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Wang W, Otieno JA, Eriksson M, Wolfe CD, Curcin V, Bray BD. Developing and externally validating a machine learning risk prediction model for 30-day mortality after stroke using national stroke registers in the UK and Sweden. BMJ Open 2023; 13:e069811. [PMID: 37968001 PMCID: PMC10660948 DOI: 10.1136/bmjopen-2022-069811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 07/27/2023] [Indexed: 11/17/2023] Open
Abstract
OBJECTIVES We aimed to develop and externally validate a generalisable risk prediction model for 30-day stroke mortality suitable for supporting quality improvement analytics in stroke care using large nationwide stroke registers in the UK and Sweden. DESIGN Registry-based cohort study. SETTING Stroke registries including the Sentinel Stroke National Audit Programme (SSNAP) in England, Wales and Northern Ireland (2013-2019) and the national Swedish stroke register (Riksstroke 2015-2020). PARTICIPANTS AND METHODS Data from SSNAP were used for developing and temporally validating the model, and data from Riksstroke were used for external validation. Models were developed with the variables available in both registries using logistic regression (LR), LR with elastic net and interaction terms and eXtreme Gradient Boosting (XGBoost). Performances were evaluated with discrimination, calibration and decision curves. OUTCOME MEASURES The primary outcome was all-cause 30-day in-hospital mortality after stroke. RESULTS In total, 488 497 patients who had a stroke with 12.4% 30-day in-hospital mortality were used for developing and temporally validating the model in the UK. A total of 128 360 patients who had a stroke with 10.8% 30-day in-hospital mortality and 13.1% all mortality were used for external validation in Sweden. In the SSNAP temporal validation set, the final XGBoost model achieved the highest area under the receiver operating characteristic curve (AUC) (0.852 (95% CI 0.848 to 0.855)) and was well calibrated. The performances on the external validation in Riksstroke were as good and achieved AUC at 0.861 (95% CI 0.858 to 0.865) for in-hospital mortality. For Riksstroke, the models slightly overestimated the risk for in-hospital mortality, while they were better calibrated at the risk for all mortality. CONCLUSION The risk prediction model was accurate and externally validated using high quality registry data. This is potentially suitable to be deployed as part of quality improvement analytics in stroke care to enable the fair comparison of stroke mortality outcomes across hospitals and health systems across countries.
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Affiliation(s)
- Wenjuan Wang
- Department of Population Health Sciences, King's College London, London, UK
| | | | | | - Charles D Wolfe
- Department of Population Health Sciences, King's College London, London, UK
| | - Vasa Curcin
- Department of Population Health Sciences, King's College London, London, UK
| | - Benjamin D Bray
- Department of Population Health Sciences, King's College London, London, UK
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Wang W, Snell LB, Ferrari D, Goodman AL, Price NM, Wolfe CD, Curcin V, Edgeworth JD, Wang Y. Real-world effectiveness of steroids in severe COVID-19: a retrospective cohort study. BMC Infect Dis 2022; 22:776. [PMID: 36199017 PMCID: PMC9533997 DOI: 10.1186/s12879-022-07750-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 09/06/2022] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION Randomised controlled trials have shown that steroids reduce the risk of dying in patients with severe Coronavirus disease 2019 (COVID-19), whilst many real-world studies have failed to replicate this result. We aim to investigate real-world effectiveness of steroids in severe COVID-19. METHODS Clinical, demographic, and viral genome data extracted from electronic patient record (EPR) was analysed from all SARS-CoV-2 RNA positive patients admitted with severe COVID-19, defined by hypoxia at presentation, between March 13th 2020 and May 27th 2021. Steroid treatment was measured by the number of prescription-days with dexamethasone, hydrocortisone, prednisolone or methylprednisolone. The association between steroid > 3 days treatment and disease outcome was explored using multivariable cox proportional hazards models with adjustment for confounders (including age, gender, ethnicity, co-morbidities and SARS-CoV-2 variant). The outcome was in-hospital mortality. RESULTS 1100 severe COVID-19 cases were identified having crude hospital mortality of 15.3%. 793/1100 (72.1%) individuals were treated with steroids and 513/1100 (46.6%) received steroid ≤ 3 days. From the multivariate model, steroid > 3 days was associated with decreased hazard of in-hospital mortality (HR: 0.47 (95% CI: 0.31-0.72)). CONCLUSION The protective effect of steroid treatment for severe COVID-19 reported in randomised clinical trials was replicated in this retrospective study of a large real-world cohort.
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Affiliation(s)
- Wenjuan Wang
- School of Population Health and Environmental Sciences, King's College London, London, UK.
| | - Luke B Snell
- Centre for Clinical Infection and Diagnostics Research, School of Immunology and Microbial Sciences, King's College London, London, UK
- Department of Infectious Diseases, Guy's and St Thomas' NHS Foundation Trust, London, UK
- NIHR Biomedical Research Centre, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Davide Ferrari
- School of Population Health and Environmental Sciences, King's College London, London, UK
| | - Anna L Goodman
- Department of Infectious Diseases, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Nicholas M Price
- Department of Infectious Diseases, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Charles D Wolfe
- School of Population Health and Environmental Sciences, King's College London, London, UK
- NIHR Biomedical Research Centre, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Vasa Curcin
- School of Population Health and Environmental Sciences, King's College London, London, UK
- NIHR Biomedical Research Centre, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Jonathan D Edgeworth
- Centre for Clinical Infection and Diagnostics Research, School of Immunology and Microbial Sciences, King's College London, London, UK
- Department of Infectious Diseases, Guy's and St Thomas' NHS Foundation Trust, London, UK
- NIHR Biomedical Research Centre, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Yanzhong Wang
- School of Population Health and Environmental Sciences, King's College London, London, UK
- NIHR Biomedical Research Centre, Guy's and St Thomas' NHS Foundation Trust, London, UK
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Wang W, Rudd AG, Wang Y, Curcin V, Wolfe CD, Peek N, Bray B. Correction: Risk prediction of 30-day mortality after stroke using machine learning: a nationwide registry-based cohort study. BMC Neurol 2022; 22:319. [PMID: 36008776 PMCID: PMC9404635 DOI: 10.1186/s12883-022-02840-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Affiliation(s)
- Wenjuan Wang
- School of Population Health & Environmental Sciences, Faculty of Life Science and Medicine, King's College London, London, UK.
| | - Anthony G Rudd
- School of Population Health & Environmental Sciences, Faculty of Life Science and Medicine, King's College London, London, UK
| | - Yanzhong Wang
- School of Population Health & Environmental Sciences, Faculty of Life Science and Medicine, King's College London, London, UK.,NIHR Biomedical Research Centre, Guy's and St Thomas' NHS Foundation Trust and King's College London, London, UK.,NIHR Applied Research Collaboration (ARC) South London, London, UK
| | - Vasa Curcin
- School of Population Health & Environmental Sciences, Faculty of Life Science and Medicine, King's College London, London, UK.,NIHR Biomedical Research Centre, Guy's and St Thomas' NHS Foundation Trust and King's College London, London, UK.,NIHR Applied Research Collaboration (ARC) South London, London, UK
| | - Charles D Wolfe
- School of Population Health & Environmental Sciences, Faculty of Life Science and Medicine, King's College London, London, UK.,NIHR Biomedical Research Centre, Guy's and St Thomas' NHS Foundation Trust and King's College London, London, UK.,NIHR Applied Research Collaboration (ARC) South London, London, UK
| | - Niels Peek
- Division of Informatics, Imaging and Data Science, School of Health Sciences, University of Manchester, Manchester, UK.,NIHR Manchester Biomedical Research Centre, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Benjamin Bray
- School of Population Health & Environmental Sciences, Faculty of Life Science and Medicine, King's College London, London, UK
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Wang W, Rudd AG, Wang Y, Curcin V, Wolfe CD, Peek N, Bray B. Risk prediction of 30-day mortality after stroke using machine learning: a nationwide registry-based cohort study. BMC Neurol 2022; 22:195. [PMID: 35624434 PMCID: PMC9137068 DOI: 10.1186/s12883-022-02722-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 05/17/2022] [Indexed: 12/16/2022] Open
Abstract
Backgrounds We aimed to develop and validate machine learning (ML) models for 30-day stroke mortality for mortality risk stratification and as benchmarking models for quality improvement in stroke care. Methods Data from the UK Sentinel Stroke National Audit Program between 2013 to 2019 were used. Models were developed using XGBoost, Logistic Regression (LR), LR with elastic net with/without interaction terms using 80% randomly selected admissions from 2013 to 2018, validated on the 20% remaining admissions, and temporally validated on 2019 admissions. The models were developed with 30 variables. A reference model was developed using LR and 4 variables. Performances of all models was evaluated in terms of discrimination, calibration, reclassification, Brier scores and Decision-curves. Results In total, 488,497 stroke patients with a 12.3% 30-day mortality rate were included in the analysis. In 2019 temporal validation set, XGBoost model obtained the lowest Brier score (0.069 (95% CI: 0.068–0.071)) and the highest area under the ROC curve (AUC) (0.895 (95% CI: 0.891–0.900)) which outperformed LR reference model by 0.04 AUC (p < 0.001) and LR with elastic net and interaction term model by 0.003 AUC (p < 0.001). All models were perfectly calibrated for low (< 5%) and moderate risk groups (5–15%) and ≈1% underestimation for high-risk groups (> 15%). The XGBoost model reclassified 1648 (8.1%) low-risk cases by the LR reference model as being moderate or high-risk and gained the most net benefit in decision curve analysis. Conclusions All models with 30 variables are potentially useful as benchmarking models in stroke-care quality improvement with ML slightly outperforming others. Supplementary Information The online version contains supplementary material available at 10.1186/s12883-022-02722-1.
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Affiliation(s)
- Wenjuan Wang
- School of Population Health & Environmental Sciences, Faculty of Life Science and Medicine, King's College London, London, UK.
| | - Anthony G Rudd
- School of Population Health & Environmental Sciences, Faculty of Life Science and Medicine, King's College London, London, UK
| | - Yanzhong Wang
- School of Population Health & Environmental Sciences, Faculty of Life Science and Medicine, King's College London, London, UK.,NIHR Biomedical Research Centre, Guy's and St Thomas' NHS Foundation Trust and King's College London, London, UK.,NIHR Applied Research Collaboration (ARC) South London, London, UK
| | - Vasa Curcin
- School of Population Health & Environmental Sciences, Faculty of Life Science and Medicine, King's College London, London, UK.,NIHR Biomedical Research Centre, Guy's and St Thomas' NHS Foundation Trust and King's College London, London, UK.,NIHR Applied Research Collaboration (ARC) South London, London, UK
| | - Charles D Wolfe
- School of Population Health & Environmental Sciences, Faculty of Life Science and Medicine, King's College London, London, UK.,NIHR Biomedical Research Centre, Guy's and St Thomas' NHS Foundation Trust and King's College London, London, UK.,NIHR Applied Research Collaboration (ARC) South London, London, UK
| | - Niels Peek
- Division of Informatics, Imaging and Data Science, School of Health Sciences, University of Manchester, Manchester, UK.,NIHR Manchester Biomedical Research Centre, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Benjamin Bray
- School of Population Health & Environmental Sciences, Faculty of Life Science and Medicine, King's College London, London, UK
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Wang W, Kiik M, Peek N, Curcin V, Marshall IJ, Rudd AG, Wang Y, Douiri A, Wolfe CD, Bray B. A systematic review of machine learning models for predicting outcomes of stroke with structured data. PLoS One 2020; 15:e0234722. [PMID: 32530947 PMCID: PMC7292406 DOI: 10.1371/journal.pone.0234722] [Citation(s) in RCA: 65] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Accepted: 06/01/2020] [Indexed: 12/11/2022] Open
Abstract
Background and purpose Machine learning (ML) has attracted much attention with the hope that it could make use of large, routinely collected datasets and deliver accurate personalised prognosis. The aim of this systematic review is to identify and critically appraise the reporting and developing of ML models for predicting outcomes after stroke. Methods We searched PubMed and Web of Science from 1990 to March 2019, using previously published search filters for stroke, ML, and prediction models. We focused on structured clinical data, excluding image and text analysis. This review was registered with PROSPERO (CRD42019127154). Results Eighteen studies were eligible for inclusion. Most studies reported less than half of the terms in the reporting quality checklist. The most frequently predicted stroke outcomes were mortality (7 studies) and functional outcome (5 studies). The most commonly used ML methods were random forests (9 studies), support vector machines (8 studies), decision trees (6 studies), and neural networks (6 studies). The median sample size was 475 (range 70–3184), with a median of 22 predictors (range 4–152) considered. All studies evaluated discrimination with thirteen using area under the ROC curve whilst calibration was assessed in three. Two studies performed external validation. None described the final model sufficiently well to reproduce it. Conclusions The use of ML for predicting stroke outcomes is increasing. However, few met basic reporting standards for clinical prediction tools and none made their models available in a way which could be used or evaluated. Major improvements in ML study conduct and reporting are needed before it can meaningfully be considered for practice.
