Joanna Broad

Health-Related Quality of Life Among Long-Term Survivors of Stroke: Results From the Auckland Stroke Study, 1991–1992

BACKGROUND AND PURPOSE The consequences of stroke are a major health concern. This study was conducted to compare the health-related quality of life among long-term survivors of stroke with that of the general population. METHODS Our data are taken from a population-based case-control study of all 6-year survivors of stroke with an age- and sex-matched control population. SF-36 mean scores for cases were compared with raw and standardized control and New Zealand norm mean scores. RESULTS Of the original 1761 registered cases, 639 were still alive at 6-year follow-up, and all of these participated in the study. Case patients were more likely than control subjects to be dependent in all basic activities of daily living. Crude mean scores were lower for women; as age increased; for those living in institutions; when the SF-36 was completed by proxy; and when help was required with the activities of daily living. Cases had statistically lower mean scores than both the control group and New Zealand norms for physical functioning and general health. After standardization for age and sex, no differences were found between cases and controls in mental health and bodily pain. CONCLUSIONS Health-related quality of life appears to be relatively good for the majority of patients 6 years after stroke. Despite significant ongoing physical disability, survivors of stroke appear to adjust well psychologically to their illness.

Changes in stroke incidence and case-fatality in Auckland, New Zealand, 1981-91

The explanation for the substantial decline in stroke death rates can be investigated only by measuring trends in stroke incidence and case-fatality. Two community-based studies carried out in Auckland, New Zealand, in 1981 and 1991 used comparable methods and definitions, met criteria for well-designed studies, and had the power to detect small changes in incidence and case-fatality rates. 703 events (representing 50% of all strokes) were registered in 1981 and 1735 events in 1991. 521 (74.1%) and 1255 (72.3%) events in 1981 and 1991, respectively, were first-ever (in a lifetime) strokes. Although there was no change in overall stroke incidence between 1981 and 1991, there were changes in age and sex groups. The incidence rate among women younger than 75 years rose by a fifth (rate ratio 1.23 [95% CI 1.04-1.47]), whereas that in men of 75 years and older fell by a third (rate ratio 0.67 [0.54-0.82]). The 28-day case-fatality declined from 27.1 (21.7-32.6)% to 21.9 (18.1-25.7)% in men and from 37.6 (31.8-43.5)% to 25.8 (22.3-29.4)% in women from 1981 to 1991, but the decline was not statistically significant in any age or sex group. These findings suggest that we need to reappraise strategies for the prevention of stroke and assess the implications of improved survival in elderly stroke patients.

Trends in Stroke Incidence in Auckland, New Zealand, During 1981 to 2003

Background and Purpose— Long-term trends in stroke incidence in different populations have not been well characterized, largely as a result of the complexities associated with population-based stroke surveillance. Methods— We assessed temporal trends in stroke incidence using standard diagnostic criteria and community-wide surveillance procedures in the population (≈1 million) of Auckland, New Zealand, over 12-month calendar periods in 1981–1982, 1991–1992, and 2002–2003. Age-adjusted first-ever (incident) and total (attack) rates, and temporal trends, were reported with 95% confidence intervals (CIs). Rates were analyzed by sex and major age groups. Results— From 1981 to 1982, stroke rates were stable in 1991–1992 and then declined in 2002–2003, to produce overall modest declines in standardized incidence (11%; 95% CI, 1 to 19%) and attack rates (9%; 95% CI, 0 to 16%) between the first and last study periods. Some favorable downward trends in vascular risk factors such as cigarette smoking were counterbalanced by increasing age and body mass index, and frequency of diabetes, in patients with stroke. Conclusions— There has been a modest decline in stroke incidence in Auckland over the last 2 decades, mainly during 1991 to 2003, in association with divergent trends in major risk factors.

Shoulder pain in people with a stroke: a population-based study

Objective: To measure the occurrence of shoulder pain after stroke. To identify the factors that predict risk of shoulder pain after stroke. Design: Auckland Stroke Study, population-based case-cohort study. Setting and subjects: All cases of stroke, including those managed outside hospital, over a 12-month period ending February 1992 were considered in Auckland. Outcome measures: Self-reported shoulder pain at one week, one month and six months after the onset of stroke for each person. Results: A total of 1761 stroke events were identified. Self-reported shoulder pain among survivors increased from 256/1474 (17%) at one week, to 261/1336 (20%) at one month and 284/1201 (23%) at six months. Shoulder pain was positively associated with motor deficit, side of deficit and severity of deficit. In those surviving to six months after stroke, the risk of shoulder pain was higher in those with severe upper limb motor deficit (odds ratio (OR) 4.94; 95% confidence interval (CI) 3.06–7.98) and in diabetics (OR 1.57, 95% CI 1.15–2.14). Risk of shoulder pain increased with time and was lower for those in institutional care. Conclusion: Shoulder pain after stroke is common, especially in patients with severe sensorimotor deficits, diabetics and those living at home. Appropriate management may reduce the rate of occurrence.

