 What types of ischemic stroke imaging modalities are accessible in Canadian
260 jurisdictions across urban, rural, and remote health care settings?
261
262 CT imaging is the most common and widely used imaging modality for stroke in Canada.6
263 MRI is also used in the diagnosis of stroke, however less frequently than CT scanning.6
264 Single-photon emission computed tomography (SPECT) and positron emission tomography
265 (PET) scanners are also used in neurology to visualize brain physiology.28 PET is
266 considered gold standard for measuring brain physiology, but is not generally used in the
267 acute stroke setting as it is not considered practical, due to the long interval between probe
CADTH ENVIRONMENTAL SCAN: Diagnostic Imaging of Ischemic Stroke in the Emergency Room
Setting: Implementation Considerations
7268 injection and imaging, the relatively smaller number of PET scanners available 24/7, and
269 difficulties for the stroke patient to remain still during imaging.29,30
270
271 To determine what stroke imaging modalities are accessible in Canadian jurisdictions in a
272 variety of health care settings, data from the 2017 Canadian Medical Imaging Inventory
273 (CMII) was used.12 The CADTH CMII report provides an update on the availability and use of
274 specialist imaging equipment across the country. Data is provided from a web-based survey
275 of private or public health care settings that operate medical imaging equipment,
276 supplemented by provincial data validators. The most recent survey was completed in 2017.
277
278 Data from the CMII survey indicated that there are 561 computed tomography (CT)
279 scanners, 366 magnetic resonance imaging (MRI) scanners, 51 positron emission
280 tomography (PET) CT scanners, 3 PET-MRI scanners, 330 single-photon emission
281 computed tomography (SPECT) scanners, and 261 SPECT-CT scanners in Canada, as of
282 2017.12
283
284 The majority of CT scanners are located in Ontario (32.7%) and Quebec (29.1%), with the
285 least number of CT scanners available in Nunavut, NWT, and Yukon. Each province has
286 access to at least one CT scanner. Per one million people, Ontario has 13.0 CT scanners,
287 whilst Nunavut, NWT and Yukon have 26.5, 22.7, and 26.4 respectively. The highest number
288 of CT scanners per million residents is in Newfoundland and Labrador, at 30.3.12
289
290 The majority of MRI scanners are also located in Ontario (33.1%), and there are 8.5 MRI
291 scanners per million people in Ontario. However, there are no MRI scanners in NWT or
292 Nunavut. Per one million residents, Yukon has the highest number of MRIs, at 26.5.12
293
294 There are only three PET-MRI scanners available in Canada, and all three are located in
295 Ontario. PET-CT scanners are available in nine provinces, with the majority located in
296 Quebec (41.2%). Per one million residents, New Brunswick has the most PET-CT scanners
297 available (2.6).12
298
299 SPECT is also available in nine provinces, with the majority available in Ontario (45.8%).
300 Ontario also has the most SPECT scanners available per one million residents, at 10.7.
301 SPECT-CT scanners are also most abundant in Ontario and Quebec (29.9% and 29.1%
302 respectively). Newfoundland and Labrador have the most SPECT-CT scanners available per
303 one million residents, at 17.12
304
305 Rural, Remote, and Urban Healthcare Settings
306
307 The 2017 CMII survey also collected information on the setting in which the healthcare
308 facility is located – this was self-reported as “urban”, “rural” or “remote”. 31 The 39.9% of sites
309 who responded to this part of the survey their setting amounted to 46.5% of imaging units
310 available in Canada.31
311
CADTH ENVIRONMENTAL SCAN: Diagnostic Imaging of Ischemic Stroke in the Emergency Room
Setting: Implementation Considerations
8312 Urban settings contained the majority of stroke imaging modalities, ranging from 75.4% of
313 CT scanners to 85.5% of MRI scanners. Rural settings contained 23.1% of CT scanners,
314 14.5% of MRI scanners, 11.4% of SPECT scanners, and 10.3% of SPECT-CT scanners.31
315 There are four CT scanners available in remote regions in Canada.31 Table 3 and 4 provide
316 additional details regarding urban, rural, and remote settings and the imaging modalities
317 available.31
318
319 What are the main challenges and enablers of diagnosing ischemic stroke in
320 the emergency setting in Canadian jurisdictions?