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Affiliation(s)
- Wenjuan Wang
- School of Population Health & Environmental Sciences, Faculty of Life Science and Medicine, King’s College London, London, United Kingdom
- * E-mail:
| | - Martin Kiik
- School of Medical Education, Faculty of Life Science and Medicine, King’s College London, London, United Kingdom
| | - Niels Peek
- Division of Informatics, Imaging and Data Science, School of Health Sciences, University of Manchester, Manchester, United Kingdom
- NIHR Manchester Biomedical Research Centre, Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom
| | - Vasa Curcin
- School of Population Health & Environmental Sciences, Faculty of Life Science and Medicine, King’s College London, London, United Kingdom
- NIHR Biomedical Research Centre, Guy's and St Thomas' NHS Foundation Trust and King's College London, London, United Kingdom
- NIHR Applied Research Collaboration (ARC) South London, London, United Kingdom
| | - Iain J. Marshall
- School of Population Health & Environmental Sciences, Faculty of Life Science and Medicine, King’s College London, London, United Kingdom
| | - Anthony G. Rudd
- School of Population Health & Environmental Sciences, Faculty of Life Science and Medicine, King’s College London, London, United Kingdom
| | - Yanzhong Wang
- School of Population Health & Environmental Sciences, Faculty of Life Science and Medicine, King’s College London, London, United Kingdom
- NIHR Biomedical Research Centre, Guy's and St Thomas' NHS Foundation Trust and King's College London, London, United Kingdom
- NIHR Applied Research Collaboration (ARC) South London, London, United Kingdom
| | - Abdel Douiri
- School of Population Health & Environmental Sciences, Faculty of Life Science and Medicine, King’s College London, London, United Kingdom
- NIHR Biomedical Research Centre, Guy's and St Thomas' NHS Foundation Trust and King's College London, London, United Kingdom
- NIHR Applied Research Collaboration (ARC) South London, London, United Kingdom
| | - Charles D. Wolfe
- School of Population Health & Environmental Sciences, Faculty of Life Science and Medicine, King’s College London, London, United Kingdom
- NIHR Biomedical Research Centre, Guy's and St Thomas' NHS Foundation Trust and King's College London, London, United Kingdom
- NIHR Applied Research Collaboration (ARC) South London, London, United Kingdom
| | - Benjamin Bray
- School of Population Health & Environmental Sciences, Faculty of Life Science and Medicine, King’s College London, London, United Kingdom
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Sen A, Bisquera A, Wang Y, McKevitt CJ, Rudd AG, Wolfe CD, Bhalla A. Factors, trends, and long-term outcomes for stroke patients returning to work: The South London Stroke Register. Int J Stroke 2019; 14:696-705. [DOI: 10.1177/1747493019832997] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and purpose There is limited information on factors, trends, and outcomes in return to work at different time-points post-stroke; this study aims to identify these in a multi-ethnic urban population. Methods Patterns of return to work were identified in individuals in paid work prior to first-ever stroke in the population-based South London Stroke Register (SLSR) between 1995 and 2014. Multivariable logistic regression examined associations between patient characteristics and return to work at 1 year (1 y), 5 years (5 y) and 10 years (10 y) post-stroke. Results Among 5609 patients, 940 (17%) were working prior to their stroke, of whom 177 (19%) were working 3 months post-stroke, declining to 172 (18%) at 1 y, 113 (12%) at 5 y, and 27 (3%) at 10 y. Factors associated with return to work within 1 y, after logistic regression, included functional independence (BI ≥ 19; p < 0.01) and shorter length of stay ( p < 0.05). Younger age ( p < 0.01) was associated with return to work at 5 y and 10 y post-stroke. Non-manual occupation ( p < 0.05) was associated with return to work at 10 y post-stroke. Return to work within 1 y increased the likelihood of working at 5 y (OR: 13.68; 95% CI 5.03–37.24) and 10 y (9.07; 2.07–39.8). Of those who were independent at follow-up (BI ≥ 19), 48% were working at 1 y, 42% at 5 y, and 28% at 10 y. Lower rates of anxiety and depression and higher self-rated health were associated with return to work at 1 y ( p < 0.01). Conclusion Although functionally independent stroke survivors are more likely to return to work long-term, a large proportion do not return to work despite functional independence. Return to work post-stroke is associated with improved long-term psychological outcomes and quality of life.
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Affiliation(s)
- Arup Sen
- Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - Alessandra Bisquera
- School of Population Health & Environmental Sciences, King’s College London, London, UK
| | - Yanzhong Wang
- School of Population Health & Environmental Sciences, King’s College London, London, UK
- National Institute for Health Research Comprehensive Biomedical Research Centre, Guy’s & St. Thomas’ NHS Foundation Trust and King’s College London, London, UK
| | - Christopher J McKevitt
- School of Population Health & Environmental Sciences, King’s College London, London, UK
- National Institute for Health Research Comprehensive Biomedical Research Centre, Guy’s & St. Thomas’ NHS Foundation Trust and King’s College London, London, UK
| | - Anthony G Rudd
- Guy’s and St Thomas’ NHS Foundation Trust, London, UK
- School of Population Health & Environmental Sciences, King’s College London, London, UK
- National Institute for Health Research Comprehensive Biomedical Research Centre, Guy’s & St. Thomas’ NHS Foundation Trust and King’s College London, London, UK
| | - Charles D Wolfe
- School of Population Health & Environmental Sciences, King’s College London, London, UK
- National Institute for Health Research Comprehensive Biomedical Research Centre, Guy’s & St. Thomas’ NHS Foundation Trust and King’s College London, London, UK
| | - Ajay Bhalla
- Guy’s and St Thomas’ NHS Foundation Trust, London, UK
- School of Population Health & Environmental Sciences, King’s College London, London, UK
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Butland BK, Atkinson RW, Crichton S, Barratt B, Beevers S, Spiridou A, Hoang U, Kelly FJ, Wolfe CD. Air pollution and the incidence of ischaemic and haemorrhagic stroke in the South London Stroke Register: a case-cross-over analysis. J Epidemiol Community Health 2017; 71:707-712. [PMID: 28408613 PMCID: PMC5485750 DOI: 10.1136/jech-2016-208025] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Revised: 02/28/2017] [Accepted: 03/06/2017] [Indexed: 12/17/2022]
Abstract
Background Few European studies investigating associations between short-term exposure to air pollution and incident stroke have considered stroke subtypes. Using information from the South London Stroke Register for 2005–2012, we investigated associations between daily concentrations of gaseous and particulate air pollutants and incident stroke subtypes in an ethnically diverse area of London, UK. Methods Modelled daily pollutant concentrations based on a combination of measurements and dispersion modelling were linked at postcode level to incident stroke events stratified by haemorrhagic and ischaemic subtypes. The data were analysed using a time-stratified case–cross-over approach. Conditional logistic regression models included natural cubic splines for daily mean temperature and daily mean relative humidity, a binary term for public holidays and a sine–cosine annual cycle. Of primary interest were same day mean concentrations of particulate matter <2.5 and <10 µm in diameter (PM2.5, PM10), ozone (O3), nitrogen dioxide (NO2) and NO2+nitrogen oxide (NOX). Results Our analysis was based on 1758 incident strokes (1311 were ischaemic and 256 were haemorrhagic). We found no evidence of an association between all stroke or ischaemic stroke and same day exposure to PM2.5, PM10, O3, NO2 or NOX. For haemorrhagic stroke, we found a negative association with PM10 suggestive of a 14.6% (95% CI 0.7% to 26.5%) fall in risk per 10 µg/m3 increase in pollutant. Conclusions Using data from the South London Stroke Register, we found no evidence of a positive association between outdoor air pollution and incident stroke or its subtypes. These results, though in contrast to recent meta-analyses, are not inconsistent with the mixed findings of other UK studies.
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Affiliation(s)
- B K Butland
- Population Health Research Institute and MRC-PHE Centre for Environment and Health, St George's, University of London, London, UK
| | - R W Atkinson
- Population Health Research Institute and MRC-PHE Centre for Environment and Health, St George's, University of London, London, UK
| | - S Crichton
- Division of Health and Social Care Research, Department of Primary Care and Public Health Sciences, King's College London, London, UK
| | - B Barratt
- Department of Analytical and Environmental Sciences and MRC-PHE Centre for Environment and Health, King's College London, Waterloo, UK
- National Institute for Health Research Comprehensive Biomedical Research Centre at Guy's and St Thomas’ NHS Foundation Trust and King's College London, London, UK
| | - S Beevers
- Department of Analytical and Environmental Sciences and MRC-PHE Centre for Environment and Health, King's College London, Waterloo, UK
| | - A Spiridou
- Division of Health and Social Care Research, Department of Primary Care and Public Health Sciences, King's College London, London, UK
- National Institute for Health Research Comprehensive Biomedical Research Centre at Guy's and St Thomas’ NHS Foundation Trust and King's College London, London, UK
| | - U Hoang
- Division of Health and Social Care Research, Department of Primary Care and Public Health Sciences, King's College London, London, UK
- National Institute for Health Research Comprehensive Biomedical Research Centre at Guy's and St Thomas’ NHS Foundation Trust and King's College London, London, UK
| | - F J Kelly
- Department of Analytical and Environmental Sciences and MRC-PHE Centre for Environment and Health, King's College London, Waterloo, UK
- National Institute for Health Research Comprehensive Biomedical Research Centre at Guy's and St Thomas’ NHS Foundation Trust and King's College London, London, UK
| | - C D Wolfe
- Division of Health and Social Care Research, Department of Primary Care and Public Health Sciences, King's College London, London, UK
- National Institute for Health Research Comprehensive Biomedical Research Centre at Guy's and St Thomas’ NHS Foundation Trust and King's College London, London, UK
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Murray CJL, Barber RM, Foreman KJ, Abbasoglu Ozgoren A, Abd-Allah F, Abera SF, Aboyans V, Abraham JP, Abubakar I, Abu-Raddad LJ, Abu-Rmeileh NM, Achoki T, Ackerman IN, Ademi Z, Adou AK, Adsuar JC, Afshin A, Agardh EE, Alam SS, Alasfoor D, Albittar MI, Alegretti MA, Alemu ZA, Alfonso-Cristancho R, Alhabib S, Ali R, Alla F, Allebeck P, Almazroa MA, Alsharif U, Alvarez E, Alvis-Guzman N, Amare AT, Ameh EA, Amini H, Ammar W, Anderson HR, Anderson BO, Antonio CAT, Anwari P, Arnlöv J, Arsic Arsenijevic VS, Artaman A, Asghar RJ, Assadi R, Atkins LS, Avila MA, Awuah B, Bachman VF, Badawi A, Bahit MC, Balakrishnan K, Banerjee A, Barker-Collo SL, Barquera S, Barregard L, Barrero LH, Basu A, Basu S, Basulaiman MO, Beardsley J, Bedi N, Beghi E, Bekele T, Bell ML, Benjet C, Bennett DA, Bensenor IM, Benzian H, Bernabé E, Bertozzi-Villa A, Beyene TJ, Bhala N, Bhalla A, Bhutta ZA, Bienhoff K, Bikbov B, Biryukov S, Blore JD, Blosser CD, Blyth FM, Bohensky MA, Bolliger IW, Bora Başara B, Bornstein NM, Bose D, Boufous S, Bourne RRA, Boyers LN, Brainin M, Brayne CE, Brazinova A, Breitborde NJK, Brenner H, Briggs AD, Brooks PM, Brown JC, Brugha TS, Buchbinder R, Buckle GC, Budke CM, Bulchis A, Bulloch AG, Campos-Nonato IR, Carabin H, Carapetis JR, Cárdenas R, Carpenter DO, Caso V, Castañeda-Orjuela CA, Castro RE, Catalá-López F, Cavalleri F, Çavlin A, Chadha VK, Chang JC, Charlson FJ, Chen H, Chen W, Chiang PP, Chimed-Ochir O, Chowdhury R, Christensen H, Christophi CA, Cirillo M, Coates MM, Coffeng LE, Coggeshall MS, Colistro V, Colquhoun SM, Cooke GS, Cooper C, Cooper LT, Coppola LM, Cortinovis M, Criqui MH, Crump JA, Cuevas-Nasu L, Danawi H, Dandona L, Dandona R, Dansereau E, Dargan PI, Davey G, Davis A, Davitoiu DV, Dayama A, De Leo D, Degenhardt L, Del Pozo-Cruz B, Dellavalle RP, Deribe K, Derrett S, Des Jarlais DC, Dessalegn M, Dharmaratne SD, Dherani MK, Diaz-Torné C, Dicker D, Ding EL, Dokova K, Dorsey ER, Driscoll TR, Duan L, Duber HC, Ebel BE, Edmond KM, Elshrek YM, Endres M, Ermakov SP, Erskine HE, Eshrati B, Esteghamati A, Estep K, Faraon EJA, Farzadfar F, Fay DF, Feigin VL, Felson DT, Fereshtehnejad SM, Fernandes JG, Ferrari AJ, Fitzmaurice C, Flaxman AD, Fleming TD, Foigt N, Forouzanfar MH, Fowkes FGR, Paleo UF, Franklin RC, Fürst T, Gabbe B, Gaffikin L, Gankpé FG, Geleijnse JM, Gessner BD, Gething P, Gibney KB, Giroud M, Giussani G, Gomez Dantes H, Gona P, González-Medina D, Gosselin RA, Gotay CC, Goto A, Gouda HN, Graetz N, Gugnani HC, Gupta R, Gupta R, Gutiérrez RA, Haagsma J, Hafezi-Nejad N, Hagan H, Halasa YA, Hamadeh RR, Hamavid H, Hammami M, Hancock J, Hankey GJ, Hansen GM, Hao Y, Harb HL, Haro JM, Havmoeller R, Hay SI, Hay RJ, Heredia-Pi IB, Heuton KR, Heydarpour P, Higashi H, Hijar M, Hoek HW, Hoffman HJ, Hosgood HD, Hossain M, Hotez PJ, Hoy DG, Hsairi M, Hu G, Huang C, Huang JJ, Husseini A, Huynh C, Iannarone ML, Iburg KM, Innos K, Inoue M, Islami F, Jacobsen KH, Jarvis DL, Jassal SK, Jee SH, Jeemon P, Jensen PN, Jha V, Jiang G, Jiang Y, Jonas JB, Juel K, Kan H, Karch A, Karema CK, Karimkhani C, Karthikeyan G, Kassebaum NJ, Kaul A, Kawakami