Hospital services for patients with acute stroke in the United Kingdom: the Stroke Association Survey of consultant opinion

An assessment of the cost-effectiveness of magnetic resonance, including diffusion-weighted imaging, in patients with transient ischaemic attack and minor stroke: a systematic review, meta-analysis and economic evaluation

BACKGROUND

Patients with transient ischaemic attack (TIA) or minor stroke need rapid treatment of risk factors to prevent recurrent stroke. ABCD2 score or magnetic resonance diffusion-weighted brain imaging (MR DWI) may help assessment and treatment.

OBJECTIVES

Is MR with DWI cost-effective in stroke prevention compared with computed tomography (CT) brain scanning in all patients, in specific subgroups or as 'one-stop' brain-carotid imaging? What is the current UK availability of services for stroke prevention?

DATA SOURCES

Published literature; stroke registries, audit and randomised clinical trials; national databases; survey of UK clinical and imaging services for stroke; expert opinion.

REVIEW METHODS

Systematic reviews and meta-analyses of published/unpublished data. Decision-analytic model of stroke prevention including on a 20-year time horizon including nine representative imaging scenarios.

RESULTS

The pooled recurrent stroke rate after TIA (53 studies, 30,558 patients) is 5.2% [95% confidence interval (CI) 3.9% to 5.9%] by 7 days, and 6.7% (5.2% to 8.7%) at 90 days. ABCD2 score does not identify patients with key stroke causes or identify mimics: 66% of specialist-diagnosed true TIAs and 35-41% of mimics had an ABCD2 score of ≥ 4; 20% of true TIAs with ABCD2 score of < 4 had key risk factors. MR DWI (45 studies, 9078 patients) showed an acute ischaemic lesion in 34.3% (95% CI 30.5% to 38.4%) of TIA, 69% of minor stroke patients, i.e. two-thirds of TIA patients are DWI negative. TIA mimics (16 studies, 14,542 patients) make up 40-45% of patients attending clinics. UK survey (45% response) showed most secondary prevention started prior to clinic, 85% of primary brain imaging was same-day CT; 51-54% of patients had MR, mostly additional to CT, on average 1 week later; 55% omitted blood-sensitive MR sequences. Compared with 'CT scan all patients' MR was more expensive and no more cost-effective, except for patients presenting at > 1 week after symptoms to diagnose haemorrhage; strategies that triaged patients with low ABCD2 scores for slow investigation or treated DWI-negative patients as non-TIA/minor stroke prevented fewer strokes and increased costs. 'One-stop' CT/MR angiographic-plus-brain imaging was not cost-effective.

LIMITATIONS

Data on sensitivity/specificity of MR in TIA/minor stroke, stroke costs, prognosis of TIA mimics and accuracy of ABCD2 score by non-specialists are sparse or absent; all analysis had substantial heterogeneity.

CONCLUSIONS

Magnetic resonance with DWI is not cost-effective for secondary stroke prevention. MR was most helpful in patients presenting at > 1 week after symptoms if blood-sensitive sequences were used. ABCD2 score is unlikely to facilitate patient triage by non-stroke specialists. Rapid specialist assessment, CT brain scanning and identification of serious underlying stroke causes is the most cost-effective stroke prevention strategy.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Clinical and imaging services for TIA and minor stroke: results of two surveys of practice across the UK

OBJECTIVES

Transient ischaemic attack (TIA) is a medical emergency requiring rapid access to effective, organised, stroke prevention. There are about 90 000 TIAs per year in the UK. We assessed whether stroke-prevention services in the UK meet Government targets.

DESIGN

Cross-sectional survey.

SETTING

All UK clinical and imaging stroke-prevention services.

INTERVENTION

Electronic structured survey delivered over the web with automatic recording of responses into a database; reminders to non-respondents. The survey sought information on clinic frequency, staff, case-mix, details of brain and carotid artery imaging, medical and surgical treatments.

RESULTS

114 stroke clinical and 146 imaging surveys were completed (both response rates 45%). Stroke-prevention services were available in most (97%) centres but only 31% operated 7 days/week. Half of the clinic referrals were TIA mimics, most patients (75%) were prescribed secondary prevention prior to clinic referral, and nurses performed the medical assessment in 28% of centres. CT was the most common and fastest first-line investigation; MR, used in 51% of centres, mostly after CT, was delayed up to 2 weeks in 26%; 51% of centres omitted blood-sensitive (GRE/T2*) MR sequences. Carotid imaging was with ultrasound in 95% of centres and 59% performed endarterectomy within 1 week of deciding to operate.

