Access to stroke care units in Australian public hospitals: facts and temporal progress

Twenty years of monitoring acute stroke care in Australia through the national stroke audit programme (1999-2019): A cross-sectional study

BACKGROUND

National organisational surveys and clinical audits to monitor and guide improvements to the delivery of evidence-based acute stroke care have been undertaken in Australia since 1999. This study aimed to determine the association between repeated national audit cycles on stroke service provision and care delivery from 1999 to 2019.

METHODS

Cross-sectional study using data from organisational surveys (1999, 2004, 2007-2019) and clinical data from the biennial National Stroke Acute Audit (2007-2019). Age-, sex-, and stroke severity-adjusted proportions were reported for adherence to guideline-recommended care processes. Multivariable, logistic regression models were performed to determine the association between repeated audit cycles and service provision (organisational) and care delivery (clinical).

RESULTS

Overall, 197 hospitals provided organisational survey data (1999-2019), with 24,996 clinical cases from 136 hospitals (around 40 cases per audit) (2007-2019). We found significant improvements in service organisation between 1999 and 2019 for access to stroke units (1999: 42%, 2019: 81%), thrombolysis services (1999: 6%, 2019: 85%), and rapid assessment/management for patients with transient ischaemic attack (1999: 11%, 2019: 61%). Analyses of patient-level audits for 2007 to 2019 found the odds of receiving care processes per audit cycle to have significantly increased for thrombolysis (2007: 3%, 2019: 11%; OR 1.15, 95% CI 1.13, 1.17), stroke unit access (2007: 52%, 2019: 69%; OR 1.15, 95% CI 1.14, 1.17), risk factor advice (2007: 40%, 2019: 63%; OR 1.10, 95% CI 1.09, 1.12), and carer training (2007: 24%, 2019: 51%; OR 1.12, 95% CI 1.10, 1.15).

CONCLUSIONS

Between 1999 and 2019, the quality of acute stroke care in Australia has improved in line with best practice evidence. Standardised monitoring of stroke care can inform targeted efforts to reduce identified gaps in best practice, and illustrate the evolution of the health system for stroke.

Economic Evaluation Protocol and Statistical Analysis Plan for the Cost-Effectiveness of a Novel Australian Stroke Telemedicine Program; the Victorian Stroke Telemedicine (VST) program

Introduction: Telemedicine can address limited access to medical specialists in rural hospitals. Stroke provides an important case study because: it is a major cause of disease burden; effective treatments to reduce disability (e.g., thrombolysis) can be provided within the initial hours of stroke onset; careful selection of patients is needed by skilled doctors to minimize adverse events from thrombolysis; and there are major treatment gaps (only about half of regional hospitals in Australia provide thrombolysis for stroke). Few economic analyses have been undertaken on telestroke and the majority have been simulation models. The aim of this protocol and statistical analysis plan is to outline the methods for the cost-effectiveness evaluation of a large, multicentre acute stroke telemedicine program being conducted in Victoria, Australia.

Methods: Using a historical- and prospective-controlled design, we will compare patient-level data obtained in the 12 months prior to the Victorian Stroke Telemedicine (VST) program implementation and during the first 12 months of VST to determine the incremental difference in costs and patient outcomes at 3 and 12 months. Secondary aims include assessing the cost per additional patient receiving intravenous thrombolysis and the cost per additional patient receiving intravenous thrombolysis within 60 min. Tertiary aims include assessing the potential longer-term cost-effectiveness in the second year of the program at the hospitals to determine whether any program benefits are sustained once site coordinators are no longer employed; and modeling the potential net life-time costs and benefits from a societal perspective. Multivariable uncertainty and one-way sensitivity analyses will be performed to assess the robustness of results.

Results: Sixteen hospitals participated. Patient-level data collection including 12-month outcomes for the cohorts obtained in the first and second year of the program for each hospital was completed in January 2020.