N, Kazanjan K, Kemp AH, Kengne AP, Keren A, Khader YS, Khalifa SEA, Khan EA, Khan G, Khang YH, Kieling C, Kim D, Kim S, Kim Y, Kinfu Y, Kinge JM, Kivipelto M, Knibbs LD, Knudsen AK, Kokubo Y, Kosen S, Krishnaswami S, Kuate Defo B, Kucuk Bicer B, Kuipers EJ, Kulkarni C, Kulkarni VS, Kumar GA, Kyu HH, Lai T, Lalloo R, Lallukka T, Lam H, Lan Q, Lansingh VC, Larsson A, Lawrynowicz AEB, Leasher JL, Leigh J, Leung R, Levitz CE, Li B, Li Y, Li Y, Lim SS, Lind M, Lipshultz SE, Liu S, Liu Y, Lloyd BK, Lofgren KT, Logroscino G, Looker KJ, Lortet-Tieulent J, Lotufo PA, Lozano R, Lucas RM, Lunevicius R, Lyons RA, Ma S, Macintyre MF, Mackay MT, Majdan M, Malekzadeh R, Marcenes W, Margolis DJ, Margono C, Marzan MB, Masci JR, Mashal MT, Matzopoulos R, Mayosi BM, Mazorodze TT, Mcgill NW, Mcgrath JJ, Mckee M, Mclain A, Meaney PA, Medina C, Mehndiratta MM, Mekonnen W, Melaku YA, Meltzer M, Memish ZA, Mensah GA, Meretoja A, Mhimbira FA, Micha R, Miller TR, Mills EJ, Mitchell PB, Mock CN, Mohamed Ibrahim N, Mohammad KA, Mokdad AH, Mola GLD, Monasta L, Montañez Hernandez JC, Montico M, Montine TJ, Mooney MD, Moore AR, Moradi-Lakeh M, Moran AE, Mori R, Moschandreas J, Moturi WN, Moyer ML, Mozaffarian D, Msemburi WT, Mueller UO, Mukaigawara M, Mullany EC, Murdoch ME, Murray J, Murthy KS, Naghavi M, Naheed A, Naidoo KS, Naldi L, Nand D, Nangia V, Narayan KMV, Nejjari C, Neupane SP, Newton CR, Ng M, Ngalesoni FN, Nguyen G, Nisar MI, Nolte S, Norheim OF, Norman RE, Norrving B, Nyakarahuka L, Oh IH, Ohkubo T, Ohno SL, Olusanya BO, Opio JN, Ortblad K, Ortiz A, Pain AW, Pandian JD, Panelo CIA, Papachristou C, Park EK, Park JH, Patten SB, Patton GC, Paul VK, Pavlin BI, Pearce N, Pereira DM, Perez-Padilla R, Perez-Ruiz F, Perico N, Pervaiz A, Pesudovs K, Peterson CB, Petzold M, Phillips MR, Phillips BK, Phillips DE, Piel FB, Plass D, Poenaru D, Polinder S, Pope D, Popova S, Poulton RG, Pourmalek F, Prabhakaran D, Prasad NM, Pullan RL, Qato DM, Quistberg DA, Rafay A, Rahimi K, Rahman SU, Raju M, Rana SM, Razavi H, Reddy KS, Refaat A, Remuzzi G, Resnikoff S, Ribeiro AL, Richardson L, Richardus JH, Roberts DA, Rojas-Rueda D, Ronfani L, Roth GA, Rothenbacher D, Rothstein DH, Rowley JT, Roy N, Ruhago GM, Saeedi MY, Saha S, Sahraian MA, Sampson UKA, Sanabria JR, Sandar L, Santos IS, Satpathy M, Sawhney M, Scarborough P, Schneider IJ, Schöttker B, Schumacher AE, Schwebel DC, Scott JG, Seedat S, Sepanlou SG, Serina PT, Servan-Mori EE, Shackelford KA, Shaheen A, Shahraz S, Shamah Levy T, Shangguan S, She J, Sheikhbahaei S, Shi P, Shibuya K, Shinohara Y, Shiri R, Shishani K, Shiue I, Shrime MG, Sigfusdottir ID, Silberberg DH, Simard EP, Sindi S, Singh A, Singh JA, Singh L, Skirbekk V, Slepak EL, Sliwa K, Soneji S, Søreide K, Soshnikov S, Sposato LA, Sreeramareddy CT, Stanaway JD, Stathopoulou V, Stein DJ, Stein MB, Steiner C, Steiner TJ, Stevens A, Stewart A, Stovner LJ, Stroumpoulis K, Sunguya BF, Swaminathan S, Swaroop M, Sykes BL, Tabb KM, Takahashi K, Tandon N, Tanne D, Tanner M, Tavakkoli M, Taylor HR, Te Ao BJ, Tediosi F, Temesgen AM, Templin T, Ten Have M, Tenkorang EY, Terkawi AS, Thomson B, Thorne-Lyman AL, Thrift AG, Thurston GD, Tillmann T, Tonelli M, Topouzis F, Toyoshima H, Traebert J, Tran BX, Trillini M, Truelsen T, Tsilimbaris M, Tuzcu EM, Uchendu US, Ukwaja KN, Undurraga EA, Uzun SB, Van Brakel WH, Van De Vijver S, van Gool CH, Van Os J, Vasankari TJ, Venketasubramanian N, Violante FS, Vlassov VV, Vollset SE, Wagner GR, Wagner J, Waller SG, Wan X, Wang H, Wang J, Wang L, Warouw TS, Weichenthal S, Weiderpass E, Weintraub RG, Wenzhi W, Werdecker A, Westerman R, Whiteford HA, Wilkinson JD, Williams TN, Wolfe CD, Wolock TM, Woolf AD, Wulf S, Wurtz B, Xu G, Yan LL, Yano Y, Ye P, Yentür GK, Yip P, Yonemoto N, Yoon SJ, Younis MZ, Yu C, Zaki ME, Zhao Y, Zheng Y, Zonies D, Zou X, Salomon JA, Lopez AD, Vos T. Global, regional, and national disability-adjusted life years (DALYs) for 306 diseases and injuries and healthy life expectancy (HALE) for 188 countries, 1990-2013: quantifying the epidemiological transition. Lancet 2015; 386:2145-91. [PMID: 26321261 PMCID: PMC4673910 DOI: 10.1016/s0140-6736(15)61340-x] [Citation(s) in RCA: 1284] [Impact Index Per Article: 142.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND The Global Burden of Disease Study 2013 (GBD 2013) aims to bring together all available epidemiological data using a coherent measurement framework, standardised estimation methods, and transparent data sources to enable comparisons of health loss over time and across causes, age-sex groups, and countries. The GBD can be used to generate summary measures such as disability-adjusted life-years (DALYs) and healthy life expectancy (HALE) that make possible comparative assessments of broad epidemiological patterns across countries and time. These summary measures can also be used to quantify the component of variation in epidemiology that is related to sociodemographic development. METHODS We used the published GBD 2013 data for age-specific mortality, years of life lost due to premature mortality (YLLs), and years lived with disability (YLDs) to calculate DALYs and HALE for 1990, 1995, 2000, 2005, 2010, and 2013 for 188 countries. We calculated HALE using the Sullivan method; 95% uncertainty intervals (UIs) represent uncertainty in age-specific death rates and YLDs per person for each country, age, sex, and year. We estimated DALYs for 306 causes for each country as the sum of YLLs and YLDs; 95% UIs represent uncertainty in YLL and YLD rates. We quantified patterns of the epidemiological transition with a composite indicator of sociodemographic status, which we constructed from income per person, average years of schooling after age 15 years, and the total fertility rate and mean age of the population. We applied hierarchical regression to DALY rates by cause across countries to decompose variance related to the sociodemographic status variable, country, and time. FINDINGS Worldwide, from 1990 to 2013, life expectancy at birth rose by 6·2 years (95% UI 5·6-6·6), from 65·3 years (65·0-65·6) in 1990 to 71·5 years (71·0-71·9) in 2013, HALE at birth rose by 5·4 years (4·9-5·8), from 56·9 years (54·5-59·1) to 62·3 years (59·7-64·8), total DALYs fell by 3·6% (0·3-7·4), and age-standardised DALY rates per 100 000 people fell by 26·7% (24·6-29·1). For communicable, maternal, neonatal, and nutritional disorders, global DALY numbers, crude rates, and age-standardised rates have all declined between 1990 and 2013, whereas for non-communicable diseases, global DALYs have been increasing, DALY rates have remained nearly constant, and age-standardised DALY rates declined during the same period. From 2005 to 2013, the number of DALYs increased for most specific non-communicable diseases, including cardiovascular diseases and neoplasms, in addition to dengue, food-borne trematodes, and leishmaniasis; DALYs decreased for nearly all other causes. By 2013, the five leading causes of DALYs were ischaemic heart disease, lower respiratory infections, cerebrovascular disease, low back and neck pain, and road injuries. Sociodemographic status explained more than 50% of the variance between countries and over time for diarrhoea, lower respiratory infections, and other common infectious diseases; maternal disorders; neonatal disorders; nutritional deficiencies; other communicable, maternal, neonatal, and nutritional diseases; musculoskeletal disorders; and other non-communicable diseases. However, sociodemographic status explained less than 10% of the variance in DALY rates for cardiovascular diseases; chronic respiratory diseases; cirrhosis; diabetes, urogenital, blood, and endocrine diseases; unintentional injuries; and self-harm and interpersonal violence. Predictably, increased sociodemographic status was associated with a shift in burden from YLLs to YLDs, driven by declines in YLLs and increases in YLDs from musculoskeletal disorders, neurological disorders, and mental and substance use disorders. In most country-specific estimates, the increase in life expectancy was greater than that in HALE. Leading causes of DALYs are highly variable across countries. INTERPRETATION Global health is improving. Population growth and ageing have driven up numbers of DALYs, but crude rates have remained relatively constant, showing that progress in health does not mean fewer demands on health systems. The notion of an epidemiological transition--in which increasing sociodemographic status brings structured change in disease burden--is useful, but there is tremendous variation in burden of disease that is not associated with sociodemographic status. This further underscores the need for country-specific assessments of DALYs and HALE to appropriately inform health policy decisions and attendant actions. FUNDING Bill & Melinda Gates Foundation.
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Maheswaran R, Pearson T, Beevers SD, Campbell MJ, Wolfe CD. Outdoor air pollution, subtypes and severity of ischemic stroke--a small-area level ecological study. Int J Health Geogr 2014; 13:23. [PMID: 24939673 PMCID: PMC4070355 DOI: 10.1186/1476-072x-13-23] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2014] [Accepted: 06/08/2014] [Indexed: 12/24/2022] Open
Abstract
Background Evidence linking outdoor air pollution and incidence of ischemic stroke subtypes and severity is limited. We examined associations between outdoor PM10 and NO2 concentrations modeled at a fine spatial resolution and etiological and clinical ischemic stroke subtypes and severity of ischemic stroke. Methods We used a small-area level ecological study design and a stroke register set up to capture all incident cases of first ever stroke (1995–2007) occurring in a defined geographical area in South London (948 census output areas; population of 267839). Modeled PM10 and NO2 concentrations were available at a very fine spatial scale (20 meter by 20 meter grid point resolution) and were aggregated to output area level using postcode population weighted averages. Ischemic stroke was classified using the Oxford clinical classification, the Trial of Org 10172 in Acute Stroke Treatment (TOAST) etiological classification, National Institutes of Health Stroke Scale (NIHSS) score and a pragmatic clinical severity classification based on Glasgow coma score, ability to swallow, urinary continence and death <2 days of stroke onset. Results Mean (SD) concentrations were 25.1 (1.2) ug/m3 (range 23.3-36.4) for PM10 and 41.4 (3.0) ug/m3 (range 35.4-68.0) for NO2. There were 2492 incident cases of ischemic stroke. We found no evidence of association between these pollutants and the incidence of ischemic stroke subtypes classified using the Oxford and TOAST classifications. We found no significant association with stroke severity using NIHSS severity categories. However, we found that outdoor concentrations of both PM10 and NO2 appeared to be associated with increased incidence of mild but not severe ischemic stroke, classified using the pragmatic clinical severity classification. For mild ischemic stroke, the rate ratio in the highest PM10 category by tertile was 1.20 (1.05-1.38) relative to the lowest category. The rate ratio in the highest NO2 category was 1.22 (1.06-1.40) relative to the lowest category. Conclusions We found no evidence of association between outdoor PM10 and NO2 concentrations and ischemic stroke subtypes but there was a suggestion that living in areas with elevated outdoor PM10 and NO2 concentrations might be associated with increased incidence of mild, but not severe, ischemic stroke.
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Affiliation(s)
- Ravi Maheswaran
- Public Health GIS Unit, School of Health and Related Research, University of Sheffield, Regent Court, 30 Regent Street, Sheffield S1 4DA, UK.
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Fleming MK, Sorinola IO, Roberts-Lewis SF, Wolfe CD, Wellwood I, Newham DJ. The Effect of Combined Somatosensory Stimulation and Task-Specific Training on Upper Limb Function in Chronic Stroke. Neurorehabil Neural Repair 2014; 29:143-52. [DOI: 10.1177/1545968314533613] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background. Somatosensory stimulation (SS) is a potential adjuvant to stroke rehabilitation, but the effect on function needs further investigation. Objective. To explore the effect of combining SS with task-specific training (TST) on upper limb function and arm use in chronic stroke survivors and determine underlying mechanisms. Methods. In this double-blinded randomized controlled trial (ISRCTN 05542931), 33 patients (mean 37.7 months poststroke) were block randomized to 2 groups: active or sham SS. They received 12 sessions of 2 hours of SS (active or sham) to all 3 upper limb nerves immediately before 30 minutes of TST. The primary outcome was the Action Research Arm Test (ARAT) score. Secondary outcomes were time to perform the ARAT, Fugl-Meyer Assessment score (FM), Motor Activity Log (MAL), and Goal Attainment Scale (GAS). Underlying mechanisms were explored using transcranial magnetic stimulation stimulus–response curves and intracortical inhibition. Outcomes were assessed at baseline, immediately following the intervention (mean 2 days), and 3 and 6 months (mean 96 and 190 days) after the intervention. Results. The active group (n = 16) demonstrated greater improvement in ARAT score and time immediately postintervention (between-group difference; P < .05), but not at 3- or 6-month follow-ups ( P > .2). Within-group improvements were seen for both groups for ARAT and GAS, but for the active group only for FM and MAL ( P < .05). Corticospinal excitability did not change. Conclusions. Long-lasting improvements in upper limb function were observed following TST. Additional benefit of SS was seen immediately post treatment, but did not persist and the underlying mechanisms remain unclear.
