Alex Hoffman

Stroke Unit Care and Outcome Results from the 2001 National Sentinel Audit of Stroke (England, Wales, and Northern Ireland)

Background and Purpose— Stroke unit care is one of the most powerful interventions available to help stroke patients. There are limited data available to assess the impact of stroke units in routine clinical practice outside randomized clinical trials. This article uses data from the 2001 to 2002 National Stroke Audit to assess the effectiveness of stroke unit care in England, Wales, and Northern Ireland in delivering effective processes of care and in reducing case fatality and disability. Methods— An observational study of the organization, structure, process of care, and outcomes for stroke in 2001. Case fatality after stroke in England was compared using data from the audit and routinely collected data from the Department of Health. 240 hospitals (196 Trusts) from England, Wales, and Northern Ireland took part in the 2001 to 2002 National Stroke Audit, a response rate of >95%. These sites assessed a total of 8200 patients using the Royal College of Physicians Intercollegiate Working Party Stroke Audit Tool. Results— The availability of stroke unit care varies hugely across the country. Case fatality after stroke was higher in Trusts with least availability of stroke unit care. These differences persisted after control for case mix. The process of care was better for patients managed on stroke units compared with other settings. Overall, the risk of death for patients who received stroke unit care was estimated to be ≈75% that of the risk for those having no stroke unit care (95% CI, 60 to 90). Conclusions— Stroke unit care as provided in routine clinical practice in England, Wales, and Northern Ireland reduces case fatality by ≈25%, which is in line with the figures obtained from systematic analysis of stroke unit trial data.

Waiting times for carotid endarterectomy in UK: observational study

Objectives To assess timeliness of carotid endarterectomy services in the United Kingdom. Design Observational study with follow-up to March 2008. Setting UK hospitals performing carotid endarterectomy. Participants UK surgeons undertaking carotid endarterectomy from December 2005 to December 2007. Main outcome measures Provision and speed of delivery of appropriate assessments of patients; carotid endarterectomy and operative mortality; 30 day postoperative mortality. Results 240 (61% of those eligible) consultant surgeons took part from 102 (76%) hospitals and trusts. Of 9913 carotid endarterectomies recorded on hospital episode statistics, 5513 (56%) were included. Of the patients who underwent endarterectomy, 83% had a history of transient ischaemic attack or stroke. Of these recently symptomatic patients, 20% had their operation within two weeks of onset of symptoms and 30% waited more than 12 weeks. Operative mortality was 0.5% during the inpatient stay and 1.0% (95% confidence interval 0.7% to 1.3%) by 30 days. Conclusion Only 20% of symptomatic patients had surgery within the two week target time set by the National Institute for Health and Clinical Excellence (NICE). Although operative mortality rates are comparable with those in other countries, some patients might experience disabling or fatal stroke while waiting for surgery and hence not be included in operative statistics. Major improvements in services are necessary to enable early surgery in appropriate patients in order to prevent strokes.

Stroke units: research and reality. Results from the National Sentinel Audit of Stroke

Objectives: To use data from the 2001–2 National Stroke Audit to describe the organisation of stroke units in England, Wales and Northern Ireland, and to see if key characteristics deemed effective from the research literature were present. Design: Data were collected as part of the National Sentinel Audit of Stroke in 2001, both on the organisation and structure of inpatient stroke care and the process of care to hospitals managing stroke patients. Setting: 240 hospitals from England, Wales and Northern Ireland took part in the 2001–2 National Stroke Audit, a response rate of over 95%. These sites audited a total of 8200 patients. Audit tool: Royal College of Physicians Intercollegiate Working Party Stroke Audit Tool. Results: 73% of hospitals participating in the audit had a stroke unit but only 36% of stroke admissions spent any time on one. Only 46% of all units describing themselves as stroke units had all five organisational characteristics that previous research literature had identified as being key features, while 26% had four and 28% had three or less. Better organisation was associated with better process of care for patients, with patients managed on stroke units receiving better care than those managed in other settings. Conclusion: The National Service Framework for Older People set a target for all hospitals treating stroke patients to have a stroke unit by April 2004. This study suggests that in many hospitals this is being achieved without adequate resource and expertise.

Stroke thrombolysis in England, Wales and Northern Ireland: how much do we do and how much do we need?

Background Data are limited on the proportion of stroke patients nationally appropriate for thrombolysis either within the 3 h time window or the recently tested 4.5 h. This information is important for the redesign of services. Methods Data on case mix, eligibility for thrombolysis, treatment and outcomes were extracted from the National Sentinel Stroke 2008 Audit dataset. This contains retrospective data on up to 60 consecutive stroke admissions from each acute hospital in England, Wales and Northern Ireland between 1 April and 30 June 2008. Findings All relevant hospitals participated, submitting data on 11 262 acute stroke patients. 2118 patients arrived within 2 h and 2596 within 3 h of the onset of symptoms and 587 people were already in hospital. Therefore, 28% (3183) were potentially eligible for thrombolysis based on a 3 h time criterion. Of these, 1914 were under 80 years and 2632 had infarction with 14% (1605) meeting all three National Institute of Neurological Disorders and Stroke study criteria and so being potentially eligible for thrombolysis. If the time window is increased to 4.5 h then only another 2% became eligible. If the age limit was removed for treatment, the percentage potentially appropriate for tissue plasminogen activator increased to 23% within 3 h and 26% within 4.5 h. Overall, 1.4% (160) of patients were thrombolysed. Interpretation Thrombolysis rates are currently low in the UK. 14% of patients in this sample were potentially suitable for thrombolysis using the 3 h time window. This would only increase marginally if thrombolysis was extended to include those up to 4.5 h. The greatest impact on increasing the proportion of patients suitable for thrombolysis would be to increase the number of patients presenting early and by demonstrating that the treatment is safe and effective in patients over 80 years of age.