321
322 Geography and Setting
323
324 The INTEGRATE-HTA domain of geography refers to the broader physical environment,
325 landscapes and resources, available at a given location. Issues of geography can refer to
326 infrastructure (e.g., transportation), access to health care, and geographical isolation, etc.11
327 The setting domain according to INTEGRATE-HTA encompasses the immediate physical
328 and organizational environment, in which an intervention is delivered. It also comprises the
329 effect the location has on affected stakeholder. Issues of setting can refer to region, country
330 (e.g., urban and rural), or type of facility.11
331
332 Several articles reviewed pointed to the challenge posed by Canada’s vast geography,
333 varying size of regions and provinces, and larger proportion of rural and remote communities
334 in accessing care.10,13,14,32 These issues coupled with Canada’s challenging landscapes and
335 climate can limit the speed of access to hospital in time for treatment, even with fast door-to-
336 treatment times.9,14 One of the biggest factors in delays of prompt neuroimaging is the arrival
337 to the hospital from a setting other than home, and the presentation to rural hospitals versus
338 urban hospitals (even if neuroimaging is available at rural locations).17 The distance between
339 the patient and the hospital contributes to non-timely diagnosis.9 In rural areas, the distance
340 makes accessing emergency medical services (EMS) difficult for urgent conditions, including
341 stroke.9
342
343 In widely dispersed regions with long distances between a more comprehensive stroke
344 center and regional (rural) stroke center, diversion of patients to comprehensive centers has
345 the potential to substantially improve outcomes.15 Dr. Eddy Lang indicated that in more
346 remote locations of Alberta, patients who meet certain key symptoms of stroke such as
347 speech disorder, extremity weakness, or lack of consciousness, will usually have to be flown
348 out of the community via air ambulance (Dr. Eddy Lang, Alberta Health Services, Calgary,
349 AB: personal communication, 2017 Aug 8). Lori Latta, a project manager supporting stroke
350 initiatives for the Saskatchewan Ministry of Health, indicated that in Saskatchewan the use of
351 air ambulances to transport patients from remote (northern) areas is fairly common given its
352 geography, although volume of stroke patients from those regions is typically low (Ms. Lori
353 Latta, Project Manager, Clinical Pathways Ministry of Health, Saskatchewan: personal
354 communication, 2017 Nov 17).
355
356 A Canadian study found access to specialized services varying greatly across Canada. In
CADTH ENVIRONMENTAL SCAN: Diagnostic Imaging of Ischemic Stroke in the Emergency Room
Setting: Implementation Considerations
9357 general, rural communities in Canada tend to have limited access to advanced neuroimaging
358 or stroke specialists, and small hospitals may have minimal or no access to diagnostic
359 services.9,16The vastness of regions in larger provinces with a large proportion of rural areas
360 also contributes to untimely diagnosis.32 Additionally, even with access to imaging at rural
361 hospitals, individuals presenting with symptoms to rural hospitals were less likely to receive
362 timely neuroimaging when compared to urban hospitals.17 One possible explanation for this,
363 according to Dr. Patrice Lindsay is that regional centers in Canadian rural settings tend to
364 experience longer wait times because the emergency room is also the trauma center and
365 cardiac center and there is no local option of a specialized stroke center (Dr. Patrice
366 Lindsay, Director, Stroke, Heart & Stroke (National), Ottawa, Ontario: personal
367 communication, 2017 Sep 12).
368
369 Access to Diagnostic Services and Imaging
370 According to Dr. Devin Harris there is a gap in access to CT in rural and remote areas in BC
371 (Dr. Devin R. Harris, Medical Advisor, Stroke Services BC: personal communication, 2017
372 Aug 22). Furthermore, current clinical practice guidelines state that CT tests must be
373 performed when ischemic stroke is suspected, though this technology is not always available
374 in rural or remote emergency departments.27 Because of this, Dr. Harris added, patients in
375 BC being transported by EMS often need to bypass their local center to get to one that has
376 the technology (Dr. Devin R. Harris: personal communication, 2017 Aug 22). Dr. Eddy Lang
377 furthered this by noting that, while some rural facilities in Alberta may have a CT scanner,
378 stroke patients may still require a transfer to a regional center where CTA is available (Dr.
379 Eddy Lang: personal communication, 2017 Aug 8).Generally, people living in rural and
380 remote locations also have challenges accessing EMS for urgent conditions including
381 stroke.9 The time taken to transport patients is higher, and distance highly influences
382 whether a patient is taken to a stroke center or not.14 Access to diagnostic services and
383 imaging is not exclusively an issue in rural communities, however. According to Carolyn
384 MacPhail, smaller provinces such as PEI may face similar issues as rural communities in
385 that they lack access to certain technologies, procedures and specialists that other provinces
386 might have, even in the urban setting (Ms. Carolyn MacPhail, Chronic Disease Prevention
387 and Management Manager, Health PEI, Prince Edward Island: personal communication,
388 2017 Sep 27).