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Affiliation(s)
| | | | - Sarah F. Roberts-Lewis
- School of Biomedical Sciences, King’s College London, London, UK
- School of Medicine, King’s College London, London, UK
| | - Charles D. Wolfe
- School of Medicine, King’s College London, London, UK
- National Institute for Health Research Comprehensive Biomedical Research Centre at Guy’s and St Thomas’ NHS Foundation Trust and King’s College London, London, UK
| | - Ian Wellwood
- School of Medicine, King’s College London, London, UK
- National Institute for Health Research Comprehensive Biomedical Research Centre at Guy’s and St Thomas’ NHS Foundation Trust and King’s College London, London, UK
| | - Di J. Newham
- School of Biomedical Sciences, King’s College London, London, UK
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Maheswaran R, Pearson T, Smeeton NC, Beevers SD, Campbell MJ, Wolfe CD. Outdoor air pollution and incidence of ischemic and hemorrhagic stroke: a small-area level ecological study. Stroke 2011; 43:22-7. [PMID: 22033998 DOI: 10.1161/strokeaha.110.610238] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Evidence linking outdoor air pollution and incidence of stroke is limited. We examined effects of outdoor air pollution on the incidence of ischemic and hemorrhagic stroke at the population level focusing on middle-aged and older people. METHODS We used a small-area level ecological study design and a stroke register set up to capture all incident cases of first-ever stroke occurring in a defined geographical area in south London (948 census output areas) where road traffic contributes to spatial variation in air pollution. Population-weighted averages were calculated for output areas using outdoor nitrogen dioxide and PM(10) concentrations modeled at a 20-m resolution. RESULTS There were 1832 ischemic and 348 hemorrhagic strokes in 1995 to 2004 occurring among a resident population of 267 839. Mean (SD) concentration was 25.1 (1.2) μg/m(3) (range, 23.3-36.4 μg/m(3)) for PM(10) and 41.4 (3.0) μg/m(3) (range, 35.4-68.0 μg/m(3)) for nitrogen dioxide. For ischemic stroke, adjusted rate ratios per 10-μg/m(3) increase, for all ages, 40 to 64 and 65 to 79 years, respectively, were 1.22 (0.77-1.93), 1.12 (0.55-2.28), and 1.86 (1.10-3.13) for PM(10) and 1.11 (0.93-1.32), 1.13 (0.86-1.50), and 1.23 (0.99-1.53) for nitrogen dioxide. For hemorrhagic stroke, the corresponding rate ratios were 0.52 (0.20-1.37), 0.78 (0.17-3.51), and 0.51 (0.12-2.22) for PM(10) and 0.86 (0.60-1.24), 1.12 (0.66-1.90), and 0.78 (0.44-1.39) for nitrogen dioxide. CONCLUSIONS Although there was no significant association between outdoor air pollutants and ischemic stroke incidence for all ages combined, there was a suggestion of increased risk among people aged 65 to 79 years. There was no evidence of increased incidence in hemorrhagic stroke.
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Affiliation(s)
- Ravi Maheswaran
- Public Health GIS Unit, School of Health and Related Research, University of Sheffield, Regent Court, 30 Regent Street, Sheffield S1 4DA, UK.
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Dregan A, Toschke MA, Wolfe CD, Rudd A, Ashworth M, Gulliford MC. Utility of electronic patient records in primary care for stroke secondary prevention trials. BMC Public Health 2011; 11:86. [PMID: 21299872 PMCID: PMC3041663 DOI: 10.1186/1471-2458-11-86] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2010] [Accepted: 02/07/2011] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND This study aimed to inform the design of a pragmatic trial of stroke prevention in primary care by evaluating data recorded in electronic patient records (EPRs) as potential outcome measures. The study also evaluated achievement of recommended standards of care; variation between family practices; and changes in risk factor values from before to after stroke. METHODS Data from the UK General Practice Research Database (GPRD) were analysed for 22,730 participants with an index first stroke between 2003 and 2006 from 414 family practices. For each subject, the EPR was evaluated for the 12 months before and after stroke. Measures relevant to stroke secondary prevention were analysed including blood pressure (BP), cholesterol, smoking, alcohol use, body mass index (BMI), atrial fibrillation, utilisation of antihypertensive, antiplatelet and cholesterol lowering drugs. Intraclass correlation coefficients (ICC) were estimated by family practice. Random effects models were fitted to evaluate changes in risk factor values over time. RESULTS In the 12 months following stroke, BP was recorded for 90%, cholesterol for 70% and body mass index (BMI) for 47%. ICCs by family practice ranged from 0.02 for BP and BMI to 0.05 for LDL and HDL cholesterol. For subjects with records available both before and after stroke, the mean reductions from before to after stroke were: mean systolic BP, 6.02 mm Hg; diastolic BP, 2.78 mm Hg; total cholesterol, 0.60 mmol/l; BMI, 0.34 Kg/m2. There was an absolute reduction in smokers of 5% and heavy drinkers of 4%. The proportion of stroke patients within the recommended guidelines varied from less than a third (29%) for systolic BP, just over half for BMI (54%), and over 90% (92%) on alcohol consumption. CONCLUSIONS Electronic patient records have potential for evaluation of outcomes in pragmatic trials of stroke secondary prevention. Stroke prevention interventions in primary care remain suboptimal but important reductions in vascular risk factor values were observed following stroke. Better recording of lifestyle factors in the GPRD has the potential to expand the scope of the GPRD for health care research and practice.
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Affiliation(s)
- Alex Dregan
- Division of Health and Social Care Research, King's College London, Capital House, Weston Street, London, UK.
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Abstract
Background and Purpose—
The impact of air pollution on survival after stroke is unknown. We examined the impact of outdoor air pollution on stroke survival by studying a population-based cohort.
Methods—
All patients who experienced their first-ever stroke between 1995 and 2005 in a geographically defined part of London, where road traffic contributes to spatial variation in air pollution, were followed up to mid-2006. Outdoor concentrations of nitrogen dioxide and particulate matter <10 μm in diameter modeled at a 20-m grid point resolution for 2002 were linked to residential postal codes. Hazard ratios were adjusted for age, sex, social class, ethnicity, smoking, alcohol consumption, prestroke functional ability, pre-existing medical conditions, stroke subtype and severity, hospital admission, and neighborhood socioeconomic deprivation.
Results—
There were 1856 deaths among 3320 patients. Median survival was 3.7 years (interquartile range, 0.1 to 10.8). Mean exposure levels were 41 μg/m
3
(SD, 3.3; range, 32.2 to 103.2) for nitrogen dioxide and 25 μg/m
3
(SD, 1.3; range, 22.7 to 52) for particulate matter <10 μm in diameter. A 10-μg/m
3
increase in nitrogen dioxide was associated with a 28% (95% CI, 11% to 48%) increase in risk of death. A 10-μg/m
3
increase in particulate matter <10 μm in diameter was associated with a 52% (6% to 118%) increase in risk of death. Reduced survival was apparent throughout the follow-up period, ruling out short-term mortality displacement.
Conclusions—
Survival after stroke was lower among patients living in areas with higher levels of outdoor air pollution. If causal, a 10-μg/m
3
reduction in nitrogen dioxide exposure might be associated with a reduction in mortality comparable to that for stroke units. Improvements in outdoor air quality might contribute to better survival after stroke.
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Affiliation(s)
- Ravi Maheswaran
- From the Public Health GIS Unit (R.M., T.P.), School of Health and Related Research, University of Sheffield, Sheffield; the Division of Health and Social Care Research (N.C.S., C.D.W.), and National Institute for Health Research Biomedical Research Centre, Guy’s and St. Thomas’ NHS Foundation Trust, King’s College London, London; the Environmental Research Group (S.D.B.), King’s College London; the Health Services Research Section (M.J.C.), School of Health and Related Research, University of
| | - Tim Pearson
- From the Public Health GIS Unit (R.M., T.P.), School of Health and Related Research, University of Sheffield, Sheffield; the Division of Health and Social Care Research (N.C.S., C.D.W.), and National Institute for Health Research Biomedical Research Centre, Guy’s and St. Thomas’ NHS Foundation Trust, King’s College London, London; the Environmental Research Group (S.D.B.), King’s College London; the Health Services Research Section (M.J.C.), School of Health and Related Research, University of
| | - Nigel C. Smeeton
- From the Public Health GIS Unit (R.M., T.P.), School of Health and Related Research, University of Sheffield, Sheffield; the Division of Health and Social Care Research (N.C.S., C.D.W.), and National Institute for Health Research Biomedical Research Centre, Guy’s and St. Thomas’ NHS Foundation Trust, King’s College London, London; the Environmental Research Group (S.D.B.), King’s College London; the Health Services Research Section (M.J.C.), School of Health and Related Research, University of
| | - Sean D. Beevers
- From the Public Health GIS Unit (R.M., T.P.), School of Health and Related Research, University of Sheffield, Sheffield; the Division of Health and Social Care Research (N.C.S., C.D.W.), and National Institute for Health Research Biomedical Research Centre, Guy’s and St. Thomas’ NHS Foundation Trust, King’s College London, London; the Environmental Research Group (S.D.B.), King’s College London; the Health Services Research Section (M.J.C.), School of Health and Related Research, University of
| | - Michael J. Campbell
- From the Public Health GIS Unit (R.M., T.P.), School of Health and Related Research, University of Sheffield, Sheffield; the Division of Health and Social Care Research (N.C.S., C.D.W.), and National Institute for Health Research Biomedical Research Centre, Guy’s and St. Thomas’ NHS Foundation Trust, King’s College London, London; the Environmental Research Group (S.D.B.), King’s College London; the Health Services Research Section (M.J.C.), School of Health and Related Research, University of
| | - Charles D. Wolfe
- From the Public Health GIS Unit (R.M., T.P.), School of Health and Related Research, University of Sheffield, Sheffield; the Division of Health and Social Care Research (N.C.S., C.D.W.), and National Institute for Health Research Biomedical Research Centre, Guy’s and St. Thomas’ NHS Foundation Trust, King’s College London, London; the Environmental Research Group (S.D.B.), King’s College London; the Health Services Research Section (M.J.C.), School of Health and Related Research, University of
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Gulliford MC, Charlton J, Rudd A, Wolfe CD, Toschke AM. Declining 1-year case-fatality of stroke and increasing coverage of vascular risk management: population-based cohort study. J Neurol Neurosurg Psychiatry 2010; 81:416-22. [PMID: 20176596 PMCID: PMC2921278 DOI: 10.1136/jnnp.2009.193136] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND The authors estimated trends in 1-year case-fatality of stroke in relation to changes in vascular risk management from 1997 to 2005. METHODS A cohort study was implemented using data for 407 family practices in the UK General Practice Research Database, including subjects with first acute strokes between 1997 and 2005. One-year case-fatality was estimated by year and sex. Rate ratios were estimated using Poisson regression. RESULTS There were 19 143 women and 16 552 men who had first acute strokes between 1997 and 2005. In women, the 1-year case-fatality declined from 41.2% in 1997 to 29.2% in 2005. In men, the decline was from 29.2% in 1997 to 22.2% in 2005. The proportion of general practices that prescribed antihypertensive drugs to two-thirds or more of new patients with stroke increased from 6% in 1997 to 48% in 2005, for statins from 1% to 39% and for antiplatelet drugs from 11% to 39%. The rate ratio for 1-year mortality in 2005, compared with 1997-1998, adjusted for age group, sex, prevalent coronary heart disease, prevalent hypertension and deprivation quintile was 0.79 (0.74 to 0.86, p<0.001). After adjustment for antihypertensive, statin and antiplatelet prescribing, the rate ratio was 1.29 (1.17 to 1.42). CONCLUSIONS Reducing 1-year case-fatality after acute stroke may be partly explained by increased prescribing of antihypertensive, statin and antiplatelet drugs to patients with recent strokes. However, these analyses did not include measures of possible changes over time in stroke severity or acute stroke management.
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Affiliation(s)
- Martin C Gulliford
- Department of Public Health Sciences, King's College London, Capital House, 42 Weston Street, London SE1 3QD, UK.
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Hillen T, Davies S, Rudd AG, Kieselbach T, Wolfe CD. Self ratings of health predict functional outcome and recurrence free survival after stroke. J Epidemiol Community Health 2004; 57:960-6. [PMID: 14652262 PMCID: PMC1732360 DOI: 10.1136/jech.57.12.960] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
STUDY OBJECTIVE To measure stroke victims' self rated health (SRH) status and SRH transition, and to compare how the two are prospectively associated with disability and recurrence free survival. DESIGN Prospective case registry study with face to face follow up interviews at three months, one, two, and three years. Ascertained were SRH status and SRH transition using single question assessments, Barthel Index (BI), Frenchay Activities Index (FAI), and Mini Mental State Examination (MMSE). SETTING A multiethnic inner city population of 234 533. PARTICIPANTS Patients surviving the initial three months after a first in a lifetime stroke in 1995 to 1998. RESULTS Of 690 stroke survivors 561 (81.3%) could complete the self report items. Answers to the item on SRH status did not vary significantly between the four follow up interviews. However, responses to the item on SRH transition changed significantly during follow up with three months ratings being more negative than all subsequent ratings. SRH transition, but not SRH status, showed a prospective association with long term outcome in multivariate analyses controlling for the BI, FAI, and MMSE. Compared with all other patients, patients reporting "Much worse health" at three months were more likely to be disabled ( = BI<20) at one year (OR 6.29, 95% CI 2.26 to 17.52) and their combined risk of stroke recurrence and death was increased over five years (HR 1.72, 95% CI 1.25 to 2.38). CONCLUSIONS Items on SRH should be used with caution in populations with high rates of disability and language problems, as many participants are unable to complete them. SRH transition may be a better predictor of disability and recurrence free survival after major medical events than SRH status.
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Affiliation(s)
- T Hillen
- Division of Primary Care and Public Health Sciences, Guy's, King's and St Thomas' School of Medicine, King's College, London, UK
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Jerrard-Dunne P, Evans A, McGovern R, Hajat C, Kalra L, Rudd AG, Wolfe CD, Markus HS. Ethnic differences in markers of thrombophilia: implications for the investigation of ischemic stroke in multiethnic populations: the South London Ethnicity and Stroke Study. Stroke 2003; 34:1821-6. [PMID: 12843341 DOI: 10.1161/01.str.0000083049.65008.5f] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND AND PURPOSE The role of hypercoagulable states in the pathogenesis of ischemic stroke in black subjects is not known, and data on normal reference ranges in black populations are lacking. This study estimated ethnic-specific reference ranges in a community population to determine the prevalence of thrombophilic states in a multiethnic stroke population. METHODS Free protein S, protein C, antithrombin III, activated protein C resistance, IgG anticardiolipin antibodies, and lupus anticoagulant were determined in 130 consecutive ischemic stroke cases < or =65 years of age (50 black Caribbeans, 30 black Africans, 50 whites) and 130 community controls. RESULTS Black African controls had significantly lower protein S (P<0.001) and protein C (P=0.049) and a trend toward lower antithrombin III (P=0.056) levels compared with white controls. Black Caribbean and African controls had higher diluted Russell's viper venom time ratios compared with whites (P=0.001, P<0.001). Using ethnic-specific reference ranges, 8 controls (6.3%) and 11 cases (8.5%) had thrombophilia abnormalities (odds ratio [OR], 1.39; 95% confidence interval [CI], 0.54 to 3.57; P=0.50). ORs were 0.96 (95% CI, 0.18 to 4.99; P=0.96) for whites, 1.57 (95% CI, 0.41 to 5.94; P=0.51) for black Caribbeans, and 2.07 (95% CI, 0.18 to 24.2; P=0.95) for black Africans. CONCLUSIONS Failure to account for ethnic differences in the normal reference ranges for thrombophilia markers may lead to inappropriate diagnosis and investigation of hypercoagulable states in black individuals. Protein S and protein C deficiencies and lupus anticoagulant may contribute to stroke risk in a minority of black cases, but they are unlikely to be major contributors to the excess stroke risk seen in young individuals of African and African-Caribbean descent.