Conclusion: The results from this real-world study with patient-level data will provide high quality evidence of the costs, health benefits and policy implications of telestroke programs, including the potential for application in other locations within Australia or other countries with similar health system delivery and financing.

Barriers to evidence-based acute stroke care in Ghana: a qualitative study on the perspectives of stroke care professionals

OBJECTIVE

Despite major advances in research on acute stroke care interventions, relatively few stroke patients benefit from evidence-based care due to multiple barriers. Yet current evidence of such barriers is predominantly from high-income countries. This study seeks to understand stroke care professionals' views on the barriers which hinder the provision of optimal acute stroke care in Ghanaian hospital settings.

DESIGN

A qualitative approach using semistructured interviews. Both thematic and grounded theory approaches were used to analyse and interpret the data through a synthesis of preidentified and emergent themes.

SETTING

A multisite study, conducted in six major referral acute hospital settings (three teaching and three non-teaching regional hospitals) in Ghana.

PARTICIPANTS

A total of 40 participants comprising neurologists, emergency physician specialists, non-specialist medical doctors, nurses, physiotherapists, clinical psychologists and a dietitian.

RESULTS

Four key barriers and 12 subthemes of barriers were identified. These include barriers at the patient (financial constraints, delays, sociocultural or religious practices, discharge against medical advice, denial of stroke), health system (inadequate medical facilities, lack of stroke care protocol, limited staff numbers, inadequate staff development opportunities), health professionals (poor collaboration, limited knowledge of stroke care interventions) and broader national health policy (lack of political will) levels. Perceived barriers varied across health professional disciplines and hospitals.

CONCLUSION

Barriers from low/middle-income countries differ substantially from those in high-income countries. For evidence-based acute stroke care in low/middle-income countries such as Ghana, health policy-makers and hospital managers need to consider the contrasts and uniqueness in these barriers in designing quality improvement interventions to optimise patient outcomes.

Hospitals admitting at least 100 patients with stroke a year should have a stroke unit: a case study from Australia

BACKGROUND

Establishing a stroke unit (SU) in every hospital may be infeasible because of limited resources. In Australia, it is recommended that hospitals that admit ≥100 strokes per year should have a SU. We aimed to describe differences in processes of care and outcomes among hospitals with and without SUs admitting at least 100 patients/year.

METHODS

National stroke audit data of 40 consecutive patients per hospital admitted between 1/7/2010-31/12/2010 and organizational survey for annual admissions were used. Descriptive analyses and multilevel regression were used to compare patient outcomes. Sensitivity analysis including only hospitals meeting all of the Australian SU criteria (e.g., co-location of beds; inter-professional team; weekly meetings; regular training) was performed.

RESULTS

Two thousand eight hundred ninety-eight patients from 72/108 eligible hospitals completing the audit (SU = 60; patients: 2,481 [mean age 76 years; 55% male] and non-SU patients: 417 [mean age 77; 53% male]). Hospitals with SUs had greater adherence to recommended care processes than non-SU hospitals. Patients treated in a SU hospital had fewer new strokes while in hospital (OR: 0.20; 95% CI 0.06, 0.61) and there was a borderline reduction in the odds of dying in hospital compared to patients in non-SU hospitals (OR 0.57 95%CI 0.33, 1.00). Among SU hospitals meeting all SU criteria (n = 59; 91%) the adjusted odds of having a poor outcome was further reduced compared with patients attending non-SU hospitals.

CONCLUSION

Hospitals annually admitting ≥100 patients with acute stroke should be prioritized for establishment of a SU that meet all recommended criteria to ensure better outcomes.

Towards best practice in acute stroke care in Ghana: a survey of hospital services

Background

Stroke and other non-communicable diseases are important emerging public health concerns in sub-Saharan Africa where stroke-related mortality and morbidity are higher compared to other parts of the world. Despite the availability of evidence-based acute stroke interventions globally, uptake in low-middle income countries (LMIC) such as Ghana is uncertain. This study aimed to identify and evaluate available acute stroke services in Ghana and the extent to which these services align with global best practice.