389
390 Access to Stroke Specialists
391 In urban centers, stroke specialists are often available in hospitals, however, they are usually
392 not immediately available in rural centers.18 Carolyn MacPhail noted that overall it can be a
393 challenge to get specialists in smaller provinces like PEI (Ms. Carolyn MacPhail: personal
394 communication, 2017 Sep 27). The specialized expertise required to provide advanced
395 stroke care is generally limited to larger communities and urban areas, and patients living
396 outside these boundaries in the past did not have access to this care.9 Moreover, Dr.
397 Stephen Phillips stated, the low population density in Nova Scotia’s rural settings means
398 hospitals do not manage many stroke patients, and clinicians are therefore less familiar with
399 recognizing stroke symptoms and signs (Dr. Stephen Phillips, Professor of Medicine
400 (Neurology), Dalhousie University, Nova Scotia; Stroke Neurologist, Halifax Infirmary, Nova
401 Scotia: personal communication, 2017 Sep 27). According to Dr. Devin Harris, rural
CADTH ENVIRONMENTAL SCAN: Diagnostic Imaging of Ischemic Stroke in the Emergency Room
Setting: Implementation Considerations
10402 paramedics in BC may not have as much stroke experience as their urban counterparts,
403 travel times take longer and management within the emergency room (ER) is dependent on
404 local expertise and imaging capabilities (Dr. Devin R. Harris: personal communication, 2017
405 Aug 22).
406
407 While there have been improvements, according to Dr. Stephen Phillips in Nova Scotia,
408 facilities in urban settings generally have in-house radiologists and 24/7 access to CT
409 scanning and technicians (Dr. Stephen Phillips: personal communication, 2017 Sep 27). Dr.
410 Devin Harris added that urban facilities in BC will also offer neurology services and stroke
411 teams including stroke neurologists and nurses (Dr. Devin R. Harris: personal
412 communication, 2017 Aug 22). Conversely, rural areas may not have a CT scanner staffed
413 at all times and technologists therefore need to be called in during off-hours which may
414 cause further delays in getting a patient scanned. This becomes especially problematic in
415 smaller communities where the expense of a standard CT scanner with the requirement of
416 specialized technicians may not be feasible.19 Moreover, Dr. Stephen Phillips and Lori Latta
417 both noted that in hospitals serving large rural areas, pressure on limited radiology resources
418 means that radiologists may not be available to read a CT image in a timely manner (Dr.
419 Stephen Phillips: personal communication, 2017 Sep 27, Ms. Lori Latta: personal
420 communication, 2017 Nov 17). Pam Ramsay indicated that in BC, this challenge has been
421 mitigated through the creation of Tiers of Service for Stroke. These tiers of service support
422 decisions regarding bypassing of rural and remote patients to a higher level of care (Ms.
423 Pam Ramsay, Provincial Director, Stroke Services BC, Provincial Health Services Authority,
424 British Columbia: personal communication, 2017 Aug 30).
425
426 While access to CT imaging can be a significant barrier for some areas, one study
427 demonstrated that a portable CT scanner can be used successfully in the evaluation of
428 patients in remote regions that are not within timely reach of stroke experts or do not have
429 available conventional imaging with CT scans.19 Another strategy identified in the literature is
430 the use of mobile stroke units, which are ambulances equipped with point-of-care blood tests
431 and CT imaging and staffed with specially trained nurses, paramedics, and physicians.20 The
432 results from several studies in a meta-analysis reported that the time from symptom onset to
433 treatment with intravenous thrombolytic agents is significantly shorter with patients arriving at
434 hospital by mobile stroke unit compared with patients arriving by ambulance.20
435
436 Telestroke
437 The use of Telestroke systems enables improved communication and networking to increase
438 access to stroke expertise, regardless of the physical location of the patient.20 One challenge
439 is that Telestroke delivery of care still requires the treating center to complete a CT scan
440 immediately, which is not always feasible due to several issues including the availability of
441 skilled technicians.19 A further challenge to the use of this technology identified by Pam
442 Ramsay was that when a rural or remote community hospital is consulting with a
443 comprehensive stroke centre to determine if a patient is eligible for transfer for endovascular
444 treatment, there may be delays in transmission/availability of CT imaging (multiphase CTA).