The GATE frame: critical appraisal with pictures

Epidemiological evidence about the accuracy of diagnostic tests, the power of prognostic markers, and the efficacy and safety of interventions is the cornerstone of evidence-based health care.1 Practitioners of evidence-based health care require critical appraisal skills to judge the validity of this evidence. The Evidence-Based Medicine (EBM) Working Group members are international leaders in teaching critical appraisal skills, and their users’ guides for appraising the validity of the healthcare literature2 have long been the basis of teaching programmes worldwide. However, we found that many of our students took a reductionist “paint by numbers” approach when using the Working Group’s guides. Students could answer individual appraisal questions correctly but would have difficulty assessing overall study quality. We believe this is due to a poor understanding of epidemiological study design. So over the past 15 years of teaching critical appraisal we have modified the EBM Working Group approach and developed the Graphic Appraisal Tool for Epidemiological studies (GATE) frame to help our students conceptualise the whole study as well as its component parts. GATE is a visual framework that illustrates the generic design of all epidemiological studies (figure 1). We now teach critical appraisal by “hanging” studies and the EBM Working Group’s appraisal questions on the GATE frame. Figure 1  The GATE frame. This editorial outlines the GATE approach to critical appraisal, illustrated throughout using the Heart and Estrogen/progestin Replacement Study (HERS), a randomised, double blind, placebo controlled trial of the effect of daily oestrogen plus progestin on coronary heart disease (CHD) death in postmenopausal women.3 A detailed critical appraisal of HERS using a GATE-based checklist is available online.4 The GATE frame incorporates a triangle, circle, square, and arrow (figure 1), labelled with the acronym PECOT (or PICOT). The triangle (figure 2) represents the population studied: “P” for population or …

Stroke incidence and case fatality in Australasia. A comparison of the Auckland and Perth population-based stroke registers.

Background and Purpose Population-based studies are crucial for identifying explanations for the decline in mortality from stroke and for generating strategies for public health policy. However, they present particular methodological difficulties, and comparability between them is generally poor. In this article we compare the incidence and case fatality of stroke as assessed by two independent well-designed incidence studies. Methods Two registers of acute cerebrovascular events were compiled in the geographically defined metropolitan areas of Auckland, New Zealand (population 945 369), during 1991–1992 for 12 months and Perth, Australia (population 138 708), during 1989–1990 for 18 months. The protocols for each register included prospective ascertainment of cases using multiple overlapping sources and the application of standardized definitions and criteria for stroke and case fatality. Results In Auckland, 1803 events occurred in 1761 resi- dents, 73% of which were first-ever strokes. The corresponding figures for Perth were 536 events in 492 residents, 69% of which were first-ever strokes. Both studies identified a substantial proportion of nonfatal strokes managed solely outside the hospital system: 28% in Auckland and 22% in Perth of all patients registered. The age-standardized annual incidence of stroke (all events) was 27% higher among men in Perth compared with Auckland (odds ratio, 1.27; P=.O16); women tended to have higher rates in Auckland, although these differences were not statistically significant. In both centers approximately a quarter of all patients died within the first month after a stroke. There were significant differences in the prevalence of hypertension among first-ever strokes. Conclusions These two studies emphasize the importance of identifying all patients with stroke, both hospitalized and nonhospitalized, in order to measure the incidence of stroke accurately. The incidence and case fatality of stroke were remarkably similar in Auckland and Perth in the early 1990s. However, there are differences in the sex-specific rates that correspond to differences in the pattern of risk factors.

Very Long-Term Outcome After Stroke in Auckland, New Zealand

Background and Purpose— Limited information exists on the long-term outcome from stroke. We aimed to determine survival and health status at 21-year follow-up of patients who participated in a population-based stroke incidence study undertaken in Auckland, New Zealand. Methods— During 12 months beginning March 1, 1981, half of all residents of Auckland with acute first-ever or recurrent stroke (n=680) were assessed and followed up prospectively during the next 2 decades. In 2002, their vital status and health-related quality of life (HRQoL) using the 36-item short-form questionnaire (SF-36) were determined by telephone interviews. Kaplan–Meier survival probabilities for the stroke cohort were compared with life table estimates for the New Zealand population. The SF-36 profile of 21-year stroke survivors was compared with a standardized New Zealand population. Results— Overall, 626 of the original cohort had died and 4 were lost to follow-up, leaving 50 (7%) individuals (57% male; mean age 70 years) available in 2002, of whom 12% were residents of an institutional care facility and 19% required help with everyday activities. The stroke cohort had nearly twice the mortality rate of the New Zealand population, but the SF-36 profile of very long-term stroke survivors was broadly similar to the general population. Conclusions— Because stroke is generally a disease of older people and has a high case fatality, it is not surprising that <1 in 10 people survive 2 decades after onset. However, of those who do, their HRQoL profile suggests that they meld relatively successfully within the general population, despite ongoing disability and a higher mortality risk.