Methods

A multi-site, hospital-based survey was conducted in 11 major referral hospitals (regional and tertiary - teaching hospitals) in Ghana from November 2015 to April 2016. Respondents included neurologists, physician specialists and medical officers (general physicians). A pre-tested, structured questionnaire was used to gather data on available hospital-based acute stroke services in the study sites, using The World Stroke Organisation Global Stroke Services Guideline as a reference for global standards.

Results

Availability of evidence-based services for acute stroke care in the study hospitals were varied and limited. The results showed one tertiary-teaching hospital had a stroke unit. However, thrombolytic therapy (thrombolysis) using recombinant tissue plasminogen activator for acute ischemic stroke care was not available in any of the study hospitals. Aspirin therapy was administered in all the 11 study hospitals. Although eight study sites reported having a brain computed tomographic (CT) scan, only 7 (63.6%) were functional at the time of the study. Magnetic resonance imaging (MRI scan) services were also limited to only 4 (36.4%) hospitals (only functional in three). Acute stroke care by specialists, especially neurologists, was found in 36.4% (4) of the study hospitals whilst none of the study hospitals had an occupational or a speech pathologist to support in the provision of acute stroke care.

Conclusion

This study confirms previous reports of limited and variable provision of evidence based stroke services and the low priority for stroke care in resource poor settings. Health policy initiatives to enhance uptake of evidence-based acute stroke services is required to reduce stroke-related mortality and morbidity in countries such as Ghana.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-017-2061-2) contains supplementary material, which is available to authorized users.

Managing a Stroke Unit: An Example from Australia with an Emphasis on Nursing Roles

Stroke care units (SCUs), which are co-ordinated by dedicated multidisciplinary teams and geographically located in one area, are currently the most generaliseable form of effective treatment for stroke. Although the evidence for SCUs is compelling, to date there has been limited evidence regarding the contribution of the different clinical team members who assist in producing the better patient outcomes observed in SCUs. In particular, there has been limited exploration of the different nursing roles. The purpose of this special report is to describe how an SCU operates and highlight the contribution of the various nursing roles as part of the multidisciplinary stroke team. The article is based on one of the longest established stroke services in Melbourne, Australia. The characteristics and composition of the Royal Melbourne Hospital stroke service in providing clinical care and management will be highlighted as an example. Further, the nursing roles related to avoiding complications, education for patients and families and other staff in the unit, as well as participation in research and future career development opportunities are discussed.

Five Years of Acute Stroke Unit Care: Comparing ASU and Non-ASU Admissions and Allied Health Involvement

Background. Evidence indicates that Stroke Units decrease mortality and morbidity. An Acute Stroke Unit (ASU) provides specialised, hyperacute care and thrombolysis. John Hunter Hospital, Australia, admits 500 stroke patients each year and has a 4-bed ASU. Aims. This study investigated hospital admissions over a 5-year period of all strokes patients and of all patients admitted to the 4-bed ASU and the involvement of allied health professionals. Methods. The study retrospectively audited 5-year data from all stroke patients admitted to John Hunter Hospital (n = 2525) and from nonstroke patients admitted to the ASU (n = 826). The study's primary outcomes were admission rates, length of stay (days), and allied health involvement. Results. Over 5 years, 47% of stroke patients were admitted to the ASU. More male stroke patients were admitted to the ASU (chi² = 5.81; P = 0.016). There was a trend over time towards parity between the number of stroke and nonstroke patients admitted to the ASU. When compared to those admitted elsewhere, ASU stroke patients had a longer length of stay (z = −8.233; P = 0.0000) and were more likely to receive allied healthcare. Conclusion. This is the first study to report 5 years of ASU admissions. Acute Stroke Units may benefit from a review of the healthcare provided to all stroke patients. The trends over time with respect to the utilisation of the John Hunter Hospitall's ASU have resulted in a review of the hospitall's Stroke Unit and allied healthcare.