445 This imposes undue delay (Ms. Pam Ramsay: personal communication, 2017 Aug 30).
CADTH ENVIRONMENTAL SCAN: Diagnostic Imaging of Ischemic Stroke in the Emergency Room
Setting: Implementation Considerations
11446
447 Political
448
449 The political domain focuses on the distribution of power, assets and interests within a
450 population, as well as the range of organizations involved, their interests and the formal and
451 informal rules that govern interactions between them.11
452
453 Dr. Stephen Phillips noted that one of the defining characteristics of stroke care is that it cuts
454 across many areas of the health care system including EMS, radiology, neuroradiology,
455 neurology nursing, and the ER, as well as internal medicine, neurology, and neurosurgery
456 (Dr. Stephen Phillips: personal communication, 2017 Sep 27). This can make it challenging
457 to determine who is ultimately responsible and who the decision-maker is not only for patient
458 care but also for system organization (Dr. Stephen Phillips: personal communication, 2017
459 Sep 27).
460
461
462 Ethical
463
464 The ethical domain refers to the concepts of morality, which encompasses beliefs, standards
465 of conduct and principles that guide the behavior of individuals and institutions.11
466
467 With regards to emergency response, there is an ethical dilemma sometimes posed for rural
468 and remote communities. More specifically, when one in-service ambulance is occupied
469 transporting a patient to a comprehensive stroke center, if there are only a small number of
470 ambulances in a region, this could compromise care for other citizens in that jurisdiction.15
471 Pam Ramsay echoed this notion stating that in BC as part of the Tiers of Service model and
472 stroke bypass protocols, the decision may be to bypass a community facility with limited
473 stroke expertise or imaging capability to a higher level of care facility. In smaller
474 communities, this may result in an ambulance leaving a community that may only have a
475 limited number of ambulances services in the community (Ms. Pam Ramsay: personal
476 communication, 2017 Aug 30). This is compounded in the winter season with variable road
477 conditions. Given this, it is critical that there be partnership with emergency health services
478 in planning for stroke transport (Ms. Pam Ramsay: personal communication, 2017 Aug 30).
479
480 Another condition was discussed with the emergence of the “opioid crisis” where the BC
481 system was faced with increasing demand for EMS. Again, partnership with emergency
482 health services was critical in ensuring no impact to response times for stroke patient
483 transports (Ms. Pam Ramsay: personal communication, 2017 Aug 30).
484
485 Domains of Implementation
486
487 Provider
488
489 This implementation domain focuses on the characteristics of the individuals adopting and
490 delivering the intervention. This domain includes both the personal attributes, knowledge,
CADTH ENVIRONMENTAL SCAN: Diagnostic Imaging of Ischemic Stroke in the Emergency Room
Setting: Implementation Considerations
12491 skills, emotions, motivations, intentions and goals.11 The literature review and consultations
492 pointed towards a few key areas when considering the role of providers with respect to
493 implementation: training and education, guidelines and buy-in, and physician collaboration.
494
495 Training and Education
496 The largest barrier to stroke training for Canadian physicians, according to Dr. Devin Harris,
497 is the limited time within emergency medicine residency programs devoted to stroke (Dr.
498 Devin R. Harris: personal communication, 2017 Aug 22 ). In one Canadian study, 1% of
499 lecture time was devoted to stroke and TIA within the emergency medicine residency
500 programs, despite neurologic emergencies being 5% of all presenting complaints to
501 emergency rooms.21 The majority of teaching around stroke and TIA is primarily academic,
502 in the form of limited lectures and oral examinations.21
503
504 Dr. Stephen Phillips pointed to the fact that internists are generally responsible for
505 conducting stroke assessments in regions and facilities in Nova Scotia without neurologists,
506 yet internal medicine residents get relatively little training in neurology (Dr. Stephen Phillips:
507 personal communication, 2017 Sep 27). Dr. Devin Harris remarked that remote outposts in
508 BC may be particularly challenged because these have limited stroke expertise and
509 diagnostic capability. In addition, pre-hospital care is often provided through caregivers (Dr.
510 Devin R. Harris: personal communication, 2017 Aug 22).
511
512 One way to mitigate this, according to Dr. Patrice Lindsay, is through in-hospital training,
513 regional stroke training, and best practice webinars so that stroke education can be provided
514 not only to physicians but also nurses, rehabilitation experts, technologists and other staff
515 who are part of the stroke continuum (Dr. Patrice Lindsay: personal communication, 2017
516 Sep 12). Dr. Lindsay added that this emphasizes the imperative need to develop strong
517 regional stroke systems of care including the use of technology such as telestroke to support
518 assessment, diagnosis and management decision-making in rural regions (Dr. Patrice
519 Lindsay: personal communication, 2017 Sep 12).
520
521 Guidelines and Buy-in
522 Clinical practice guidelines can pose a particular challenge to optimizing diagnostic
523 strategies. While there are national guidelines for the diagnosis and treatment of stroke,10
524 specialist physicians may have discipline-specific guidelines, which may not completely align
525 with the Canadian Stroke Best Practice Recommendations.10 Dr. Stephen Phillips felt that
526 this misalignment posed additional challenges for reaching agreement on how to best deliver
527 stroke care (Dr. Stephen Phillips: personal communication, 2017 Sep 27). Patrice Lindsay
528 added that some specialists may not always follow guidelines completely due to the
529 emergent nature of the situation, available resources and local protocols or restrictions, such
530 as not making CTA the routine first line imaging (and performing NCCT only) (Dr. Patrice