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Affiliation(s)
- Paula Jerrard-Dunne
- Department of Clinical Neurosciences, St. George's Hospital Medical School, Cranmer Terrace, Tooting, London SW17 0RE, UK.
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Tilling K, Sterne JA, Wolfe CD. Estimation of the incidence of stroke using a capture-recapture model including covariates. Int J Epidemiol 2001; 30:1351-9; discussion 1359-60. [PMID: 11821345 DOI: 10.1093/ije/30.6.1351] [Citation(s) in RCA: 78] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Capture-recapture is often used to assess completeness of a register. However, the usual two-source model relies on assumptions of independence of sources and equality of capture probability which are rarely satisfied in epidemiology. An alternative is to include covariates in capture-recapture models. METHODS We use capture-recapture models including covariates to estimate incidence of stroke in South London. We estimate ascertainment-adjusted age-standardized incidence rates, and calculate confidence intervals for incidence which allow for the uncertainty in estimation of the total number of cases. RESULTS The crude capture-recapture model (including no covariates) underestimated the number of non-fatal strokes. Demographic and stroke severity variables were associated with the probability of capture. Including covariates led to more plausible results for fatal and non-fatal strokes, and suggested that the stroke register was 88% complete. Adjusting for under-ascertainment increased the estimated incidence from 1.31 (95% CI : 1.21-1.42) to 1.49 (95% CI : 0.38-2.60) per 1000 people. CONCLUSIONS Incidence and age-standardized incidence can be calculated using data from an incomplete register. However, sparse strata can lead to wide confidence intervals for adjusted rates. Cost-effectiveness of routine registers might be increased by using the combination of sources and covariates which most accurately estimates the total number of cases, rather than by aiming for 100% completeness.
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Affiliation(s)
- K Tilling
- Department of Public Health Sciences, King's College London, Capital House, 42 Weston Street, London SE1 3QD, UK.
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Abstract
BACKGROUND AND PURPOSE Several prognostic factors have been identified for outcome after stroke. However, there is a need for empirically derived models that can predict outcome and assist in medical management during rehabilitation. To be useful, these models should take into account early changes in recovery and individual patient characteristics. We present such a model and demonstrate its clinical utility. METHODS Data on functional recovery (Barthel Index) at 0, 2, 4, 6, and 12 months after stroke were collected prospectively for 299 stroke patients at 2 London hospitals. Multilevel models were used to model recovery trajectories, allowing for day-to-day and between-patient variation. The predictive performance of the model was validated with an independent cohort of 710 stroke patients. RESULTS Urinary incontinence, sex, prestroke disability, and dysarthria affected the level of outcome after stroke; age, dysphasia, and limb deficit also affected the rate of recovery. Applying this to the validation cohort, the average difference between predicted and observed Barthel Index was -0.4, with 90% limits of agreement from -7 to 6. Predicted Barthel Index lay within 3 points of the observed Barthel Index on 49% of occasions and improved to 69% when patients' recovery histories were taken into account. CONCLUSIONS The model predicts recovery at various stages of rehabilitation in ways that could improve clinical decision making. Predictions can be altered in light of observed recovery. This model is a potentially useful tool for comparing individual patients with average recovery trajectories. Patients at elevated risk could be identified and interventions initiated.
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Affiliation(s)
- K Tilling
- Department of Public Health Sciences, King's College London, London, UK.
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Affiliation(s)
- R S Howard
- Department of Neurology, Guy's and St. Thomas' Hospital Trust, London, UK
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Hajat C, Coshall C, Rudd AG, Patel M, Bhalla A, Howard R, Wolfe CD. The inter- and intraobserver reliabilities of a new classification system for ischaemic stroke: the South London Stroke Register. J Neurol Sci 2001; 190:79-85. [PMID: 11574111 DOI: 10.1016/s0022-510x(01)00597-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVES This study aims to determine the inter- and intraobserver reliabilities of an aetiological classification devised as part of a community-based stroke register. METHODS Patients with first-ever acute ischaemic stroke were clinically assessed and received investigation according to a set protocol. Results of the clinical assessment and investigations were used to determine an aetiological stroke subtype for each patient by observer 1. Aetiological subtypes consisted of extracranial large artery atherosclerosis (LAAec), intracranial large artery atherosclerosis (LAAic), high-risk cardioembolism (CH), medium-risk cardioembolism (CM), small vessel occlusion (SVO), other aetiology (OTH), no aetiology identified (NA) and multiple probable or multiple possible aetiology (MPA). The same data were distributed to a further four observers along with the criteria for the classification system. Two of the observers were retested on the same patients after of period of 8 weeks. Inter- and intraobserver agreement was determined using the kappa statistic, which gives the chance-adjusted percentage agreement. RESULTS Forty-five consecutive patients were included. The overall kappa statistic for ischaemic stroke was 0.91 indicating excellent agreement. Kappa statistics were highest for the more frequent subtypes of SVO (0.97) and CH (0.97). Substantially high kappa statistics were also obtained for the less-frequent categories of LAAec (0.91), CM (0.84), NA (0.89) and MPA (0.87). A low kappa statistic was obtained for the category OTH (0.16), which had a low frequency of reporting, indicating poor agreement. The kappa statistic for probable categories was higher than the kappa statistic for all stroke subtypes at 0.96. Intraobserver agreement between first and second assignments of subtype diagnoses for both observers reached excellent agreement with kappa statistics of 0.83 and 0.85. CONCLUSION The aetiological classification system, designed for use in the investigation of the epidemiology, stroke subtype and their relation to the natural history of stroke in a multiethnic inner city population, allows high inter- and intrarater agreements of subtype diagnosis.
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Affiliation(s)
- C Hajat
- Guy's, King's and St. Thomas' School of Medicine, King's College London, 5th Floor, Capital House, 42 Westmont Street, SE13QD, London, UK
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Abstract
OBJECTIVES To determine factors associated with recovery from poststroke urinary incontinence and to estimate the impact of this recovery on stroke outcome at 3 months. DESIGN Prospective, observational study. SETTING Population-based stroke register. PARTICIPANTS Three hundred twenty-four incident cases of stroke with incontinence 1 week poststroke were identified from the register between January 1, 1995, and December 31, 1998. MEASUREMENTS At 3 months, 105 patients were dead and 12 were lost to follow-up. The remaining patients were classified by continence status; those who had regained continence (n = 127) were compared with those who remained incontinent (n = 80) in terms of demographic details, stroke risk factors, premorbid disability, neurological impairments, and Oxfordshire Community Stroke Project stroke subtypes. Data at 3 months included disability using the modified Barthel Index (BI) (without its urinary continence component) and the Frenchay Activity Index (FAI), and institutionalization. RESULTS Multivariate analysis showed being age 75 and older (odds ratio (OR) = 0.38; 95% confidence interval (CI) = 0.17-0.83) was associated with poor recovery from incontinence. Compared with subjects with total anterior circulatory infarctions, those with lacunar infarctions were more likely to regain continence (OR = 3.66; 95% CI =1.10-12.2), and compared with subjects with a BI between 0 and 14, those with a BI between 15 and 18 were also more likely to regain continence (OR = 21.8; 95% CI = 5.95-79.7). At 3 months, the incontinent group had greater institutionalization rates (27 (34%) vs 9 (7%), P <.001) and worse disability, measured with BI and FAI (BI: P <.001, FAI: P =.002). CONCLUSIONS Age 75 and older is independently associated with poor recovery from poststroke urinary incontinence. Further clinical trials are required to explore underlying mechanisms and efficacy of possible interventions for this group of stroke survivors. Recovery from poststroke urinary incontinence should be a major goal of stroke professionals because it is associated with lower institutionalization rates and less disability at 3 months.
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Affiliation(s)
- M Patel
- Departments of Public Health Medicine and Elderly Care, Guy's, King's, & St. Thomas' School of Medicine, King's College, London, England
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Abstract
OBJECTIVES To assess the influence of 24 h blood pressure (BP) levels on functional recovery 1 week after stroke and the effect of antihypertensive therapy on 24 h BP levels. DESIGN Prospective study of patients admitted to hospital over 1 year with first in a lifetime stroke who underwent 24 h BP and casual measurements. Setting. Medical wards in a teaching hospital. Subjects. Of 160 patients, 72 patients admitted to hospital within 24 h of stroke onset were investigated. Patients with conditions and therapy that interfered with autonomic and sympathetic function were excluded. Interventions. All subjects underwent 24 h BP and casual recordings on admission to hospital and at day seven after stroke. The mean 24 h, day and night systolic BP (SBP) and diastolic BP (DBP) and their differences (nocturnal BP dip) were recorded. Patients were divided into three groups according to whether they were taking antihypertensive therapy during the first week: (i) no therapy, (ii) therapy continued after stroke, and (iii) new therapy introduced. Main outcome measures. Functional recovery (Rankin Scale 0-1) and neurological improvement [Scandinavian Stroke Scale (SSS) >/=3 points] by 1 week of stroke. Change in circadian 24 h BP over 1 week. RESULTS For each 10 mmHg difference between day and night time DBP, the odds for making a complete recovery were 4.63 (95% CI: 1.57-13.7, P=0.01). For each 10 mmHg difference between day and night SBP, the odds for making an improvement in neurological status was 2.24 (95% CI: 1.16-4.32; P=0.016). Significant falls in 24 h DBP (P=0.01), daytime SBP (P=0.005) and mean arterial BP (MABP) (P=0.04) over 1 week were demonstrated in patients who had just commenced antihypertensive therapy (P=0.001). CONCLUSION An increase in day to night time BP change is favourable in short-term outcome after acute stroke. Significant falls in BP are more likely in patients started on antihypertensive therapy for the first time. Further research is required to understand the effects of circadian BP rhythm on stroke outcome.
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Affiliation(s)
- A Bhalla
- Department of Public Health Sciences, Guy's, King's and St Thomas' Hospital, School of Medicine, 42 Weston St, London SE1 3DQ, UK.
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Langhorne P, Dennis MS, Karla L, Shepperd S, Wade DT, Wolfe CD. Services for helping acute stroke patients avoid hospital admission. Nurs Times 2001; 97:44. [PMID: 11958107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
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Grieve R, Hutton J, Bhalla A, Rastenytë D, Ryglewicz D, Sarti C, Lamassa M, Giroud M, Dundas R, Wolfe CD. A comparison of the costs and survival of hospital-admitted stroke patients across Europe. Stroke 2001; 32:1684-91. [PMID: 11441220 DOI: 10.1161/01.str.32.7.1684] [Citation(s) in RCA: 75] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Policy makers require evidence on the costs and outcomes of different ways of organizing stroke care. This study compared the costs and survival of different ways of providing stroke care. METHODS Hospitalized stroke patients from 13 European centers were included, with demographic, case-mix, and resource use variables measured for each patient. Unit costs were collected and converted into US dollars using the purchasing power parity (PPP) index. Cox and linear regression analyses were used to compare survival and costs between the centers adjusting for case mix. RESULTS A total of 1847 patients were included in the study. After case-mix adjustment, the mean predicted costs ranged from $466 [95% CI 181 to 751] in Riga (Latvia) to $8512 [7696 to 9328] in Copenhagen (Denmark), which reflected differences in unit costs, and resource use. The mean length of hospitalization ranged from 8.3 days in Menorca (Spain) to 36.8 days in Turku B (Finland). In the 3 Finnish centers at least 80% of patients were admitted to wards providing organized stroke care, which was not provided at the centers in Almada (Portugal), Menorca, or Riga. Patients in Turku A and Turku B were less likely to die than those in Riga, Warsaw (Poland), or Menorca. The adjusted hazard ratios were 0.18 [0.10 to 0.32] for Turku A, 0.18 [0.10 to 0.32] for Turku B, 0.68 [0.48 to 0.96] for Warsaw, and 0.56 [0.33 to 0.96] for Menorca, all compared with Riga. CONCLUSIONS The cost of stroke care varies across Europe because of differences in unit costs, and resource use. Further research is needed to assess which ways of organizing stroke care are the most cost-effective.
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Affiliation(s)
- R Grieve
- Department of Public Health Sciences, GKT School of Medicine, London, UK.
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Lawrence ES, Coshall C, Dundas R, Stewart J, Rudd AG, Howard R, Wolfe CD. Estimates of the prevalence of acute stroke impairments and disability in a multiethnic population. Stroke 2001; 32:1279-84. [PMID: 11387487 DOI: 10.1161/01.str.32.6.1279] [Citation(s) in RCA: 472] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE The goals of the present study were to estimate the prevalence of acute impairments and disability in a multiethnic population of first-ever stroke and to identify differences in impairment and early disability between pathological and Bamford subtypes. Associations between impairments and death and disability at 3 months were identified. METHODS Impairments that occur at the time of maximum neurological deficit were recorded, and disability according to the Barthel Index (BI) was assessed 1 week and 3 months after stroke in patients in the South London Stroke Register: RESULTS Of 1259 registered patients, 6% had 1 or 2, 31.1% had 3 to 5, 50.6% had 6 to 10, and 10.6% had >10 impairments. Common impairments were weakness (upper limb, 77.4%), urinary incontinence (48.2%), impaired consciousness (44.7%), dysphagia (44.7%), and impaired cognition (43.9%). Patients with total anterior circulation infarcts had the highest age-adjusted prevalence of weakness, dysphagia, urinary incontinence, cognitive impairment, and disability. Patients with subarachnoid hemorrhage had the highest rates of coma. Patients with lacunar stroke had the high prevalence of weakness but were least affected by disability, incontinence, and cognitive dysfunction. Blacks had higher age- and sex-adjusted rates of disability in ischemic stroke (BI <20, odds ratio 2.76, 95% CI 1.47 to 5.21, P=0.002; BI <15, odds ratio 1.8, 95% CI 1.45 to 2.81, P=0.01) but impairment rates similar to those of whites. On multivariable analysis, incontinence, coma, dysphagia, cognitive impairment, and gaze paresis were independently associated with severe disability (BI <10) and death at 3 months. CONCLUSIONS The extent of these findings indicates that an acute assessment of impairments and disability is necessary to determine the appropriate nursing and rehabilitation needs of patients with stroke.