Management of Fever, Hyperglycemia, and Swallowing Dysfunction following Hospital Admission for Acute Stroke in New South Wales, Australia

Background

Fever, hyperglycemia, and swallow dysfunction poststroke are associated with significantly worse outcomes. We report treatment and monitoring practices for these three items from a cohort of acute stroke patients prior to randomization in the Quality in Acute Stroke Care trial.

Method

Retrospective medical record audits were undertaken for prospective patients from 19 stroke units. For the first three-days following stroke, we recorded all temperature readings and administration of paracetamol for fever (≥37.5°C) and all glucose readings and administration of insulin for hyperglycemia (>11 mmol/L). We also recorded swallow screening and assessment during the first 24 h of admission.

Results

Data for 718 (98%) patients were available; 138 (19%) had four hourly or more temperature readings and 204 patients (29%) had a fever, with 44 (22%) receiving paracetamol. A quarter of patients ( n = 102/412, 25%) had six hourly or more glucose readings and 23% (95/412) had hyperglycemia, with 31% (29/95) of these treated with insulin. The majority of patients received a swallow assessment ( n = 562, 78%) by a speech pathologist in the first instance rather than a swallow screen by a nonspeech pathologist ( n = 156, 22%). Of those who passed a screen ( n = 108 of 156, 69%), 68% ( n = 73) were reassessed by a speech pathologist and 97% ( n = 71) were reconfirmed to be able to swallow safely.

Conclusions

Our results showed that acute stroke patients were: undermonitored and undertreated for fever and hyperglycemia; and underscreened for swallowing dysfunction and unnecessarily reassessed by a speech pathologist, indicating the need for urgent behavior change.

Establishment of an effective acute stroke telemedicine program for Australia: protocol for the Victorian Stroke Telemedicine project

RATIONALE

Urgent treatment of acute stroke in rural Australia is problematic partly because of limited access to medical specialists. Utilization of telemedicine could improve delivery of acute stroke treatments in rural communities.

AIM

The study aims to demonstrate enhanced clinical decision making for use of thrombolysis within 4·5 h of ischemic stroke symptom onset in a rural setting using a telemedicine specialist support model.

DESIGN

A formative program evaluation research design was used. The Victorian Stroke Telemedicine program was developed and will be evaluated over five stages to ensure successful implementation. The phases include: (a) preimplementation phase to establish the Victorian Stroke Telemedicine program including the clinical pathway, data collection tools, and technology processes; (b) pilot clinical application phase to test the pathway in up to 10 patients; (c) modification phase to refine the program; (d) full clinical implementation phase where the program is maintained for one-year; and (e) a sustainability phase to assess project outcomes over five-years. Qualitative (clinician interviews) and quantitative data (patient, clinician, costs, and technology processes) are collected in each phase.

STUDY OUTCOMES

The primary outcome is to achieve a minimum 10% absolute increase in eligible patients treated with thrombolysis. Secondary outcomes are utilization of the telestroke pathway and improvements in processes of stroke care (e.g., time to brain scan). We will report door to telemedicine consultation time, length of telemedicine consultation, clinical utility and acceptability from the perspective of clinicians, and 90-day patient outcomes.

SUMMARY

This research will provide evidence for an effective telestroke program for use in regional Australian hospitals.

Implementation of evidence-based treatment protocols to manage fever, hyperglycaemia, and swallowing dysfunction in acute stroke (QASC): a cluster randomised controlled trial

BACKGROUND

We assessed patient outcomes 90 days after hospital admission for stroke following a multidisciplinary intervention targeting evidence-based management of fever, hyperglycaemia, and swallowing dysfunction in acute stroke units (ASUs).