531 Lindsay: personal communication, 2017 Sep 12).
532
533 Buy-in was cited by many interviewed as a common barrier with respect to providers. Dr.
534 Patrice Lindsay and Dr. Stephen Phillips were of the opinion that, regardless of practice
535 guidelines or department policy, some physicians are more committed to and engaged in
CADTH ENVIRONMENTAL SCAN: Diagnostic Imaging of Ischemic Stroke in the Emergency Room
Setting: Implementation Considerations
13536 stroke care than others. (Dr. Patrice Lindsay: personal communication, 2017 Sep 12, Dr.
537 Stephen Phillips: personal communication, 2017 Sep 27). Carolyn MacPhail pointed to the
538 importance of family physicians and nurse practitioners also needing to buy-into the value of
539 having a stroke unit although the majority of persons with stroke spend at least part of their
540 stay on the provincial stroke unit and some family physicians in PEI do not yet utilize
541 established protocols (Ms. Carolyn MacPhail: personal communication, 2017 Sep 27).
542
543 Dr. Stephen Phillips added that there are still physicians in Canada who are not supportive
544 of tPA (tissue plasminogen activator, a treatment for stroke), which slows down buy-in for
545 stroke care improvements (Dr. Stephen Phillips: personal communication, 2017 Sep 27). In
546 Nova Scotia, efforts to enhance stroke care are continuing more than a decade after the
547 provincial government committed dedicated funding to it. An enabler identified by both Dr.
548 Devin Harris and Lori Latta was the use of physician champions to implement protocols and
549 promote guideline uptake in both BC and Saskatchewan (Dr. Devin R. Harris: personal
550 communication, 2017 Aug 22, Ms. Lori Latta: personal communication, 2017 Nov 17). For
551 Carolyn MacPhail this included bringing together physician groups including ER physicians
552 and radiology peers about the use of protocols and benefits of CTA, for example (Ms.
553 Carolyn MacPhail: personal communication, 2017 Sep 27). Dr. Phillips added that in each
554 health district in Nova Scotia, they appointed and provided some salary support for a lead
555 stroke physician - family physician or internist – who took responsibility for helping build the
556 local stroke program, and this turned out to be a key component of their implementation
557 success (Dr. Stephen Phillips: personal communication, 2017 Sep 27).
558
559 Physician Collaboration
560 There was general agreement among those interviewed that collaboration between
561 physicians across radiology, neurology and emergency was key to a successful stroke
562 program. Both Dr. Eddy Lang and Dr. Patrice Lindsay highlighted the importance of these
563 specialties coming together to find a common approach and working towards better
564 integration in order to provide the best care possible (Dr. Eddy Lang: personal
565 communication, 2017 Aug 8, Dr. Patrice Lindsay: personal communication, 2017 Sep 12).
566 There was agreement between Jeremy Measham in PEI and Dr. Eddy Lang in Alberta that
567 there is room for improvement in communication between ER physicians, neurologists and
568 radiologists and understanding who is ultimately the decision-maker for the stroke patient
569 presenting to the ER (Mr. Jeremy Measham, Special Projects Coordinator, Island EMS,
570 Prince Edward Island: personal communication, 2017 Sep 26; Dr. Eddy Lang: personal
571 communication, 2017 Aug 8).
572
573 Patient
574
575 The additional patient domain was also considered, which combines socio-cultural, socio-
576 economic, and epidemiological components of the context domains of the INTEGRATE-HTA
577 framework.
578 Stroke often renders patients incapable of seeking help themselves, leaving bystanders or
579 family members responsible for contacting emergency services.17 Approximately two-thirds
580 of all patients who seek acute care for stroke in Canada arrive at the ER by ambulance.10
CADTH ENVIRONMENTAL SCAN: Diagnostic Imaging of Ischemic Stroke in the Emergency Room
Setting: Implementation Considerations
14581 The greatest proportion of patients who received timely neuroimaging were those who
582 presented to the ER within 30 to 60 minutes after symptom onset.17
583 Stroke does not uniformly engender a sense of urgency because it does not usually cause
584 pain and many people do not know how to recognize stroke in another person and to seek
585 help.14 As such, people need to be aware of the signs of stroke and contact EMS without
586 delay to maximize eligibility for these time-sensitive treatments.9 Dr. Devin Harris
587 emphasized the need for patient and family awareness as to the signs and symptoms of
588 stroke which can be difficult to recognize, leading to people arriving too late to the ER.