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Affiliation(s)
- E S Lawrence
- Department of Public Health Medicine, Guy's, King's & St Thomas' School of Medicine, London, UK
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Abstract
OBJECTIVES to identify the factors associated with hospital admission and the differences in management and outcome of stroke patients between hospital and home. DESIGN a prospective community stroke register (1995-8) with multiple notification sources. SETTING an inner city multi-ethnic population of 234 533 in South London, UK. PARTICIPANTS 975 subjects with first in a lifetime strokes, whether or not they were admitted to hospital. Patients dying suddenly and those already hospitalized at the time of stroke were excluded. MAIN OUTCOME MEASURES factors associated with hospital admission; differences in management in the acute phase of stroke; mortality and dependency assessed by the Barthel index 3 months post-stroke. RESULTS 812 patients were admitted to hospital for stroke; 163 were managed in the community. Factors independently associated with hospital admission included stroke severity, pre-stroke independence, atrial fibrillation, having an intracranial haemorrhage and having a non-lacunar infarction. Computed tomography scan rates were higher in admitted (78%) than non-admitted patients (63%; P=0.001). By 3 months, 285 (35%) of the admitted patients had died compared with 13 (8%) of non-admitted patients (P<0.001). Of the admitted patients, 241 (47%) had a Barthel index > or =18 compared with 106 (72%) of those who were not admitted (P<0.001). After adjusting for case-mix variables, the odds ratios for death and dependency (Barthel index<18) in admitted and non-admitted patients were 2.21 (0.96-5.12) and 2.39 (1.35-4.22) respectively. CONCLUSION patients with clinical indicators for a more severe stroke were more likely to be admitted to hospital. Hospitalized stroke patients may have poorer survival and disability rates than those who remain at home, even after adjustment for case mix. There may be some aspects of acute hospital care that may be detrimental to outcome in certain groups of stroke patients. This requires further investigation.
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Affiliation(s)
- A Bhalla
- Department of Public Health Sciences, Guy's, King's and St Thomas' Hospital School of Medicine, Capital House, 42 Weston Street, London SE1 3DQ, UK.
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Abstract
In measuring the progression of, or recovery from, a disease an individual's outcome may be assessed on a number of occasions. A model of the relationship between outcome and time since disease occurred which accounts for patient characteristics could be used to describe patterns of recovery, to predict outcome for a patient, or to evaluate health interventions. We use multilevel models to analyse such data, focusing on the choice of powers of time both for mean outcome and covariate effects. We give equations for predicted outcome and corresponding standard errors (i) based only on baseline characteristics, and (ii) by conditioning on previous outcomes for an individual. In a study of 331 stroke patients, outcome was measured approximately 0, 2,4,6 and 12 months after stroke. Patient characteristics included age, sex, and pre-stroke handicap, together with stroke-severity indicators (presence of limb deficit, dysphasia, dysarthria or incontinence). Of these, only the effects of age, dysphasia and presence of deficit varied with time. Conditioning on previous observations improved the accuracy of predictions. The outcome variable clearly had a skewed distribution, and the model residuals showed evidence of non-Normality. We discuss alternative models for non-Normal data, and show that, here, the standard (Normal errors) multilevel model gives equivalent parameter estimates and predictions to those obtained from alternative models.
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Affiliation(s)
- K Tilling
- Division of Public Health Sciences, King's College, 5th Floor, Capital House, 42 Weston Street, London SE1 3QD, UK.
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Abstract
Considerable effort has been directed towards acute stroke research with numerous drug therapies being tried and tested. As yet there is still no routine treatment that is unequivocally effective in acute stroke. The development of stroke units has been a major breakthrough in reducing disability through co-ordinated rehabilitation, and new interest is being focussed towards limiting acute neurological deterioration through acute stroke units. Monitoring and attempting to stabilize acute physiological parameters within normal limits such as blood pressure, temperature, hydration status, glucose levels and oxygen saturations, has become standard practice for some acute stroke units. Strategies to correct hypertension, hypotension, dehydration, hyperglycaemia, pyrexia and hypoxia may potentially reduce neuronal damage in the acute phase of stroke and subsequently improve functional outcome and survival. Whether we require large prospective randomized controlled trials to test whether these specific interventions are to be used in mainstay practice is unclear.
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Affiliation(s)
- A Bhalla
- Department of Public Health Sciences, Guy's, King's and St Thomas' School of Medicine, London, UK.
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Abstract
The aim of this paper is to determine whether antenatal detection of small-for-gestational-age (SGA) babies influences 2-year outcomes. All low-birth-weight (<2,500g) infants born in South-EastThames region, England from September 1, 1992 to August 31, 1993 were identified at birth. Antenatal "suspicion" and ultrasound assessment confirming growth restriction was categorized as "detection" of SGA. Postnatally, infants were classified as SGA if they had a birth weight for given gestation below the 10th centile. At 2 years, those below 32 weeks' gestation and a random 25% sample of infants of 32 weeks' gestation or more underwent pediatric assessments. Of 49,787 births, 3,456 (6.9%) were of low birth weight. One thousand four hundred and fifty one (42.5%) were SGA, of whom 611 (42%) were detected antenatally by ultrasound scan. At 2 years, 1,008 (75.8%) of 1,358 expected infants were assessed, 379 (37.6%) were SGA at birth, and 188 (49.6%) were confirmed antenatally. Although undetected infants had higher mean birth weights and gestational ages, they had a higher proportion of perinatal deaths (12.6 vs. 6.4%, RR 1.96: CI 1.32-2.86) than detected infants. At 2 years, detected SGA infants had smaller head circumferences (p = 0.026), a higher prevalence of febrile convulsions (8.0 vs. 3.1 %: p = 0.040) and lower scores on the locomotor (DQA) scale of Griffith's developmental test (p = 0.021) compared with undetected SGA infants. Despite detected SGA fetuses having lower weights and gestation at birth than undetected fetuses, they had significantly lower mortality without a parallel increase in severe 2-year neuro-developmental, clinical, or growth morbidity.
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Affiliation(s)
- E M Ogundipe
- Department of Public Health Sciences, Guy's King's & St Thomas's School of Medicine and Dentistry, London, United Kingdom
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Lamassa M, Di Carlo A, Pracucci G, Basile AM, Trefoloni G, Vanni P, Spolveri S, Baruffi MC, Landini G, Ghetti A, Wolfe CD, Inzitari D. Characteristics, outcome, and care of stroke associated with atrial fibrillation in Europe: data from a multicenter multinational hospital-based registry (The European Community Stroke Project). Stroke 2001; 32:392-8. [PMID: 11157172 DOI: 10.1161/01.str.32.2.392] [Citation(s) in RCA: 259] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE The role of atrial fibrillation (AF) as a determinant of stroke outcome is not well established. Studies focusing on this topic relied on relatively small samples of patients, scarcely representative of the older age groups. We aimed at evaluating clinical characteristics, care, and outcome of stroke associated with AF in a large European sample. METHODS In a European Concerted Action involving 7 countries, 4462 patients hospitalized for first-in-a-lifetime stroke were evaluated for demographics, risk factors, clinical presentation, resource use, and 3-month survival, disability (Barthel Index), and handicap (Rankin scale). RESULTS AF was present in 803 patients (18.0%). AF patients, compared with those without AF, were older, were more frequently female, and more often had experienced a previous myocardial infarction; they were less often diabetics, alcohol consumers, and smokers (all P:<0.001). At 3 months, 32.8% of the AF patients were dead compared with 19.9% of the non-AF patients (P:<0.001). With control for baseline variables, AF increased by almost 50% the probability of remaining disabled (multivariate odds ratio 1.43, 95% CI 1.13 to 1.80) or handicapped (multivariate odds ratio 1.51, 95% CI 1.13 to 2.02). Before stroke, only 8.4% of AF patients were on anticoagulants. The chance of being anticoagulated was reduced by 4% per year of increasing age. AF patients underwent CT scan and other diagnostic procedures less frequently and received less physiotherapy or occupational therapy. CONCLUSIONS Stroke associated with AF has a poor prognosis in terms of death and function. Prevention and care of stroke with AF is a major challenge for European health systems.
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Affiliation(s)
- M Lamassa
- Department of Neurological and Psychiatric Sciences, University of Florence, Florence, Italy
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31
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Hajat C, Dundas R, Stewart JA, Lawrence E, Rudd AG, Howard R, Wolfe CD. Cerebrovascular risk factors and stroke subtypes: differences between ethnic groups. Stroke 2001; 32:37-42. [PMID: 11136911 DOI: 10.1161/01.str.32.1.37] [Citation(s) in RCA: 97] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE The excess risk of stroke seen in the black population has not been explained by differences in age, sex, and social class, although differences in the frequency of cerebrovascular risk factors may be partly responsible. Data on risk factor profiles for the UK black stroke population are sparse. Previous studies have contrasted the association of cerebrovascular risk factors between hemorrhagic and ischemic stroke and between etiologic subtypes of infarct. The relationship of cerebrovascular risk factors to clinical classifications of stroke, however, has been little examined. The aim of this study was to establish the frequency of cerebrovascular risk factors in patients with first-ever strokes in the South London, UK, population and to examine the relationship of these risk factors to both ethnicity and Bamford stroke subtype. METHODS The study included 1254 first-ever stroke patients registered in the South London Community Stroke Register between 1995 and 1998; 995 patients (79.3%) were white, 203 (16.2%) were black, 52 (4.1%) were of other ethnic origin, and 4 (0. 3%) were of unknown ethnic origin. RESULTS In multivariate analysis, increasing age (P:<0.001) and previous cerebrovascular disease (P:=0.007) were independently associated with infarct rather than hemorrhage. Atrial fibrillation was associated with all nonlacunar (P:=0.02), total anterior circulation (P:=0.007), and partial anterior circulation infarcts (P:=0.02) compared with the lacunar group. All other risk factors were similar between infarct subtypes. Risk factors for hemorrhage subtypes were similar in multivariate analysis; increasing age was the only factor associated with primary intracerebral hemorrhage over subarachnoid hemorrhage (P:<0.001). The black stroke population suffered significantly less atrial fibrillation (P:=0.001) and engaged in less alcohol excess (P:<0. 001) and were less likely to have ever smoked (P:<0.001). Hypertension (P:<0.001) and diabetes mellitus (P:<0.001) were more prevalent in the black population. CONCLUSIONS Physiological cerebrovascular risk factors for the UK black population are similar to those of the US black population, but behavioral risk factors differ. Risk factors differ between ethnic groups in the United Kingdom, and future measures for secondary prevention should take this into consideration. Bamford clinical subtypes bear little association with cerebrovascular risk factors. Other classification systems, such as those that classify stroke by etiology, may be more useful in explaining the excess risk of stroke and the scope for its prevention.
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Affiliation(s)
- C Hajat
- Public Health Sciences, London, UK.
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Abstract
BACKGROUND AND PURPOSE We sought to describe the natural history of poststroke incontinence and estimate its effect on survival and 2-year outcomes in stroke survivors. METHODS Two hundred thirty-five incident cases of stroke in 1995 were classified by continence status at 10 days after stroke. Age, sex, ethnicity, diabetes, hypertension, atrial fibrillation, premorbid disability, and Oxfordshire Community Stroke Project classification were recorded. Outcome data collected at 3 months and at 1 and 2 years included disability, case-fatality rates, and institutionalization rates. Disability was classified as severe, moderate, mild, or independent using the Barthel Index (without its "continence" component: 0-9, 10-14, 15-17, and 18, respectively) and Frenchay Activity Index (0-15, 16-30, and 31-45). RESULTS Of 235 cases, 95 were initially incontinent (group 1); 140 were continent (group 2). At the initial, 3-month, and 1- and 2-year assessments, incontinence was recorded in 95 patients (40%), 34 (19%), 23 (15%), and 12 (10%), respectively. In univariate analyses, the 2 groups were not different in terms of demographic factors and risk factors. Compared with group 2, group 1 patients were more likely to have atrial fibrillation (28% versus 16%; P:=0.02). Multivariate analyses showed that age >75 years (OR 15.9; CI 2.2 to 116.2), dysphagia (OR 4.03; CI 1.85 to 8.73), motor weakness (OR 5.41; CI 1.38 to 21.1) and visual field defects (OR 4.78; CI 1.78 to 12.9) were all significantly associated with incontinence. Incontinence was less common in lacunar infarctions (OR 0.12; CI 0.02 to 0.62). At 2 years, compared with group 2, group 1 had higher case-fatality rates (67% versus 20%; P:<0.001), higher institutionalization rates (39% versus 16%; P:=0.007), and greater disability (Barthel [0-9]: 39% versus 5%; P:<0.001; Frenchay [0-15]: 75% versus 37%; P:=0.001). Death or disability at 2 years was worse in subjects with initial incontinence(OR 4.43; CI 1.76 to 11.2). CONCLUSIONS Incontinence remains a prevalent condition 2 years after stroke. Initial incontinence was associated with age >75 years, dysphagia, visual field defect, and motor weakness. Poststroke incontinence adversely affected 2-year stroke survival, disability, and institutionalization rates.
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Affiliation(s)
- M Patel
- Department of Public Health Medicine, Guy's, Kings, & St. Thomas' School of Medicine, King's College, London, England.