METHODS

In the Quality in Acute Stroke Care (QASC) study, a single-blind cluster randomised controlled trial, we randomised ASUs (clusters) in New South Wales, Australia, with immediate access to CT and on-site high dependency units, to intervention or control group. Patients were eligible if they spoke English, were aged 18 years or older, had had an ischaemic stroke or intracerebral haemorrhage, and presented within 48 h of onset of symptoms. Intervention ASUs received treatment protocols to manage fever, hyperglycaemia, and swallowing dysfunction with multidisciplinary team building workshops to address implementation barriers. Control ASUs received only an abridged version of existing guidelines. We recruited pre-intervention and post-intervention patient cohorts to compare 90-day death or dependency (modified Rankin scale [mRS] ≥2), functional dependency (Barthel index), and SF-36 physical and mental component summary scores. Research assistants, the statistician, and patients were masked to trial groups. All analyses were done by intention to treat. This trial is registered at the Australia New Zealand Clinical Trial Registry (ANZCTR), number ACTRN12608000563369.

FINDINGS

19 ASUs were randomly assigned to intervention (n=10) or control (n=9). Of 6564 assessed for eligibility, 1696 patients' data were obtained (687 pre-intervention; 1009 post-intervention). Results showed that, irrespective of stroke severity, intervention ASU patients were significantly less likely to be dead or dependent (mRS ≥2) at 90 days than control ASU patients (236 [42%] of 558 patients in the intervention group vs 259 [58%] of 449 in the control group, p=0·002; number needed to treat 6·4; adjusted absolute difference 15·7% [95% CI 5·8-25·4]). They also had a better SF-36 mean physical component summary score (45·6 [SD 10·2] in the intervention group vs 42·5 [10·5] in the control group, p=0·002; adjusted absolute difference 3·4 [95% CI 1·2-5·5]) but no improvement was recorded in mortality (21 [4%] of 558 in intervention group and 24 [5%] of 451 in the control group, p=0·36), SF-36 mean mental component summary score (49·5 [10·9] in the intervention group vs 49·4 [10·6] in the control group, p=0·69) or functional dependency (Barthel Index ≥60: 487 [92%] of 532 patients vs 380 [90%] of 423 patients; p=0·44).

INTERPRETATION

Implementation of multidisciplinary supported evidence-based protocols initiated by nurses for the management of fever, hyperglycaemia, and swallowing dysfunction delivers better patient outcomes after discharge from stroke units. Our findings show the possibility to augment stroke unit care.

FUNDING

National Health & Medical Research Council ID 353803, St Vincent's Clinic Foundation, the Curran Foundation, Australian Diabetes Society-Servier, the College of Nursing, and Australian Catholic University.

Factors affecting dysphagia management and compliance with recommendations in non-metropolitan healthcare settings

It is acknowledged that a team approach to management of stroke is essential to improving patient outcomes. For the speech-language pathologist (SLP), communication and swallowing are key concerns in stroke rehabilitation. However, little is known about how services are provided following stroke in non-metropolitan areas. This paper presents findings from a study investigating issues related to the provision of dysphagia services in non-metropolitan New South Wales (NSW) and Victoria. The theme 'You've got to have an impact' was one of the major themes identified from analysis of data gathered via semi-structured interviews with eight SLPs. Participants in this study highlighted compliance with recommendations as a point of breakdown in the care of the patient with dysphagia. Underlying compliance were issues related to team functioning that could hold the key to improving outcomes. These findings have implications for non-metropolitan SLPs' ability to participate within a stroke team, for the way care for patients with dysphagia is conceptualized, and for improvement of compliance with SLP recommendations.

A study of 90-day outcomes for a cohort of patients admitted to an Australian metropolitan acute stroke unit