589 Stroke may present with significant neurological deficits and, at other times, with headaches
590 or vision problems, so awareness is key (Dr. Devin R. Harris: personal communication, 2017
591 Aug 22). Pam Ramsay and Dr. Patrice Lindsay both referenced the Heart and Stroke
592 Foundation of Canada’s FAST campaign as being an enabler to patient education (Ms. Pam
593 Ramsay: personal communication, 2017 Aug 30, Dr. Patrice Lindsay: personal
594 communication, 2017 Sep 12).33 Dr. Patrice Lindsay noted that Canadian patients today are
595 much more informed when it comes to their health and their families are more aware about
596 when and how to act when faced with a potential stroke, although there is still much work to
597 be done (Dr. Patrice Lindsay: personal communication, 2017 Sep 12).
598
599 Organization and Structure
600
601 This domain comprises the organizational policies, guidelines and practices as well as
602 culture and climate that reside within an organization and on different levels such as the
603 organization as a whole, units, and teams through which an intervention is delivered.
604 Therefore, constructs such as team dynamics, leadership, supervision and guidance are
605 also comprised.11
606
607 The literature review and consultations highlighted the following organization and structure
608 enablers and barriers with respect to implementation: pre-arrival notification and bypass,
609 coordination of care, and culture.
610
611 Pre-arrival Notification and Bypass
612 Among patients with acute ischemic stroke, transport by EMS has been associated with
613 earlier arrival and faster emergency department evaluations – these benefits stem, at least in
614 part, from pre-arrival activation of stroke teams because of hospital pre-notification by EMS
615 and bypass protocols.22
616
617 Pre-arrival notification to hospital has been found to be extremely beneficial in PEI as
618 described by Jeremy Measham (Mr. Jeremy Measham: personal communication, 2017 Sep
619 26). Typical intake protocols for when patients present to the ER, in his opinion, simply
620 cause delays and lengthen the door-to-CT time. Instead, the ER nurse manager and
621 physician in PEI will be notified by EMS of the incoming stroke patient and will meet the
622 patient at the doors of ER and quickly triage and decide if they should go to CT rather than
623 finding a bed in the ER to wait in. These patients will thereby bypass the ER and be taken
624 directly to the CT scanner accompanied by the paramedic and then the ER physician or
CADTH ENVIRONMENTAL SCAN: Diagnostic Imaging of Ischemic Stroke in the Emergency Room
Setting: Implementation Considerations
15625 stroke specialist will see the patient later in the ER to decide on next steps (Mr. Jeremy
626 Measham: personal communication, 2017 Sep 26).
627
628 Guideline-recommended prehospital practices have been demonstrated to improve the
629 efficiency of in-hospital care for stroke patients.23 One study suggests that hospital pre-
630 notification is associated with improved stroke response as measured by door-to-evaluation
631 times and the rate and speed of tPA delivery.23 Another study found that EMS-recognized
632 strokes had faster door-to-CT times and transportation by EMS is an important predictor of
633 improved in-hospital stroke response and use of tPA for patients with acute ischemic
634 stroke.22 Findings from the North Carolina Stroke Care Collaborative showed that arrival by
635 EMS (versus private transport) was associated with faster access to brain imaging and faster
636 interpretation of these images.9
637
638 According to Dr. Patrice Lindsay, organizational relationships and partnerships with EMS are
639 key enablers with a common understanding that paramedics are not merely transporters but
640 are experts trained to recognize the signs of stroke and take appropriate actions (Dr. Patrice
641 Lindsay: personal communication, 2017 Sep 12). Dr. Stephen Phillips and Pam Ramsay
642 added that because paramedics are at the front lines, they are instrumental in
643 operationalizing bypass protocols as demonstrated in both Nova Scotia and BC respectively
644 (Dr. Stephen Phillips: personal communication, 2017 Sep 27, Ms. Pam Ramsay: personal
645 communication, 2017 Aug 30).
646
647 Jeremy Measham described how stroke system stakeholders in the province of PEI have
648 developed a diversion policy to divert stroke patients in ambulance from minor hospitals that
649 do not have CT to sites that have these technologies. Because the island’s EMS is
650 centralized, if an ambulance is moved away from one community, another will be moved to
651 fill the gap (Mr. Jeremy Measham: personal communication, 2017 Sep 26).
652
653 Coordination of Care
654 Although an ideal system might see all patients receiving care at specialized stroke centers,
655 this may be difficult to achieve in large, geographically diverse jurisdictions.8 Coordinated
656 systems of stroke care have been established in many provinces which include bypass
657 protocols for paramedics and the use of Telestroke modalities to access specialists at large
658 urban centers for consultation and to support intravenous tPA administration.10 Dr. Devin
659 Harris added that urban hospitals in BC tend to have in place structured protocols,
660 guidelines, imaging equipment, and overall access to endovascular therapy and stroke units
661 which rural facilities typically do not (Dr. Devin R. Harris: personal communication, 2017 Aug
662 22).