Associations between the organisation of stroke services, process of care, and mortality in England: prospective cohort study

Objective To estimate the relations between the organisation of stroke services, process measures of care quality, and 30 day mortality in patients admitted with acute ischaemic stroke. Design Prospective cohort study. Setting Hospitals (n=106) admitting patients with acute stroke in England and participating in the Stroke Improvement National Audit Programme and 2010 Sentinel Stroke Audit. Participants 36 197 adults admitted with acute ischaemic stroke to a participating hospital from 1 April 2010 to 30 November 2011. Main outcome measure Associations between process of care (the assessments, interventions, and treatments that patients receive) and 30 day all cause mortality, adjusting for patient level characteristics. Process of care was measured using six individual measures of stroke care and summarised into an overall quality score. Results Of 36 197 patients admitted with acute ischaemic stroke, 25 904 (71.6%) were eligible to receive all six care processes. Patients admitted to stroke services with high organisational scores were more likely to receive most (5 or 6) of the six care processes. Three of the individual processes were associated with reduced mortality, including two care bundles: review by a stroke consultant within 24 hours of admission (adjusted odds ratio 0.86, 95%confidence interval 0.78 to 0.96), nutrition screening and formal swallow assessment within 72 hours (0.83, 0.72 to 0.96), and antiplatelet therapy and adequate fluid and nutrition for first the 72 hours (0.55, 0.49 to 0.61). Receipt of five or six care processes was associated with lower mortality compared with receipt of 0-4 in both multilevel (0.74, 0.66 to 0.83) and instrumental variable analyses (0.62, 0.46 to 0.83). Conclusions Patients admitted to stroke services with higher levels of organisation are more likely to receive high quality care as measured by audited process measures of acute stroke care. Those patients receiving high quality care have a reduced risk of death in the 30 days after stroke, adjusting for patient characteristics and controlling for selection bias.

Can a Novel Clinical Risk Score Improve Pneumonia Prediction in Acute Stroke Care? A UK Multicenter Cohort Study

Background Pneumonia frequently complicates stroke and has a major impact on outcome. We derived and internally validated a simple clinical risk score for predicting stroke‐associated pneumonia (SAP), and compared the performance with an existing score (A2DS2). Methods and Results We extracted data for patients with ischemic stroke or intracerebral hemorrhage from the Sentinel Stroke National Audit Programme multicenter UK registry. The data were randomly allocated into derivation (n=11 551) and validation (n=11 648) samples. A multivariable logistic regression model was fitted to the derivation data to predict SAP in the first 7 days of admission. The characteristics of the score were evaluated using receiver operating characteristics (discrimination) and by plotting predicted versus observed SAP frequency in deciles of risk (calibration). Prevalence of SAP was 6.7% overall. The final 22‐point score (ISAN: prestroke Independence [modified Rankin scale], Sex, Age, National Institutes of Health Stroke Scale) exhibited good discrimination in the ischemic stroke derivation (C‐statistic 0.79; 95% CI 0.77 to 0.81) and validation (C‐statistic 0.78; 95% CI 0.76 to 0.80) samples. It was well calibrated in ischemic stroke and was further classified into meaningful risk groups (low 0 to 5, medium 6 to 10, high 11 to 14, and very high ≥15) associated with SAP frequencies of 1.6%, 4.9%, 12.6%, and 26.4%, respectively, in the validation sample. Discrimination for both scores was similar, although they performed less well in the intracerebral hemorrhage patients with an apparent ceiling effect. Conclusions The ISAN score is a simple tool for predicting SAP in clinical practice. External validation is required in ischemic and hemorrhagic stroke cohorts.