This study investigated patients' 90-day outcomes poststroke following an admission to one Australian metropolitan Acute Stroke Unit (ASU) and examined premorbid risk factors associated with these outcomes. Data from patients consecutively admitted from January 2006 to July 2007 (n = 54) to an acute stroke unit within 48 hours of onset of symptoms were linked with the Quality in Acute Stroke Care research project data and were analyzed to identify associations between premorbid risk factors (atrial fibrillation, hypertension, high cholesterol, smoking and diabetes); demographic, clinical and stroke characteristics; and death, disability (modified Rankin Score ≥ 2), dependency (Barthel Index score ≥ 95) and health status (SF-36) poststroke. Within 90 days, 4 participants had died and 45.5% were classified as dependent. Of the total participants, 56.8% were classified as disabled. The SF-36 mean scores indicated that the cohort had less than optimal physical health (46.7, SD = 9.8) and mental health (46.4, SD = 13.1). Analysis of baseline variables showed that participants with atrial fibrillation were more likely to have a severe stroke (p = 0.037). Patients presenting with intracerebral haemorrhage (p = 0.017) and those with subsequent strokes (p = 0.000) had significantly lower Barthel Index scores. A lower SF-36 physical component score at 90 days was significantly associated with intracerebral haemorrhages (p = 0.018) and subsequent strokes (p = 0.026). Although most patients were alive at 90 days poststroke, there were variable levels of morbidity-associated stroke type, subsequent strokes and premorbid risk factors, particularly atrial fibrillation. The findings provide insight into the 90-day outcomes of patients discharged from an ASU, which may be of use to plan appropriate postdischarge support for this group. In particular, aggressive management of stroke risk factors to prevent recurrent stroke is warranted.

Fever, hyperglycaemia and swallowing dysfunction management in acute stroke: a cluster randomised controlled trial of knowledge transfer

Background

Hyperglycaemia, fever, and swallowing dysfunction are poorly managed in the admission phase of acute stroke, and patient outcomes are compromised. Use of evidence-based guidelines could improve care but have not been effectively implemented. Our study aims to develop and trial an intervention based on multidisciplinary team-building to improve management of fever, hyperglycaemia, and swallowing dysfunction in patients following acute stroke.

Methods and design

Metropolitan acute stroke units (ASUs) located in New South Wales, Australia will be stratified by service category (A or B) and, within strata, by baseline patient recruitment numbers (high or low) in this prospective, multicentre, single-blind, cluster randomised controlled trial (CRCT). ASUs then will be randomised independently to either intervention or control groups. ASUs allocated to the intervention group will receive: unit-based workshops to identify local barriers and enablers; a standardised core education program; evidence-based clinical treatment protocols; and ongoing engagement of local staff. Control group ASUs will receive only an abridged version of the National Clinical Guidelines for Acute Stroke Management. The following outcome measures will be collected at 90 days post-hospital admission: patient death, disability (modified Rankin Score); dependency (Barthel Index) and Health Status (SF-36). Additional measures include: performance of swallowing screening within 24 hours of admission; glycaemic control and temperature control.

Discussion

This is a unique study of research transfer in acute stroke. Providing optimal inpatient care during the admission phase is essential if we are to combat the rising incidence of debilitating stroke. Our CRCT will also allow us to test interventions focussed on multidisciplinary ASU teams rather than individual disciplines, an imperative of modern hospital services.

Trial Registration

Australia New Zealand Clinical Trial Registry (ANZCTR) No: ACTRN12608000563369

Stroke Units: Many Questions, Some Answers

Background The development of specialized stroke units has been a landmark innovation in acute stroke care. However, the high scientific evidence level for the recommendation for stroke units to provide clinical attention for acute stroke patients does not correspond to the level of stroke unit implementation. A narrative, nonsystematic review on published studies on stroke units was conducted, with special emphasis on those demonstrating their efficacy and effectiveness. We also attempt to provide some answers to several open questions regarding practical issues of stroke units.

Improving access to acute stroke therapies: a controlled trial of organised pre-hospital and emergency care

OBJECTIVE

To assess the effectiveness of the PAST (Pre-hospital Acute Stroke Triage) protocol in reducing pre-hospital and emergency department (ED) delays to patients receiving organised acute stroke care, thereby increasing access to thrombolytic therapy.

DESIGN

Prospective cohort study using historical controls.

SETTING

Hunter Region of New South Wales, September 2005 to March 2006 (pre-intervention) and September 2006 to March 2007 (post-intervention).