663
664 The overall coordination of stroke care is a challenge identified by Lori Latta (Ms. Lori Latta:
665 personal communication, 2017 Nov 17). Nurse coordination or stroke team coordination, is
666 vital to raising profile of stroke and ensuring that standardized order sets for care and
667 administration of treatments adhered to (Ms. Lori Latta: personal communication, 2017 Nov
668 17).
669
CADTH ENVIRONMENTAL SCAN: Diagnostic Imaging of Ischemic Stroke in the Emergency Room
Setting: Implementation Considerations
16670 Culture
671 From a cultural perspective, Dr. Devin Harris believes that there has been a paradigm shift
672 within the medical community when it comes to stroke, stating “At one time, we did not think
673 that stroke was treatable and preventable. Now we know it is treatable and preventable and
674 this changes our approach to how we deal with patients. There is still room for improvement”
675 (Dr. Devin R. Harris: personal communication, 2017 Aug 22). Dr. Eddy Lang added that, “It
676 was only a decade ago that most urban hospitals were operating their imaging machines for
677 fixed hours but now we are seeing an evolution in thinking to recognize that neurology
678 emergencies can happen at any hour of the day and so imaging need to be available 24/7”
679 (Dr. Eddy Lang: personal communication, 2017 Aug 8).
680
681 Funding
682
683 The domain of funding relates to short-term or longer-term funding mechanisms by
684 governmental, non-governmental, private sector and philanthropic organizations used to
685 implement an intervention.11
686
687 Dr. Devin Harris highlighted that stroke is a continuum disorder, so the funding needed for it
688 in his province of BC does not usually align with the necessary silos (ER, radiology,
689 neurology, etc.) which generally have different reporting structures (Dr. Devin R. Harris:
690 personal communication, 2017 Aug 22). With shrinking budgets and hospitals often required
691 to curb spending, finding additional funds available for stroke services and costly imaging
692 technologies is challenging (Dr. Devin R. Harris: personal communication, 2017 Aug 22).
693 One study reviewed found that patients in the US used significantly more imaging resources
694 than patients in Canada, where capacity is restricted by centralized provincial budgets.26
695
696 Pam Ramsay noted that capital investments are always a challenge in the acute care setting
697 adding that we must be mindful of the capabilities of CT scanners in small communities in
698 BC and that some may be in need of upgrading (Ms. Pam Ramsay: personal
699 communication, 2017 Aug 30). Pam Ramsay and Jeremy Measham in PEI both stated that
700 operational investments (human resources) are another barrier with the need for staff
701 available to respond to stroke cases 24/7 including specialist physicians and imaging
702 technicians (Ms. Pam Ramsay: personal communication, 2017 Aug 30, Mr. Jeremy
703 Measham: personal communication, 2017 Sep 26).
704
705 One article reviewed noted that a limitation in addressing stroke patients is that 24 hour CT
706 scanning may not be possible at all acute sites due to lack of resources, and patient transfer
707 to larger centers can result in precious time loss and may not always be possible for patients
708 with unstable conditions.19
709
710 This becomes especially important in smaller communities where the expense of a standard
711 CT scanner with the requirement of specialized technicians may not be feasible.19 Dr. Devin
712 Harris and Dr. Patrice Lindsay echoed this opinion and added that funding for personnel to
713 operate diagnostic imaging equipment (CT scanners) 24 hours a day, seven days a week is
714 a challenge for many Canadian facilities including those in urban settings (Dr. Patrice
CADTH ENVIRONMENTAL SCAN: Diagnostic Imaging of Ischemic Stroke in the Emergency Room
Setting: Implementation Considerations
17715 Lindsay: personal communication, 2017 Sep 12, Dr. Devin R. Harris: personal
716 communication, 2017 Aug 22).
717
718 In some jurisdictions another challenge exists where some people avoid calling EMS
719 because of the fees associated with the ambulance. From Carolyn MacPhail’s perspective,
720 some people in PEI believe that they can get themselves faster to hospital than EMS and
721 without the associated cost (Ms. Carolyn MacPhail: personal communication, 2017 Sep
722 27).34 Given the importance of minimizing the door-to-treatment time for patients with
723 suspected stroke, it is important that people understand the specialized training that EMS
724 personnel have in responding to stroke patients and not merely as ambulance transport.
725 Moreover, stroke protocols are put in place to ensure that treatment occurs in the right place
726 and in a timely manner (Ms. Carolyn MacPhail: personal communication, 2017 Sep 27).