Bigger, Faster? Associations Between Hospital Thrombolysis Volume and Speed of Thrombolysis Administration in Acute Ischemic Stroke

Background and Purpose— There is evidence that high-volume hospitals may produce better patient outcomes. We aimed to identify whether there were any associations between hospital thrombolysis volume and speed of thrombolysis (tissue-type plasminogen activator [tPA]) administration in patients with ischemic stroke. Methods— Data were drawn from 2 national clinical audits in England: the Stroke Improvement National Audit Program and the 2012 Sentinel Stroke Audit. Hospitals were categorized into 3 groups based on the annualized volume of thrombolysis: 0 to 24, 25 to 49, and ≥50 cases per annum. Arrival-brain scan, onset-tPA, and arrival-tPA times were compared across groups and stratified by onset-arrival time. Multilevel logistic models were used to estimate the odds of receiving tPA within 60 minutes of arrival. Results— Of the 42 024 patients with acute ischemic stroke admitted to 80 hospitals, 4347 received tPA (10.3%). Patients admitted to hospitals with an annual thrombolysis volume of ≥50 cases per annum had median arrival-tPA times that were 28 and 22 minutes shorter than patients admitted to hospitals with volumes of 0 to 24 and 25 to 49, respectively. Onset-tPA times were shorter by 24 to 32 minutes across strata of onset-arrival times. In multivariable analysis, patients admitted to hospitals with a volume of ≥50 cases per annum had 4.33 (2.21–8.50; P<0.0001) the odds of receiving tPA within 60 minutes of arrival. No differences in safety outcomes were observed, with similar 30-day mortality and complication rates across the groups. Conclusions— Hospitals with higher volumes of thrombolysis activity achieve statistically and clinically significant shorter delays in administering tPA to patients after arrival in hospital.

Effects of Centralizing Acute Stroke Services on Stroke Care Provision in Two Large Metropolitan Areas in England

Background and Purpose— In 2010, Greater Manchester and London centralized acute stroke care into hyperacute units (Greater Manchester=3, London=8), with additional units providing ongoing specialist stroke care nearer patients’ homes. Greater Manchester patients presenting within 4 hours of symptom onset were eligible for hyperacute unit admission; all London patients were eligible. Research indicates that postcentralization, only London’s stroke mortality fell significantly more than elsewhere in England. This article attempts to explain this difference by analyzing how centralization affects provision of evidence-based clinical interventions. Methods— Controlled before and after analysis was conducted, using national audit data covering Greater Manchester, London, and a noncentralized urban comparator (38 623 adult stroke patients, April 2008 to December 2012). Likelihood of receiving all interventions measured reliably in pre- and postcentralization audits (brain scan; stroke unit admission; receiving antiplatelet; physiotherapist, nutrition, and swallow assessments) was calculated, adjusting for age, sex, stroke-type, consciousness, and whether stroke occurred in-hospital. Results— Postcentralization, likelihood of receiving interventions increased in all areas. London patients were overall significantly more likely to receive interventions, for example, brain scan within 3 hours: Greater Manchester=65.2% (95% confidence interval=64.3–66.2); London=72.1% (71.4–72.8); comparator=55.5% (54.8–56.3). Hyperacute units were significantly more likely to provide interventions, but fewer Greater Manchester patients were admitted to these (Greater Manchester=39%; London=93%). Differences resulted from contrasting hyperacute unit referral criteria and how reliably they were followed. Conclusions— Centralized systems admitting all stroke patients to hyperacute units, as in London, are significantly more likely to provide evidence-based clinical interventions. This may help explain previous research showing better outcomes associated with fully centralized models.

Stroke thrombolysis in England: an age stratified analysis of practice and outcome

INTRODUCTION until very recently, only small numbers of older patients with stroke had been recruited into randomised controlled trials of thrombolysis with recombinant tissue plasminogen activator (rt-PA) and patients aged >80 are excluded in the European licence for this therapy. We aimed to estimate the use and outcome of stroke thrombolysis in England across age groups, including the oldest-old. METHODS data were collected as part of the Stroke Improvement National Audit Programme. All adults receiving thrombolysis for acute ischaemic stroke as part of routine care between April 2010 and November 2011 were included. Multilevel multivariable logistic regression was used to analyse the associations between age, process of care and 30-day mortality. RESULTS of 37,151 adults admitted with acute ischaemic stroke, 3,374 (9.1%) received rt-PA. Patients aged >80 accounted for 21% of the thrombolysis recipients and 4.8% of patients in this age group received rt-PA. Treatment times were similar across all age groups, but older thrombolysis recipients were more likely to have Total anterior circulation infarct strokes and less likely to be functionally independent prior to stroke. Similar rates of post-thrombolysis complications were observed between patients aged >80 and younger patients. Mortality was high among older patients whether they were treated with rt-PA or not. Among patients treated with rt-PA, those aged 81-90 and >90 had, respectively, 34 and 270% higher odds of 30-day mortality than patients aged 70-80. CONCLUSION treatment with rt-PA is now carried out frequently for older stroke patients in England. Their care is as timely as younger patients with no higher risk of major complication but mortality rates in older patients with stroke remain high.

Urinary incontinence in stroke: results from the UK National Sentinel Audits of Stroke 1998–2004

BACKGROUND urinary incontinence (UI) after stroke is associated with significant morbidity and mortality. The UK National Sentinel Audits of Stroke have collected data on UI which has not previously been reported. METHODS data on standards relating to both organisations and process of care were extracted from the audits to look for trends in service provision, continence care planning and discharge destination of incontinent versus continent stroke survivors. In addition, 2004 data was analysed statistically to look for a link between stroke units meeting certain standards and the likelihood of patients having continence plans. RESULTS UI rates have changed little over the four audit cycles. The influence of UI on discharge destination has also altered little. Stroke unit care is more strongly associated with management planning for UI in stroke.