CONCLUSIONS

Stroke-prevention services are widely available in the UK. Delays to MRI, its use in addition to CT while omitting key sequences to diagnose haemorrhage, limit the potential benefit of MRI in stroke prevention, but inflate costs. Assessing TIA mimics requires clinical neurology expertise yet nurses run 28% of clinics. Further improvements are still required for optimal stroke prevention.

Are There Inequalities in the Provision of Stroke Care?

Background and Purpose— There is evidence of unequal access to health care interventions even where universal health systems operate. We investigated associations between patients’ sociodemographic characteristics and the provision of acute and longer-term stroke care in a multiethnic urban population.

Methods— We used data from 1635 patients with first-ever stroke, collected by a population-based stroke register from 1995 to 2000. Using multivariable analyses, controlled for sociodemographic and clinical factors, we investigated access to 22 evidence-based components of care.

Results— 1392 patients (85.1%) were admitted to hospital; of these, 354 (25.4%) were admitted or transferred to a stroke unit. Of those with clinical need, 607 (70.7%) received physical therapies; 477 (59.8%) received speech and language therapy. Older age was associated with lower odds of hospitalization (odds ratio [OR], 0.50; 95% CI, 0.32 to 0.77, P =0.02) and diagnostic brain imaging (OR, 0.15; 95% CI, 0.08 to 0.30, P <0.01) but higher odds of receiving physical therapy (OR, 4.24; 95% CI, 1.22 to 14.73, P <0.01). Black ethnicity was associated with higher odds of stroke unit admission (OR, 1.59; 95% CI, 1.01 to 2.49, P <0.04). There was a weak association between socioeconomic status and admission to hospital and stroke unit. Gender was associated only with treatment of hypertension before stroke.

Conclusions— Provision of individual components of care over 1 year varied for specific sociodemographic categories, but there was no consistent pattern of inequality. Clinical decision-making processes are likely to influence these patterns. Further information about clinician and patient roles in decision making is required.

Variations between countries in outcome after stroke in the International Stroke Trial (IST)

BACKGROUND AND PURPOSE

This study describes the large variations in outcome after stroke between countries that participated in the International Stroke Trial and seeks to define whether they could be explained by variations in case mix or by other factors.

METHODS

We analyzed data from the 15 116 patients recruited in Argentina, Australia, Italy, the Netherlands, Norway, Poland, Sweden, Switzerland, and the United Kingdom: We compared crude case fatality and the proportion of patients dead or dependent at 6 months; we used logistic regression to adjust for age, sex, atrial fibrillation, systolic blood pressure, level of consciousness, and number of neurological deficits. We used the frequency of prerandomization head CT scan and prescription of aspirin at discharge to indicate quality of care.

RESULTS

The differences in outcome (all treatment groups combined) between the "best" and "worst" countries were very large for death (171 cases per 1000 patients) and for death or dependency (375 cases per 1000 patients). The differences were somewhat smaller after adjustment for case mix (160 and 311 cases per 1000 patients, respectively). Process of care may have accounted for some but not all of the residual variation in outcome.

CONCLUSIONS

Adjustment for case mix explained only some of the variation in outcome between countries. The residual differences in outcome were too large to be explained by variations in care and most likely reflect differences in unmeasured baseline factors. These findings demonstrate the need to achieve balance of treatment and control within each country in multinational randomized controlled stroke trials and the need for caution in the interpretation of nonrandomized comparisons of outcome after stroke between countries.

Understanding and managing ischemic stroke

Transient or permanent focal brain injury following acute thromboembolic occlusion develops from a complex cascade of pathophysiological events. The processes of excitotoxicity, peri-infarct depolarisation, inflammation, and apoptosis within the ischemic penumbra are proposed. While the translation of therapeutic agents from the animal models to human clinical trials have been disappointing, there remains an atmosphere of optimism as a result of the development of new diagnostic and therapeutic approaches, which include physiological, as opposed to pharmacological, intervention. This article provides an insight into the understanding of cerebral ischemia, together with current and future treatment strategies.Key words: cerebral ischemia, stroke, pathophysiology.

