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BMJ Open Is Committed to Open Peer Review. As Part of This Commitment We Make the Peer Review History of Every Article We Publish Publicly Available BMJ Open: first published as 10.1136/bmjopen-2019-033055 on 6 August 2020. Downloaded from BMJ Open is committed to open peer review. As part of this commitment we make the peer review history of every article we publish publicly available. When an article is published we post the peer reviewers’ comments and the authors’ responses online. We also post the versions of the paper that were used during peer review. These are the versions that the peer review comments apply to. The versions of the paper that follow are the versions that were submitted during the peer review process. They are not the versions of record or the final published versions. They should not be cited or distributed as the published version of this manuscript. BMJ Open is an open access journal and the full, final, typeset and author-corrected version of record of the manuscript is available on our site with no access controls, subscription charges or pay-per-view fees (http://bmjopen.bmj.com). If you have any questions on BMJ Open’s open peer review process please email [email protected] http://bmjopen.bmj.com/ on October 3, 2021 by guest. Protected copyright. BMJ Open BMJ Open: first published as 10.1136/bmjopen-2019-033055 on 6 August 2020. Downloaded from Temporal trends and geographical disparities in comprehensive stroke center capabilities in Japan from 2010 to 2018 ForJournal: peerBMJ Open review only Manuscript ID bmjopen-2019-033055 Article Type: Research Date Submitted by the 22-Jul-2019 Author: Complete List of Authors: KUROGI, AI; Graduate School of Medical Sciences, Kyushu University, neurosurgery Nishimura, Ataru ; Graduate School of Medical Sciences, Kyushu University, neurosurgery Nishimura, Kunihiro; National Cerebral and Cardiovascular Center, Cerebrovascular Medicine Kada, Akiko ; National Hospital Organization Nagoya Medical Center, Department of Clinical Trials and Research Onozuka, Daisuke ; Kyushu University, Hagihara, Akihito; Kyusyu University Graduate School of Medicine, Department of Health Services Management and Policy Ogasawara, Kuniaki; Iwate Medical University School of Medicine, Department of Neurosurgery http://bmjopen.bmj.com/ Shiokawa, Yoshiaki ; Kyorin University Hospital, Department of Neurosurgery Kitazono, Takanari; Kyushu University, Arimura, Koichi; Kyushu University, Neurosurgery Iihara, Koji ; Graduate School of Medical Sciences, Kyushu University, neurosurgery Keywords: Stroke < NEUROLOGY, comprehensive stroke center, trends on October 3, 2021 by guest. 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Where the Submitting Author wishes to make the Work available on an Open Access basis (and 21 intends to pay the relevant APC), the terms of reuse of such Open Access shall be governed by a Creative 22 Commons licence – details of these licences and which Creative Commons licence will apply to this Work are set 23 out in our licence referred to above. 24 25 Other than as permitted in any relevant BMJ Author’s Self Archiving Policies, I confirm this Work has not been 26 accepted for publication elsewhere, is not being considered for publication elsewhere and does not duplicate 27 material already published. I confirm all authors consent to publication of this Work and authorise the granting 28 of this licence. 29 30 31 32 33 34 35 36 37 http://bmjopen.bmj.com/ 38 39 40 41 42 43 44 45 on October 3, 2021 by guest. Protected copyright. 