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Abstract
OBJECTIVE To assess the effectiveness of community-based rehabilitation for stroke patients who were not admitted to hospital in South London. DESIGN Randomized controlled trial. SETTING Patients' homes in South London. SUBJECTS Stroke patients not admitted to hospital after a stroke. INTERVENTION Rehabilitation at home by rehabilitation team for up to three months or usual care. MAIN OUTCOME MEASURES The primary outcome measure was the Barthel score. Secondary measures included the Motricity Index, Rivermead ADL, Hospital Anxiety and Depression score and Nottingham Health Profile. RESULTS Forty-three patients who remained at home were randomized to rehabilitation team (23) or 'usual' care (20). The mean number of physiotherapy sessions was three (range 1-14) for the rehabilitation team group and two for the usual care group. Patients (with a deficit) in the rehabilitation arm of the trial were more likely to receive occupational, physical and speech therapy than those in the control arm (p = 0.03, 0.01 and 0.008, respectively). For those patients actually receiving therapy, there was no evidence that the amount received differed between the groups. However, the number of patients in each of these comparisons was very small. The outcome for patients in the rehabilitation team arm of the trial was nonsignificantly higher (0.05 < p < 0.2) than for those in the control arm for the areas of Nottingham Health Profile, anxiety, depression, caregiver strain and the proportion of patients living at home. Based on the data observed here, a trial with approximately 150 patients in each arm would be needed to have adequate power to detect a 33% difference between intervention and control groups in these outcomes. CONCLUSION Community therapy support for patients not admitted to hospital is feasible but to determine whether it is cost- or clinically effective would require trials of adequate size.
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Affiliation(s)
- C D Wolfe
- Division of Public Health Sciences, Guy's and St Thomas' Hospital, London, UK.
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Wolfe CD, Giroud M, Kolominsky-Rabas P, Dundas R, Lemesle M, Heuschmann P, Rudd A. Variations in stroke incidence and survival in 3 areas of Europe. European Registries of Stroke (EROS) Collaboration. Stroke 2000; 31:2074-9. [PMID: 10978032 DOI: 10.1161/01.str.31.9.2074] [Citation(s) in RCA: 90] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Comparison of incidence and case-fatality rates for stroke in different countries may increase our understanding of the etiology of the disease, its natural history, and management. Within the context of an aging population and the trend for governments to set targets to reduce stroke risk and death from stroke, prospective comparison of such data across countries may identify what drives the variation in risk and outcome. METHODS Population-based stroke registers, using multiple sources of notification, ascertained cases of first in a lifetime stroke between 1995 and 1997 for all age groups. The study populations were in Erlangen, Germany; Dijon, France; and London, UK. Crude incidence rates were age-standardized to the European population for comparative purposes. Case-fatality rates up to 1 year after the stroke were obtained, and logistic regression adjusting for age group, sex, and pathological subtype of stroke was used to compare survival in the 3 communities. RESULTS A total of 2074 strokes were registered over the 3 years. The age-standardized rate to the European population was 100.4 (95% CI 91.7 to 109.1) per 100 000 in Dijon, 123.9 (95% CI 115.6 to 132.2) in London, and 136.4 (95% CI 124.9 to 147.9) in Erlangen. Both crude and adjusted rates were lowest in Dijon, France. The incidence rate ratio, with Dijon as the baseline comparison (1), was 1.21 (95% CI 1.09 to 1.34) in London and 1.37 (95% CI 1.22 to 1.54) in Erlangen (P:<0.0001). There were significant differences in the proportion of the subtypes of stroke between populations, with London having lower rates of cerebral infarction and higher rates of subarachnoid hemorrhage and unclassified stroke (P:<0.001). Case-fatality rates varied significantly between centers at 1 year, after adjustment for age, sex, and subtype of stroke (35% overall, 34% Erlangen, 41% London, and 27% Dijon; P:<0.001). CONCLUSIONS The impact of stroke is considerable, and the risk of stroke varies significantly between populations in Europe as does the risk of death. The striking differences in survival require clarification but lend weight to the evidence that stroke management may differ between northern and central Europe and influence outcome.
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Affiliation(s)
- C D Wolfe
- Department of Public Health Sciences, Guy's, King's and St Thomas' School of Medicine, London, UK.
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Abstract
BACKGROUND AND PURPOSE Abnormal physiological parameters after acute stroke may induce early neurological deterioration. Studies of the effect of dehydration on stroke outcome are limited. We examined the association of raised plasma osmolality on stroke outcome at 3 months and the change of plasma osmolality with hydration during the first week after stroke. METHODS Acute stroke patients had their plasma osmolality measured at admission and at days 1, 3, and 7. Maximum plasma osmolality and the area under curve (AUC) were also calculated during the first week. Patients were stratified according to how they were hydrated: orally, intravenously, or both. Outcome included survival at 3 months after stroke. Logistic regression was performed to examine the association between raised plasma osmolality (>296 mOsm/kg) and survival, adjusting for stroke severity. Linear regression was performed to examine the pattern of plasma osmolality across hydration groups. RESULTS One hundred sixty-seven patients were included. Mean admission (300 mOsm/kg, SD 11.4), maximum (308.1 mOsm/kg, SD 17.1), and AUC (298.3 mOsm/kg, SD 11.7) plasma osmolality were significantly higher in those who died compared with survivors (293.1 mOsm/kg [SD 8.2], 297.7 mOsm/kg [SD 8. 7], and 291.7 mOsm/kg [SD 8.1], respectively; P:<0.0001). Admission plasma osmolality >296 mOsm/kg was significantly associated with mortality (OR 2.4, 95% CI 1.0 to 5.9). In patients hydrated intravenously, there was no significant fall in plasma osmolality compared with patients hydrated orally (P:=0.68). CONCLUSIONS Raised plasma osmolality on admission is associated with stroke mortality, after correcting for case mix. Correction of dehydration after stroke requires a more systematic approach. Trials are required to determine whether correcting dehydration after stroke improves outcome.
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Affiliation(s)
- A Bhalla
- Department of Public Health Sciences, Guy's, King's and St Thomas' Hospital School of Medicine, Guy's and St Thomas' Hospital, London, England.
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36
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Abstract
BACKGROUND AND PURPOSE Stroke patients have a 15-fold increased risk of recurrent stroke, and those with > or =1 risk factor have a further increased risk of recurrence. Previous work found management of physiological risk factors after stroke to be unsatisfactory, but there is little information on behavioral risks within the stroke population. This study estimates behavioral risk factor prevalence after stroke and explores lifestyle change. METHODS The study used data from the population-based South London Stroke Register, collected prospectively between 1995 and 1998. Main measures included smoking status, alcohol use, and obesity. Logistic regression was used to determine sociodemographic differences in these measures. RESULTS At 1 year after stroke, 22% of patients still smoked, 36% of patients were obese, and 4% drank excessively. Younger patients, whites, and men were more likely to smoke, and younger whites were more likely to drink excessively. Women and nonwhites were more likely to be obese. Those living in hospital, nursing home, or residential care and nonwhites were more likely to give up smoking, but there were no other associations between lifestyle change and the sociodemographic characteristics of patients. CONCLUSIONS Different behavioral risk factors were associated with specific sociodemographic groups within the stroke population. After stroke, high-risk groups should continue to be targeted to prevent stroke recurrence. However, the relationship between sociodemographic characteristics and lifestyle change remains unclear; more research is needed into the process of change to find out how best to intervene to improve secondary prevention.
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Affiliation(s)
- J Redfern
- Division of Primary Care and Public Health Sciences, Guy's, King's and St Thomas' School of Medicine, King's College London, UK.
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37
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Hillen T, Dundas R, Lawrence E, Stewart JA, Rudd AG, Wolfe CD. Antithrombotic and antihypertensive management 3 months after ischemic stroke : a prospective study in an inner city population. Stroke 2000; 31:469-75. [PMID: 10657424 DOI: 10.1161/01.str.31.2.469] [Citation(s) in RCA: 46] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE We sought to examine the frequency, predictors, and effects of nontreatment with antithrombotic and antihypertensive therapies 3 months after ischemic stroke. METHODS The population-based South London Community Stroke Register prospectively collected data on first-in-a-lifetime strokes between 1995 and 1997. Among patients registered with ischemic stroke, treatment status with antithrombotic and antihypertensive therapies was examined 3 months after the event. RESULTS In a cohort of 457 patients with ischemic stroke, 393 (86.0%) were considered appropriate for antiplatelet medication, 32 (7.0%) for anticoagulant medication, and 254 (55.9%) for antihypertensive medication. The rates of nontreatment observed 3 months after the event were 24.4% for antiplatelet, 59.4% for anticoagulant, and 29.5% for antihypertensive medication. Independent risk factors for nontreatment with antithrombotic therapies (antiplatelets and anticoagulants) were the subtype of stroke (nonlacunar infarct: OR=1. 60, 95% CI 1.07 to 2.54), stroke severity measured by the Glasgow Coma Scale (GCS) score (GCS </=13: OR 2.08, 95% CI 1.18 to 3.66) and the Barthel Index (BI) score 5 days after the event (BI </=10: OR 1. 85, 95% CI 1.17 to 2.93). For antihypertensive therapies the stroke subtype (OR 2.46, 95% CI 1.33 to 4.54), GCS score (OR 2.97, 95% CI 1. 35 to 6.53), BI score (OR 2.33, 95% CI 1.27 to 4.29), and ethnicity (Caucasian: OR 2.43, 95% CI 1.15 to 5.14) were independently associated with nontreatment. Cox regression modeling showed no significant association between the treatment status and recurrence-free 3-year survival rates after controlling for severity and subtype of stroke. CONCLUSIONS Secondary prevention for a common disease such as stroke appears to be inadequate in the study area. Healthcare professionals need to consider antithrombotic and antihypertensive therapies for all stroke patients.
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Affiliation(s)
- T Hillen
- Division of Primary Care and Public Health Sciences, Guy's, King's and St Thomas' School of Medicine, King's College London, UK
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38
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Abstract
The socio-economic impact of stroke is considerable world-wide. Stroke is assuming an increasing impact in terms of media attention, patient and career knowledge, service developments and research. It is estimated that there are 4.5 million deaths a year from stroke in the world and over 9 million stroke survivors. Almost one in four men and nearly one in five women aged 45 years can expect to have a stroke if they live to their 85th year. The overall incidence rate of stroke is around 2-2.5 per thousand population. The risk of recurrence over 5 years is 15-40%. It is estimated that by 2023 there will be an absolute increase in the number of patients experiencing a first ever stroke of about 30% compared with 1983. There is a total prevalence rate of around 5 per thousand population. One year after a stroke, 65% of survivors are functionally independent, stroke comprising the major cause of adult disability.
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Affiliation(s)
- C D Wolfe
- Department of Public Health Sciences, Guy's, King's and St Thomas' Hospitals School of Medicine, London, UK
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39
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Abstract
BACKGROUND Stroke patients are usually admitted to hospital for their acute care and rehabilitation. Services to help acute stroke patients avoid admission to hospital ("hospital-at-home") have now been developed. OBJECTIVES The objective of this review was to establish the costs and effects of such services compared with conventional services. SEARCH STRATEGY The Stroke Group Specialist Register of Controlled Trials was searched and supplemented by discussion with colleagues and trialists. This was last updated in March 1999. SELECTION CRITERIA Controlled clinical trials recruiting stroke patients who have not been admitted to hospital and compare; a) services which provided support with an aim of helping prevent admission to hospital with b) conventional services (which could include hospital admission). DATA COLLECTION AND ANALYSIS Two independent reviewers determined the eligibility and methodological quality of trials. Trialists were then contacted to obtain standardised descriptive and outcome data. MAIN RESULTS Four trials are included in the review of which three currently have outcome data available (921 patients; 857 from one controlled trial, 64 from two randomised trials). There were no statistically significant differences between the patient and carer outcomes of the intervention and control groups either within individual trials or in pooled analyses. There was a trend toward greater hospital bed use and increased costs in the intervention groups. REVIEWER'S CONCLUSIONS There is currently no evidence from clinical trials to support a radical shift in the care of acute stroke patients from hospital-based care.
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Affiliation(s)
- P Langhorne
- Academic Section of Geriatric Medicine, 3rd Floor, Centre Block, Royal Infirmary, Glasgow, UK, G4 0SF.
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40
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Abstract
Differences in growth were investigated among ethnic groups in low-birthweight babies (< 2500 g or < 32 weeks gestation) at birth and at 2-3 years. This prospective study was based on data for all 3091 low-birthweight live births in the South East Thames Region, UK, over a 1-year period, surviving to discharge from hospital. Weights were recorded at birth and at 2-3 years for 998 babies, and head circumferences for 859. These were compared with the UK 1990 reference standards. Ethnic differences were adjusted for parity, multiple birth, smoking and alcohol during pregnancy, mother's height, weight and age, marital status, partner's support and social class. At 2-3 years, there was substantial average catch-up growth only for the weight of infants of > or = 32 weeks' gestation. Babies < 32 weeks gestation had fallen behind. Head circumferences had failed to keep up or had fallen behind for both groups. The ethnic groups had similar birthweight standard deviation scores (SDS). At 2-3 years, Black babies of < 32 weeks' gestation had gained in weight and head circumference compared with White babies (adjusted difference in weight SDS: 0.71, [95% CI 0.28, 1.13]). Asian babies of at least 32 weeks' gestation had smaller heads than White, a difference that increased with time. It was concluded that ethnic differences in the growth of low-birthweight infants are related to gestational age. Although most of the babies born at < 28 weeks' gestation were close to their birthweight reference standards, only the Black infants had maintained their position at 2-3 years. Black infants, particularly when born preterm, tend to put on more weight than White.
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Affiliation(s)
- P T Seed
- Department of Public Health Sciences, Guy's, King's and St. Thomas' School of Medicine, King's College London, UK.