Opinion of New Zealand physicians on management of acute ischaemic stroke: results of a national survey

BACKGROUND

Randomised trials have evaluated various treatments for acute ischaemic stroke, but it is unclear how the results of these studies are used in everyday practice.

AIMS

To obtain the opinions of physicians on the management of acute ischaemic stroke.

METHODS

A questionnaire was sent to 368 New Zealand Fellows of the Royal Australasian College of Physicians. The survey included questions about the availability of hospital services for stroke patients, management of acute ischaemic stroke and opinion on the efficacy of treatments used in acute ischaemic stroke.

RESULTS

Of the 293 physicians who responded to the questionnaire, 171 managed patients in the first week after stroke. Forty-seven per cent of these physicians were general physicians. Ninety-five per cent usually managed these patients in a general medical ward. Only five physicians admitted patients to an acute stroke unit and only 57% considered acute stroke units were beneficial. Aspirin was usually or sometimes used for patients with acute ischaemic stroke by 92% of physicians, intravenous heparin by 43%, low-dose subcutaneous heparin by 41%, low-molecular-weight heparin by 25% and tissue-plasminogen activator (t-PA) by 3%. Two thirds considered that aspirin was definitely beneficial, but most were uncertain about the efficacy of intravenous heparin, low-dose subcutaneous heparin, low-molecular-weight heparin and t-PA. Sixty-two per cent were prepared to begin aspirin and 21% subcutaneous heparin before computerised tomography (CT). Twenty-three per cent used anti-hypertensive treatment in the first few hours after an ischaemic stroke.

CONCLUSIONS

Several common deficiencies in the management of acute ischaemic stroke were identified. The widespread lack of stroke units, use of aspirin and heparin before CT, and lowering of blood pressure after an acute ischaemic stroke differed from accepted guidelines. Many physicians used heparin despite lack of evidence from randomised trials that it is beneficial. The development of stroke units and the appointment of physicians with a special interest in the management of stroke may improve the management of patients with acute stroke.

Variations in case fatality and dependency from stroke in western and central Europe. The European BIOMED Study of Stroke Care Group

BACKGROUND AND PURPOSE

There are significant variations in mortality rates from stroke in Europe. A European Union BIOMED Concerted Action was established to assess and determine the reasons for the variations in case fatality and disability after stroke.

METHODS

Hospital-based stroke registers were established in 12 centers in 7 western and central European countries to collect demographic, clinical, and resource use details at the time of first-ever stroke during 1993-1994. At 3 months, details of survival, activity of daily living score, and use of health services were recorded. Multinomial logistic regression was used to estimate the relationship between centers and outcome (dead, functionally independent, functionally dependent), with adjustment for case mix and resource use variables, and to predict outcomes for the full cohort. This should minimize the bias due to loss to follow-up.

RESULTS

A total of 4534 stroke events were registered. The mean age was 71.9 years (SD, 12.53). There were significant differences between centers for all case mix and resource use variables (P<0. 001). Multinomial logistic regression modeling of outcome indicated that for those patients initially unconscious (588), center was not significantly related to outcome (P=0.427). For those initially conscious, there were wide variations in death and dependency between centers after adjustment for case mix, type of bed, and use of CT scan. The predicted proportion dead at 3 months ranged from 42% (95% CI, 35% to 49%) in one UK center to 19% (95% CI, 14% to 24%) in France.

CONCLUSIONS

Areas with high mortality rates within western and central Europe have been identified for stroke outcome, and there appears to be opportunity for considerable health gain in certain centers. Adjustment for case mix and health service resource use does not explain these differences in outcome. Although there are true differences in outcome, the aspects of care that need to be altered to improve outcome remain unclear despite detailed data collection. Comparisons of outcome of the same design used in the present study do not allow rational policy decisions to be made.

Evidence-based guidelines for early stroke management

Stroke disease is the commonest neurological emergency encountered by the junior medical team. We have reviewed the literature to produce a series of substantiated guidelines to assist the admitting doctor in managing early stroke care optimally.

Why do Italian stroke patients receive CT scans earlier than UK patients? International Stroke Trial Collaborators in Italy and the UK

Computed tomography (CT) scanning is important prior to acute stroke treatment. We wished to identify factors associated with being able to obtain a CT scan quickly, from a recent large stroke treatment trial. A questionnaire survey on the organisation of CT scanning services for stroke was sent to 179 UK and Italian hospitals who had randomised patients into the International Stroke Trial and performed at least one pre-randomisation CT scan. Data from the questionnaire were analysed in conjunction with other patient data. Italian doctors expected the CT scans to be done more quickly than UK doctors, their hospitals were more likely to have a CT scanner operating all the time, and a porter was used less frequently to take the patient to the CT scanner. A few simple changes in the way CT scanning is organised for stroke patients in the UK could speed access to CT considerably.