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 2 of 31 1 2 3 4 BMJ Open: first published as 10.1136/bmjopen-2019-033055 on 6 August 2020. Downloaded from 5 6 Temporal trends and geographical disparities in comprehensive stroke center 7 8 capabilities in Japan from 2010 to 2018 9 10 11 12 １ １ 2 3 2 13 Ai Kurogi , Ataru Nishimura , Kunihiro Nishimura , Akiko Kada , Daisuke Onozuka , 14 15 Akihito Hagihara2, Kuniaki Ogasawara4, Yoshiaki Shiokawa5, Takanari Kitazono2, 16 17 Koichi Arimura１, and Koji Iihara１, on behalf of the J-ASPECT Study Collaborators 18 For peer review only 19 20 21 22 1Department of Neurosurgery, and 6Department of Medicine and Clinical Science, 23 24 25 Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan 26 27 2Department of Preventive Medicine and Epidemiology, National Cerebral and 28 29 Cardiovascular Center, Suita, Japan 30 31 3Department of Clinical Research Management, Clinical Research Center, National 32 33 34 Hospital Organization Nagoya Medical Center, Nagoya, Japan 35 36 4Department of Neurosurgery, Iwate Medical University, Morioka, Japan 37 http://bmjopen.bmj.com/ 38 5Department of Neurosurgery, Kyorin University, Mitaka, Japan 39 40 41 42 43 44 45 Correspondence to: Koji Iihara; [email protected] on October 3, 2021 by guest. Protected copyright. 46 47 48 Keywords: stroke, comprehensive stroke center, care quality 49 50 Word count: 1764 51 52 53 54 55 56 57 58 59 60 1 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 3 of 31 BMJ Open 1 2 3 4 BMJ Open: first published as 10.1136/bmjopen-2019-033055 on 6 August 2020. Downloaded from 5 6 ABSTRACT 7 8 Objectives: Comprehensive stroke center (CSC) capabilities are associated with 9 10 reduced in-hospital mortality due to acute stroke. However, it remains unclear whether 11 12 13 there are improving trends in the CSC capabilities, or how hospital-related factors 14 15 determine quality improvement. This study examined whether CSC capabilities 16 17 changed in Japan between 2010 and 2018, and whether any changes were influenced by 18 For peer review only 19 hospital characteristics. 20 21 22 Design: A hospital-based cross-sectional study. 23 24 Setting: We sent out questionnaires to the training institutions of the Japan 25 26 Neurosurgical Society and Japan Stroke Society in 2010, 2014 and 2018. 27 28 29 Participants: 749 in 2010, 532 in 2014 and 786 in 2018 hospitals that participate in the 30 31 J-ASPECT Study. 32 33 Main outcome measures: CSC capabilities were assessed using the validated scoring 34 35 36 system (CSC score:1-25 points) in 2010, 2014, and 2018 survey. The effect of hospital 37 http://bmjopen.bmj.com/ 38 characteristics was examined using multiple logistic regression analysis. 39 40 41 Results: Among the 323 hospitals that responded to all surveys, the implementation of 42 43 44 14 recommended items increased. The CSC score (median, interquartile range) was 16 45 on October 3, 2021 by guest. Protected copyright. 46 47 48 (13-19), 18 (14-20), 19 (15-21), for 2010, 2014, and 2018, respectively (p for trend< 49 50 51 0.001). There was a ≥ 20% increase in six items (e.g. endovascular physicians, stroke 52 53 54 55 unit, and interventional coverage 24/7), and a ≤ 20% decrease in community education. 56 57 58 A lower baseline CSC score (odds ratio 0.82, [95% confidence interval] 0.75-0.9), the 59 60 2 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 4 of 31 1 2 3 4 BMJ Open: first published as 10.1136/bmjopen-2019-033055 on 6 August 2020. Downloaded from 5 6 7 number of beds ≥ 500 (3.9 [1.2–13.0]), and the number of stroke physicians (7-9) (2.6 8 9 10 [1.1-6.3]) was associated with improved CSC capabilities, independent of geographical 11 12 13 location. 14 15 16 Conclusions: There was a significant improvement in CSC capabilities between 2010 17 18 and 2018, whichFor was mainly peer related reviewto the availability only of endovascular treatment and 19 20 multidisciplinary care. Hospital characteristics may be considered to further improve 21 22 systems of stroke care in light of a limited medical resources in a defined area. 23 24 25 26 27 Strengths and limitations of this study: 28 29 ・A large-scale, representative hospitals of Japan provided data on temporal trends in 30 31 32 the CSC capabilities for this cross-sectional study. 33 34 ・Hospitals actively working to improve stroke care are more likely to respond to the 35 36 questionnaire, which may lead to information bias. 37 http://bmjopen.bmj.com/ 38 39 ・ The CSC score was a significant composite measure to influence in-hospital 40 41 42 mortality of acute stroke, but little information was established on the influence of 43 44 specific items.
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