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Di Carlo A, Lamassa M, Pracucci G, Basile AM, Trefoloni G, Vanni P, Wolfe CD, Tilling K, Ebrahim S, Inzitari D. Stroke in the very old : clinical presentation and determinants of 3-month functional outcome: A European perspective. European BIOMED Study of Stroke Care Group. Stroke 1999; 30:2313-9. [PMID: 10548664 DOI: 10.1161/01.str.30.11.2313] [Citation(s) in RCA: 154] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE The oldest old represent the fastest-growing segment of the elderly population in developed countries. Knowledge of age-specific aspects of stroke is essential to establish diagnostic and therapeutic pathways and to set up prevention and rehabilitation programs. We sought to evaluate stroke features and functional outcome in patients aged >/=80 years compared with the younger age groups. METHODS In a European Union Concerted Action involving 7 countries, 4499 patients hospitalized for first-in-a-lifetime stroke were evaluated for demographics, risk factors, clinical presentation, resource use, and 3-month disability (Barthel Index) and handicap (Rankin Scale). RESULTS Overall, 3141 patients (69.8%) were aged <80 years, and 1358 (30.2%) were aged >/=80 years. At baseline, female sex, prestroke institutionalization, and a worse prestroke Rankin score were significantly more frequent in the older patients, as were coma, paralysis, swallowing problems, and urinary incontinence in the acute phase (all P values <0.001). Brain imaging and other diagnostic tools were significantly less used in the older patients. Paralysis, swallowing problems, and incontinence during hospitalization independently predicted 3-month disability or handicap in both groups. For the older patients, prestroke institutionalization proved a further strong and independent determinant of 3-month disability (odds ratio, 2.33; 95% CI, 1.22 to 4.45) and handicap (odds ratio, 7.04; 95% CI, 1.62 to 30. 69). CONCLUSIONS In the very old, both medical and sociodemographic factors may significantly influence stroke outcome, showing peculiar characteristics. Knowledge of these determinants may reduce the burden on health systems, improving quality of care.
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Affiliation(s)
- A Di Carlo
- National Research Council of Italy (CNR-CSFET), Italian Longitudinal Study on Aging, Florence, Italy
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42
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Abstract
OBJECTIVE To identify ethnic differences in the incidence of first ever stroke. DESIGN A prospective community stroke register (1995-6) with multiple notification sources. Pathological classification of stroke in all cases was based on brain imaging or necropsy data. Rates were standardised to European and world populations and adjusted for age, sex, and social class in multivariate analysis. SETTING A multi-ethnic population of 234 533 in south London, of whom 21% are black. RESULTS 612 strokes were registered. The crude annual incidence rate was 1.3 strokes per 1000 population per year (95% confidence interval 1.20 to 1.41) and 1.25 per 1000 population per year (1.15 to 1.35) age adjusted to the standard European population. Incidence rates adjusted for age and sex were significantly higher in black compared with white people (P<0.0001), with an incidence rate ratio of 2.21 (1.77 to 2.76). In multivariable analysis increasing age (P<0.0001), male sex (P<0.003), black ethnic group (P<0.0001), and lower social class (P<0.0001) in people aged 35-64 were independently associated with an increased incidence of stroke. CONCLUSIONS Incidence rates of stroke are higher in the black population; this is not explained by confounders such as social class, age, and sex. Ethnic differences in genetic, physiological, and behavioural risk factors for stroke require further elucidation to aid development of effective strategies for stroke prevention in multi-ethnic communities.
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Affiliation(s)
- J A Stewart
- Department of Public Health Sciences, Guy's, King's College, and St Thomas's School of Medicine, 5th Floor, Capital House, London SE1 3QD
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Beech R, Rudd AG, Tilling K, Wolfe CD. Economic consequences of early inpatient discharge to community-based rehabilitation for stroke in an inner-London teaching hospital. Stroke 1999; 30:729-35. [PMID: 10187870 DOI: 10.1161/01.str.30.4.729] [Citation(s) in RCA: 78] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE In an inner-London teaching hospital, a randomized trial of "conventional" care versus early discharge to community-based therapy found no significant differences in clinical outcomes between patient groups. This report examines the economic consequences of the alternative strategies. METHODS One hundred sixty-seven patients received the early discharge package, and 164 received conventional care. Patient utilization of health and social services was recorded over a 12-month period, and cost was determined using data from provider departments and other published sources. RESULTS Inpatient stay after randomization was 12 days (intervention group) versus 18 days (controls) (P=0.0001). Average units of therapy per patient were as follows: physiotherapy, 22.4 (early discharge) versus 15.0 (conventional) (P=0.0006); occupational therapy, 29.0 versus 23.8 (P=0.002); speech therapy, 13. 7 versus 5.8 (P=0.0001). The early discharge group had more annual hospital physician contacts (P=0.015) and general practitioner clinic visits (P=0.019) but fewer incidences of day hospital attendance (P=0.04). Other differences in utilization were nonsignificant. Average annual costs per patient were pound sterling 6800 (early discharge) and pound sterling 7432 (conventional). The early discharge group had lower inpatient costs per patient (pound sterling 4862 [71% of total cost] versus pound sterling 6343 [85%] for controls) but higher non-inpatient costs (pound sterling 1938 [29%] versus pound sterling 1089 [15%]). Further analysis demonstrated that early discharge is unlikely to lead to financial savings; its main benefit is to release capacity for an expansion in stroke caseload. CONCLUSIONS Overall results of this trial indicate that early discharge to community rehabilitation for stroke is cost-effective. It may provide a means of addressing the predicted increase in need for stroke care within existing hospital capacity.
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Affiliation(s)
- R Beech
- Centre for Health Planning and Management, Keele University, Staffs, England.
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44
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Wolfe CD, Tilling K, Beech R, Rudd AG. Variations in case fatality and dependency from stroke in western and central Europe. The European BIOMED Study of Stroke Care Group. Stroke 1999; 30:350-6. [PMID: 9933270 DOI: 10.1161/01.str.30.2.350] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- C D Wolfe
- Department of Public Health Sciences, The Guy's, Kings College, St Thomas' Hospital Medical and Dental School, London, England, UK.
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Abstract
BACKGROUND AND PURPOSE Despite the volume of research into patient satisfaction, it is not clear whether satisfaction ratings reflect differences in care received after stroke or the characteristics of patients. The aim of this study is to test the hypothesis that patient satisfaction is independently related to differences in care received after stroke. METHODS Stroke patients participating in a randomized controlled trial of early discharge to community therapy completed a satisfaction questionnaire and physical and psychological outcome measures at 4 and 12 months. Two hundred seventy-four patients (83%) were followed up at 4 months and 262 patients (79%) at 12 months. Use of therapy and community services was quantified. Logistic regression was used to investigate associations between satisfaction, patient characteristics, and service provision. RESULTS The more therapy, meals on wheels, and home help visits patients received, the more likely they were to be satisfied. Patients in the conventional arm of the trial were less likely to express satisfaction than those discharged early to community therapy. Women, older people, anxious people, and those more functionally independent were more likely to be satisfied, while those with depression, speech and swallowing deficit, motor deficit, and poor subjective health were less likely to be satisfied. CONCLUSIONS The finding that satisfaction assessments reflect real differences in the provision of care and occur independently of any associations with patient characteristics is new. Patient satisfaction should be taken seriously as an outcome.
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Affiliation(s)
- P Pound
- Department of Public Health Sciences, Guy's, King's and St Thomas' School of Medicine, and Elderly Care Unit, St Thomas' Hospital, London,
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Duffy TA, Wolfe CD, Varden C, Kennedy J, Chrystie IL. Women's knowledge and attitudes, and the acceptability of voluntary antenatal HIV testing. Br J Obstet Gynaecol 1998; 105:849-54. [PMID: 9746376 DOI: 10.1111/j.1471-0528.1998.tb10228.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To assess pregnant women's knowledge of, and attitudes towards, antenatal HIV testing, and its acceptability to them. SETTING Antenatal clinic at Guy's Hospital, London, six community antenatal clinics and a midwifery group practice. POPULATION Eight hundred and forty-three women attending the antenatal clinics. METHOD The women received a leaflet explaining HIV testing, and completed a questionnaire before and after their booking appointment. This included an assessment of their knowledge of, and attitudes towards HIV testing, and its acceptability. RESULTS Seven hundred and eighty-nine women (94%) completed questionnaires. Fifty-one percent (n = 405) were Caucasian, 25% (n = 195) African, 11% (n = 86) West Indian and 13% (n = 100) were from other ethnic groups. Fifty-eight percent received the HIV information leaflet, of whom 86% had read it. Knowledge relating to HIV was good, the median knowledge score being 6 out of a possible 8, but it was less in non-Caucasian women and those with lower educational qualifications. Knowledge was not related to uptake of testing. Thirty-five percent of women accepted the offer of an HIV test, rates being higher in hospital clinics (41%) than in the midwifery group practice (10%) and the community clinics (30%). Women more likely to accept the offer of an HIV test were non-Caucasian (P = 0.0443), those who had thought about the HIV test before this pregnancy (P = 0.0298) and those seeing one particular midwife (P = 0.0003). Most women (67%) thought that all pregnant women should be offered the HIV test and then make their own decision. Overall, 64% women did not change their original pre-discussion decision on testing for HIV. Thirty-six percent of women changed their decision from 'yes' to 'no' or 'don't know' after seeing the midwife. Women attending the community clinics (P = 0.003) and those who had been tested before (P = 0.0451) were more likely to change their decision. CONCLUSION This study, in a multiethnic population, has shown that knowledge regarding HIV is good but does not increase the uptake of testing. Women prefer to be offered the HIV test and make their own choice regarding whether to accept it.
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Affiliation(s)
- T A Duffy
- Women's Services, Guy's and St Thomas' Hospitals Trust, London, UK
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Dennison B, Kennedy J, Tilling K, Wolfe CD, Chrystie IL, Banatvala JE. Feasibility of named antenatal HIV screening in an inner city population. AIDS Care 1998; 10:259-65. [PMID: 9828970 DOI: 10.1080/713612415] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
The object of this study was to assess the resource use, feasibility, uptake and consumers' perspective of introducing routine named human immunodeficiency virus (HIV) testing into an inner city hospital antenatal clinic (St Thomas Hospital, part of Guy's and St Thomas Hospital Trust). Following the introduction of a new service offering routine named HIV testing at booking appointments, the length of the appointments were recorded over a three-month period and compared with appointment lengths in the previously existing service. Women being offered routine named HIV testing were asked to complete a questionnaire before and after their appointment to assess knowledge, attitudes and acceptability of HIV testing. Subjects were three-hundred-and-eighty-one pregnant women attending the antenatal clinic for their booking appointment. There was no significant difference in the length of the booking appointments following the introduction of offering routine named HIV testing. One-hundred-and-fifty-eight women (42%) consented to testing with no positive results detected. There was a significant rise in the uptake of the test over the three-month period. No other variables (demographics, perceived risk, having read the leaflet) were predictive of uptake. Anxiety scores were significantly less after the booking appointment. Routine named HIV testing was feasibly introduced into a hospital antenatal clinic with minimum resource implications. Further study is needed to monitor the ongoing uptake rate and identification of HIV-positive women before a decision can be made as to the long-term benefit of this new service. Women considered it acceptable to be offered the HIV test and were less anxious after their appointments.
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Affiliation(s)
- B Dennison
- Guy's and St Thomas' Hospitals Trust, London, UK
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Morgan M, Fenwick N, McKenzie C, Wolfe CD. Quality of midwifery led care: assessing the effects of different models of continuity for women's satisfaction. Qual Health Care 1998; 7:77-82. [PMID: 10180794 PMCID: PMC2483588 DOI: 10.1136/qshc.7.2.77] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND Changing Childbirth (1993), a report on the future of maternity services in the United Kingdom, endorsed the development of a primarily community based midwifery led service for normal pregnancy, with priority given to the provision of "woman centred care". This has led to the development of local schemes emphasising continuity of midwifery care and increased choice and control for women. AIMS To compare two models of midwifery group practices (shared caseload and personal caseload) in terms of: (a) the extent to which women see the same midwife antenatally and know the delivery midwife, and (b) women's preference for continuity and satisfaction with their care. METHODS A review of maternity case notes and survey of a cohort of women at 36 weeks of gestation and 2 weeks postpartum who attended the two midwifery group practices. Questionnaires were completed by 247 women antenatally (72% response) and 222 (68%) postnatally. Outcome measures were the level of continuity experienced during antenatal, intrapartum, and postnatal care, women's preferences for continuity of carer, and ratings of satisfaction with care. RESULTS The higher level of antenatal continuity of carer with personal caseload midwifery was associated with a lower percentage having previously met their main delivery midwife (60% v 74%). Women's preferences for antenatal continuity were significantly associated with their experiences. Postnatal rating of knowing the delivery midwife as "very important indeed" was associated with both previous antenatal ratings of its importance, and women's actual experiences. Personal continuity of carer was not a clear predictor of women's satisfaction with care. Of greater importance were women's expectations, their relations with midwives, communication, and involvement in decision making. CONCLUSIONS Midwifery led schemes based on both shared and personal caseloads are acceptable to women. More important determinants of quality and women's satisfaction are the ethos of care consistency of care, good communication, and participation in decisions.
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Affiliation(s)
- M Morgan
- Department of Public Health Medicine, United Medical and Dental Schools, St Thomas' Hospital, London, UK
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Tilling K, Wolfe CD, Raju KS. Variations in the management and survival of women with endometrial cancer in south east England. EUR J GYNAECOL ONCOL 1998; 19:64-8. [PMID: 9476063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVES To compare the management of women with endometrial cancer to locally developed clinical guidelines, and to examine the factors influencing their survival. STUDY DESIGN Observational study in seven districts of the South East Thames Regional Health Authority. RESULTS 133 women were diagnosed with endometrial cancer. 40 (30%) women had all appropriate staging investigations, stage was stated in the notes for 38 (29%) women, and 42 (32%) women were treated appropriately. Forty-three (32%) women died during the study period. Histology of adenocarcinoma, stage I disease, appropriate surgery/radiotherapy, good differentiation of tumour and depth of myometrial invasion less than two-thirds were significantly associated with increased survival. CONCLUSIONS In addition to the usual clinical variables, appropriate treatment was associated with increased survival. Adherence to the guidelines for both treatment and staging was low, so ways of improving compliance with guidelines need to be found.
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Affiliation(s)
- K Tilling
- Division of Public Health Sciences, United Medical School of Guy's Hospital, London, United Kingdom
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Duffy TA, Wolfe CD, Varden C, Kennedy J, Chrystie IL, Banatvala JE. Antenatal HIV testing: current problems, future solutions. Survey of uptake in one London hospital. BMJ 1998; 316:270-1. [PMID: 9472508 PMCID: PMC2665514 DOI: 10.1136/bmj.316.7127.270] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- T A Duffy
- Department of Midwifery, Guy's NHS Trust, St Thomas's Hospital, London
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