727
728 Policy
729
730 According to INTEGRATE-HTA, the policy domain comprises policy measures and
731 processes of government, public, private or other organizations directly concerning or
732 indirectly influencing the implementation of an intervention.11
733
734 There is much agreement in the literature and among most interviewed that one of the
735 biggest enablers to managing ischemic stroke is the use of standardized protocols in both
736 urban and rural/remote settings. One article underscored that effective and standardized
737 imaging protocols are necessary for clinical decision making.25 In BC, Dr. Devin Harris
738 reports that a key enabler for his facility has been the use of standardized stroke protocols
739 (Dr. Devin R. Harris: personal communication, 2017 Aug 22).
740
741 Dr. Patrice Lindsay added that protocols facilitate the process for paramedics in more urban
742 settings as they are often trained and can identify the signs of stroke (Dr. Patrice Lindsay:
743 personal communication, 2017 Sep 12). Pam Ramsay in BC added that a policy around
744 bypass is also necessary, particularly when a decision needs to be made regarding air
745 versus ground transport of stroke patients (Ms. Pam Ramsay: personal communication,
746 2017 Aug 30). This type of system coordination requires that hospitals work with EMS which,
747 according to Trish Helm-Neima, they are doing in PEI (Ms. Trish Helm-Neima, Provincial
748 Stroke Coordinator, Health PEI, Prince Edward Island: personal communication, 2017 Sep
749 27). One article emphasized that coordinated systems of care and ambulance bypass
750 agreements must continue to evolve to ensure maximal access to hyper acute stroke
751 services.9
752
753 In BC, an example of a policy that potentiated a barrier to implementing “best practice stroke
754 care” was described by Pam Ramsay (Ms. Pam Ramsay: personal communication, 2017
755 Aug 30). In an effort to reduce wait times and backlogs in the ER, patients were being
756 transferred out of the ER into the first available hospital bed (in-patient) as quickly as
757 possible. Although patient focused, this might mean that a patient with a stroke could be
758 transferred to a bed other than the most appropriate stroke unit bed. Efforts are required to
CADTH ENVIRONMENTAL SCAN: Diagnostic Imaging of Ischemic Stroke in the Emergency Room
Setting: Implementation Considerations
18759 harmonize competing policies/guidelines (Ms. Pam Ramsay: personal communication, 2017
760 Aug 30).
761
762 One key policy change that is expected to drive change in the stroke system is the
763 mandating to collect key data elements in a jurisdiction. Pam Ramsay noted that in BC all
764 health authorities are now recording stroke information in the discharge abstract database
765 (DAD) to measure time-to-CT and transfer time-to-stroke unit for example (Ms. Pam
766 Ramsay: personal communication, 2017 Aug 30).
767
768 Socio-economic, Socio-cultural, Legal and Epidemiological
769
770 The consultations and literature search together did not yield any articles which addressed
771 the INTEGRATE-HTA domains of socio-economic, socio-cultural, legal and epidemiological.
772 All other domains are described with respect to challenges and enablers of implementation
773
774 Limitations
775 The findings of this environmental scan aim to present an overview of examples and current
776 information regarding the diagnostic imaging for ischemic stroke in the emergency room
777 setting and are not intended to provide a comprehensive review of the topic. The results are
778 based on a limited, non-systematic literature search and consultations with nine
779 stakeholders. While there was representation from BC, Alberta, Saskatchewan, Ontario,
780 Nova Scotia and PEI not all jurisdictions responded to our request for an interview and some
781 respondents were only able to speak on behalf of a single site or organization and not the
782 jurisdiction’s health care system as a whole. Moreover, opinions and perspectives provided
783 as part of the targeted stakeholder consultations may not be representative of the views of
784 all stakeholders across Canadian jurisdictions.
785 The literature search did not identify studies pertaining to many aspects of issues relating to
786 implementation, or aspects of the integrate-HTA framework. There was a lack of information
787 regarding the epidemiology, socio-economic status, political, policy, socio-cultural and legal
788 domains of integrate-HTA.
789 There were also limitations in the data used from the CMII database. The setting of “urban”,
790 “rural”, or “remote” were self-reported by the individual who filled out the survey and were not
791 guided by a specific definition of these settings. This means that the categorization by setting
792 may not be completely accurate. Additionally, 39.9% of respondents reported on the setting
793 of their site, thus some information may not have been captured in the survey, and therefore
794 not reported.
795
796 Conclusion
797
798 The Environmental Scan included a review of the literature and targeted consultations with
799 stakeholders from British Columbia, Alberta, Saskatchewan, Ontario, Nova Scotia and
800 Prince Edward Island and included both health care professionals and health system
801 administrators.
802
CADTH ENVIRONMENTAL SCAN: Diagnostic Imaging of Ischemic Stroke in the Emergency Room
Setting: Implementation Considerations
19You can also read