Can simple clinical features be used to identify patients with severe carotid stenosis on Doppler ultrasound?

OBJECTIVES

Carotid endarterectomy reduces the risk of stroke in symptomatic patients with severe ipsilateral carotid stenosis. Symptomatic patients should therefore undergo carotid Doppler imaging, but in some centres access to imaging is limited. It was therefore investigated whether simple clinical features alone or in combination could be used to identify patients with severe carotid stenosis, so that they could be referred preferentially for carotid imaging.

METHODS

1041 patients with acute stroke, cerebral or retinal transient ischaemic attacks, and retinal strokes admitted to Western General Hospital or seen in neurovascular clinics were assessed by a stroke physician. Their carotid arteries were investigated using colour Doppler imaging by a consultant neuroradiologist. Patients with primary intracerebral haemorrhage, total anterior circulation strokes, posterior circulation strokes, or posterior circulation transient ischaemic attacks were excluded because carotid surgery would be inappropriate.

RESULTS

726 patients were used in the analysis. Stepwise logistic regression showed that there were significant positive associations between severe carotid stenosis and an ipsilateral bruit, diabetes mellitus, and previous transient ischaemic attacks; and a negative association with lacunar events. The strategy with the highest specificity (97%) was "any three of these four features" but sensitivity was only 17%. The strategy with the highest sensitivity (99%) was to use one or more of the four features, but specificity was only 22%.

CONCLUSION

None of the strategies identified all patients with severe carotid stenosis with a reasonable specificity. When access to carotid imaging is severely limited, simple clinical features are of some use in prioritising patients for imaging, but access to carotid imaging should be improved.

An analysis of admission, discharge and bed occupancy of stroke patients aged 65 and over in English hospitals

Stroke illness is a common problem in the UK. Factors such as incidence, age, and ethnicity have already been shown to affect admission patterns and discharge outcomes. Our analysis of an English Hospital Episode Statistics database shows that weekends and public holidays also influence the admission and discharge patterns of elderly stroke patients. We discuss the possible reasons for this.

The uptake and costs of guidelines for stroke in a district of southern England

STUDY OBJECTIVE

To assess the impact of guidelines for stroke management on the utilisation of services by patients and the cost consequences of implementation.

DESIGN

Prospective audit.

SETTING

District health authority in southern England.

PATIENTS

A total of 468 live non-comatose stroke patients registered between November 1991 and May 1993.

MAIN OUTCOME MEASURES

A comparison between the three, six month periods for investigations performed and rehabilitation received and their associated costs.

RESULTS

The appropriateness of the use of investigations improved over time to between 88 and 92% except for computed tomography (CT) (24%). Younger, more severely impaired patients in a medical bed were more likely to have CT. Overall levels of rehabilitation were low. There was no change in use of physiotherapy (61% to 63%), a significant increase in occupational therapy (26% to 39%) and a non significant change in speech therapy (34% to 25%) over time. Guideline introduction caused a modest 23 Pounds increase in costs per patient in the 2nd six months and 41 Pounds in the 3rd six months but this sum could rise to 430 Pounds per patient if full implementation of the guidelines occurred which is still only around 13% of the costs of nursing care while in hospital.

CONCLUSIONS

This 18 month aduit shows only modest changes in practice compared with guidelines, and overall levels of rehabilitation were low. The costs of full implementation seem considerable, but in fact constitute only a small proportion of nursing care costs.

Early management and outcome of acute stroke in Auckland

BACKGROUND

Studies of acute stroke management in stroke units and tertiary referral hospitals may not accurately reflect practice within the population. Reliable information on the management of stroke within a population is sparse.

AIMS

To compare clinical practice in acute stroke management in Auckland with guidelines for the management and treatment of stroke in other countries; to provide a baseline measure against which future changes in management can be evaluated.

METHODS

All new stroke events in Auckland residents in 12 months were traced through multiple case finding sources. For each patient, a record of investigations and treatment during the first week of hospital admission was kept.