PARTICIPANTS

Consecutive patients presenting with acute stroke to a regional, tertiary referral hospital.

INTERVENTION

PAST protocol, comprising a pre-hospital stroke assessment tool for ambulance officers, an ambulance protocol for hospital bypass for potentially thrombolysis-eligible patients, and pre-hospital notification of the acute stroke team.

MAIN OUTCOME MEASURES

Proportion of patients who received intravenous tissue plasminogen activator (tPA), process of care time points (symptom onset to ED arrival, ED arrival to tPA treatment, and ED transit time), and clinical outcomes of patients treated with tPA.

RESULTS

The proportion of ischaemic stroke patients treated with tPA increased from 4.7% (pre-intervention) to 21.4% (post-intervention) (P < 0.001). Time point outcomes also improved, with a reduction in median times from symptom onset to ED arrival from 150 to 90.5 min (P = 0.004) and from ED arrival to stroke unit admission from 361 to 232.5 minutes (P < 0.001). Of those treated with tPA, 43% had minimal or no disability at 3 months.

CONCLUSIONS

Organised pre-hospital and ED acute stroke care increases patient access to tPA treatment, which is proven to reduce stroke-related disability.

Rural Organisation of Acute Stroke Teams project

BACKGROUND

Improving the care of stroke patients is a national priority for the health system in Australia. In rural areas the challenges may be greater. Although best-practice guidelines for acute and subacute stroke care are well established, their general uptake appears to be limited and implementation strategies are required to promote the use of this evidence-based care. The Rural Organisation of Australian Stroke Teams (ROAST) project sought to promote the evidence-based stroke practice in rural hospitals.

METHODS

This was a prospective observational project designed to improve the services provided to rural stroke patients, primarily through better organisation of care on general medical wards and emergency departments. Using recognized support strategies, we encouraged the use of nationally recognized key performance indicators and provided audit and feedback of adherence to these indicators to participating hospitals.

RESULTS

Six Victorian hospitals participated in this initial phase of the ROAST project. Information was collected on 348 patients. Ten of the 11 indicators showed greater than 10% improvement in adherence levels and by the end of the project period compared favourably to levels of adherence described in metropolitan hospitals.

CONCLUSION

The ROAST projected supported a network of clinicians to implement evidence-based guidelines in acute stroke care in the setting of general medical wards. In doing so, this project has shown that it is quite feasible to deliver best-practice care to stroke patients in rural Australia.

Economic Evaluation of Australian Stroke Services

Background and Purpose— Level I evidence from randomized controlled trials demonstrates that the model of hospital care influences stroke outcomes; however, the economic evaluation of such is limited. An economic appraisal of 3 acute stroke care models was facilitated through the Stroke Care Outcomes: Providing Effective Services (SCOPES) study in Melbourne, Australia. The aim was to describe resource use up to 28 weeks poststroke for each model and examine the cost-effectiveness of stroke care units (SCUs).

Methods— A prospective, multicenter, cohort study design was used. Costs and outcomes of stroke patients receiving 100% treatment in 1 of 3 inpatient care models (SCUs, mobile service, conventional care) were compared. Health-sector resource use up to 28 weeks was measured in 1999. Outcomes were thorough adherence to a suite of important clinical processes and the number of severe inpatient complications.

Results— The sample comprised 395 participants (mean age 73 [SD 14], 77% first-ever strokes, males 53%). When compared with conventional care (n=84), costs for mobile service (n=209) were significantly higher ( P =0.024), but borderline for SCU (n=102, P =0.08; $AUD12 251; $AUD15 903; $AUD15 383 respectively). This was primarily explained by the greater use of specialist medical services. The incremental cost-effectiveness of SCUs over conventional care was $AUD9867 per patient achieving thorough adherence to clinical processes and $AUD16 372 per patient with severe complications avoided, based on costs to 28 weeks.

Conclusions— Although acute SCU costs are generally higher, they are more cost-effective than either mobile service or conventional care.