Trends in Ethnic Disparities in Stroke Incidence in Auckland, New Zealand, During 1981 to 2003

Background and Purpose— Although geographical variations in stroke rates are well documented, limited data exist on temporal trends in ethnic-specific stroke incidence. Methods— We assessed trends in ethnic-specific stroke rates using standard diagnostic criteria and community-wide surveillance procedures in Auckland, New Zealand (NZ) in 1981 to 1982, 1991 to 1992, and 2002 to 2003. Indirect and direct methods were used to adjust first-ever (incident) and total (attack) rates for changes in the structure of the population and reported with 95% CIs. Ethnicity was self-defined and categorized as “NZ/European,” “Maori,” “Pacific peoples,” and “Asian and other.” Results— Stroke attack (19%; 95% CI, 11% to 26%) and incidence rates (19%; 95% CI, 12% to 24%) declined significantly in NZ/Europeans from 1981 to 1982 to 2002 to 2003. These rates remained high or increased in other ethnic groups, particularly for Pacific peoples in whom stroke attack rates increased by 66% (95% CI; 11% to 225%) over the periods. Some favorable downward trends in vascular risk factors, such as cigarette smoking, were counterbalanced by increasing age, body mass index, and diabetes in certain ethnic groups. Conclusions— Divergent trends in ethnic-specific stroke incidence and attack rates, and of associated risk factors, have occurred in Auckland over recent decades. The findings provide mixed views as to the future burden of stroke in populations undergoing similar lifestyle and structural changes.

Should the first priority in cardiovascular risk management be those with prior cardiovascular disease

Background: Cardiovascular disease (CVD) prevention guidelines typically dichotomise patients by history of CVD, as patients with prior CVD are assumed to be at high CVD risk, whatever their CVD risk profiles. Objective: To assess the appropriateness of this practice by comparing CVD event rates of patients with and without prior CVD, over and above risk predicted by standard CVD risk factors. Methods: Between 2002 and 2007 CVD risk assessments were generated using a web-based Framingham risk prediction algorithm in routine primary care. Individual risk profiles were subsequently linked to national hospitalisation and death records. Observed and predicted (Framingham) CVD risk were compared in patients with and without prior CVD. Results: 35 760 patients were assessed including 10.4% with prior CVD. Of 1216 first CVD events during an average follow-up of 2.05 years, 42% occurred in those with prior CVD. Among those without prior CVD, the predicted Framingham five-year CVD risk was similar to the observed risk extrapolated to five years; in the highest Framingham risk band (>20% five-year risk), observed risk was 25.3%. Among those with prior CVD the observed risk extrapolated to five years rose from 21.7% in the lowest Framingham risk band (<5%) to 49% in the highest (>20%). Conclusions: Patients with prior CVD have five-year CVD risks approximately 20% higher, in absolute terms than patients without prior CVD, after accounting for standard risk factors. Almost half the CVD events occurred in those with prior CVD. These patients should be the highest priority for intensive preventive management in primary care.

Is There a Temporal Pattern in the Occurrence of Subarachnoid Hemorrhage in the Southern Hemisphere? Pooled Data From 3 Large, Population-Based Incidence Studies in Australasia, 1981 to 1997

Background and Purpose— Publications on the temporal pattern of the occurrence of subarachnoid hemorrhage (SAH) have produced conflicting results. Variations between studies may relate to the relatively small numbers of SAH cases analyzed, including those in meta-analyses. Methods— We identified all cases of SAH from 3 well-designed population-based studies in Australia (Adelaide, Hobart, and Perth) and New Zealand (Auckland) during 3 periods between 1981 and 1997. The diagnosis of SAH was confirmed with CT, cerebral angiography, cerebrospinal fluid analysis, or autopsy in all cases. Information on the time of occurrence of each event was obtained. Risk ratios (RRs) and 95% CIs were calculated using Poisson regression, with age, sex, smoking status, and history of hypertension entered in the model as covariates. Results— A total of 783 cases of SAH were registered. Age- and sex-adjusted RRs of SAH occurrence were highest in the period between 6 am and 12 midnight (RR 3.2, 95% CI 2.4–4.3) and in winter and spring (RR 1.3, 95% CI 1.1–1.5; RR 1.3, 95% CI 1.1–1.5; respectively). No particular pattern of SAH occurrence was observed according to the day of the week. Restriction of the analyses to proved aneurysmal SAH did not substantially change the point estimates. Conclusions— Circadian and circaseptan (weekly) fluctuations of SAH occurrence in the southern hemisphere are similar to those in the northern hemisphere, but the occurrence of SAH in Australasia exhibits clear seasonal (winter and spring) peaks.