RESULTS

One thousand eight hundred and three stroke events (including subarachnoid haemorrhages) occurred in 1761 patients in one year. Twenty-seven per cent of all events were managed outside hospital and 73% of the stroke events were treated in an acute hospital. Of the 1242 stroke events admitted to an acute hospital in the first week, only 6% were managed on the neurology and neurosurgery ward, 83% were managed by a general physician or geriatrician and 42% had computed tomography (CT). Of 376 validated ischaemic strokes, 44% were treated with aspirin and 12% with intravenous heparin. Of the 690 unspecified strokes (no CT or autopsy), 38% received aspirin and 0.5% heparin. The 28 day in-hospital case fatality for all stroke events admitted to an acute hospital during the first week was 25%.

CONCLUSIONS

In Auckland, management of acute stroke differed from clinical guidelines in the high proportion of patients managed in the community, the low rate of neurological consultation, and the low frequency of CT scanning. Despite these deficiencies in management, the 28 day hospital case fatality in Auckland was similar to other comparable studies which had a high proportion of cases evaluated by a neurologist and CT.

Hospital management of acute ischemic stroke in China

OBJECTIVE

Hospital management of acute ischemic stroke varies greatly within and between different countries. This study assesses the current practices and opinions of doctors in China routinely involved in the treatment of stroke, and compares them with those of British doctors.

METHODS

Questionnaires about the usual management of acute ischemic stroke were sent to 247 Chinese hospitals (mostly urban) collaborating in an acute stroke trial, seeking responses from five doctors (one consultant, two registrars, and two house officers) in each. After one mailing, 1,095 doctors (89%) responded.

RESULTS

Sixty-nine percent of the hospitals had computed tomography scanners, and 88% of the doctors in those hospitals reported that they would routinely scan acute stroke patients (78% usually within 24 hours of admission and 22% only later). Sixty-two percent of doctors reported average hospital stays of 2 to 4 weeks, whereas 36% reported longer average stays. Treatments reported to be used routinely within the first 48 hours of acute ischemic stroke included glycerol or mannitol (69% of doctors), Chinese herb products (66%), calcium antagonists (54%), and aspirin (53%); for each of these treatments, over 70% of all doctors believed it produced definite benefit. Reported routine use of dextran (44%), snake venom (32%), "photo-therapy" (22%), and steroids (19%) was also moderately common, and about half of all doctors believed each was beneficial. In contrast, routine use of thrombolytic agents (4%) or anticoagulants (1%) was uncommon. Only one third of the doctors reported active treatment of hypertension immediately after admission.

CONCLUSIONS

Comparison with a similar survey in Britain showed reported use of most treatments for acute ischemic stroke was more extensive in China, but that within both countries there was wide variation. The substantial variations in clinical practice both within and between China, the United Kingdom and other countries reflect, at least in part, the substantial uncertainty about the effectiveness of many of the possible treatments for acute ischemic stroke. Large-scale randomized evidence is needed to confirm or refute the efficacy of these and newer treatments for acute stroke.

Hospital services for stroke care. A European Perspective. European Study of Stroke Care

BACKGROUND AND PURPOSE

Stroke is a common cause of mortality and morbidity in Europe and a major consumer of healthcare costs. However, outcomes from stroke vary significantly across Europe, raising the issue of the extent to which the delivery of care varies across Europe.

METHODS

A multicenter, multinational study collected data on hospital admission for stroke. These included patient baseline characteristics, clinical status, and use of inpatient services.

RESULTS

Initial results examined inpatient services in nine hospitals in six countries. Statistically significant differences existed between hospitals in key processes of care, most notably in the areas of (1) mean length of stay (11 to 39 days) and median length of stay (8 to 21 days), (2) percentage of admissions receiving brain imaging (30% to 98%) and neurosurgery (0% to 31%), and (3) percentage of admissions with an identified "need" who received physiotherapy (44% to 90%) and occupational (0% to 65%) and speech (0% to 59%) therapy. Although there were significant hospital differences (P < .001) in the case mix of admissions in terms of level of consciousness, presence of incontinence, prestroke Rankin Scale score, and age, these did not explain the differences in care across sites.

CONCLUSIONS

There is geographic inequity across Europe in the care a stroke patient can expect to receive. Ongoing analysis will examine the link between European variations in service use and outcomes, in terms of mortality, handicap, and functional ability, as a means of indicating which patterns of care are the most effective.