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BETTER STROKE CARE AND MORTALITY
- Pazhvoor shibu, Peter O Agyei , Sunku H Guptha (27 August 2007)
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Management of acute stroke
- Roger A Fisken (27 August 2007)
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Stroke: full system development required
- Desmond O'Neill, Daniel Ronan Collins (29 August 2007)
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Imaging capacity must meet demand
- S. Michael Crawford (29 August 2007)
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What about TIA ?
- L S Lewis (29 August 2007)
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Variables not parameters
- Neville W Goodman (29 August 2007)
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Stroke Outcomes are also Influenced by Organised, Timely and Intensive Rehabilitation
- Ruth M Kent, Professor MA Chamberlain, emeritus Professor of Rehabilitation Medicine University of Leeds (29 August 2007)
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Acute Stroke Care: Science not Politics
- David Barer (30 August 2007)
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Improving the outcome of stroke
- Philip L Clatworthy, Diana J. Day, Jean-Claude Baron, Elizabeth A. Warburton (30 August 2007)
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Pazhvoor shibu, Specialist Registrar Peterborough District Hospital,pe296ur, Peter O Agyei , Sunku H Guptha
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We agree with the article by Professor Marcus which suggests that stroke outcomes are worse in the United Kingdom compared to similar European countries despite matched overall stroke care costs.1 This suggests a lack of relation between overall resource use and clinical stroke outcome.2 Our local experience reiterates the effects of improved acute stroke care on overall mortality rates. Local stroke guidelines were introduced in 1999 and we later also used the national guidelines which were first published in 2000 by The Royal College of Physicians.3 We audited all adult stroke admissions in 1998 and 2005 to our large district hospital with a designated stroke unit. There were 369 patients in 1998 and 331 in 2005. The rate of brain imaging was 66% in 1998 and 95% in 2005 (p<0.05). Appropriate use of aspirin in ischemic stroke was 87% (156/179) in 1998 and 99% (260/262) in 2005 (p<0.05). Appropriate prescriptions for anticoagulation for AF in patients with ischemic stroke were 59% (22/37) in 1998 and 77% (24/31) in 2005 (p<0.05). The number of stroke patients who died in hospital was 40% (146/369) in 1998 and 29% (97/331) in 2005(p=0.005). Our data shows significant improvement in brain imaging and the use of anti-thrombotic agents. The implementation of stroke guidelines is at least partly responsible for the improvement in patient care which has translated to a significant reduction in stroke mortality. We expect a reorganisation of stroke services as suggested by Professor Marcus1 to result in a further improvement in our local stroke outcome and should therefore be considered as a priority. References 1. Marcus H. Improving the outcome of stroke. BMJ 2007;335:359-60. 2. Asplund K. Health care resource use and stroke outcome. Multinational comparisons within the GAIN International trial. International Journal of Technology Assessment in Health Care. 19(2):267- 77, 2003. 3. Royal College of Physicians. National clinical guidelines for stroke, 2nd edition. Prepared by the Intercollegiate Stroke Working Party. London: RCP, 2004. Competing interests: None declared |
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Roger A Fisken, Consultant Physician Friarage Hospital, Northallerton, North Yorkshire, UK,, DL6 1JG
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I have to confess to some disappointment with this article, which seems to be long on rhetoric and short on evidence. Despite claims that things are done better in Europe we are not told much about how services can be improved to give better clinical outcomes. We are told that the best services in other countries can deliver thrombolysis to patients with cerebral thrombosis in up to 30% of cases. However, as Markus himself concedes, much of the delay associated with scanning of patients with suspected stroke relates to the behaviour of the patients and their families; how do other countries manage to do better? For those patients who present beyond about two and a half hours from the onset of symptoms Markus present no evidence that scanning needs to be done immediately: his reference to the paper by Wardlaw et al (reference 7) is actually a misquotation, as the paper deals with cost-utility arguments based on the interaction between various strategies for CT scanning and the daily cost of an inpatient stay - the paper says nothing about early scanning improving clinical outcomes. Wardlaw et al do, moreover, point out that the majority of stroke patients will receive aspirin as their definitive therapy and go on to confirm that there is no evidence for a time-dependency of the effect of aspirin within the first 48 hours after a stroke. I do not mind at all lobbying for better services for stroke patients but I would like to know what I am lobbying for and why. Competing interests: None declared |
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Desmond O'Neill, consultant physician in geriatric & stroke medicine Stroke-Service /Age-Related Health Care, Adelaide & Meath Hospital Tallaght, Dublin 24, Daniel Ronan Collins
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Writing from the perspective of a country where only 3% of hospitals have an acute stroke unit and which, like the UK, seems to perform less well in international comparisons of outcomes of stroke care (1), we would welcome the general thrust of Prof Marcus’ commentary on the urgent need to develop stroke services. However, we would question his interpretation of acknowledged “limited available data” citing Grieve et al (2) that successful outcome was predominantly linked to focussing resources more heavily on the acute aspects of care. This may fail to recognize the role of a well developed system which also includes rehabilitation, multidisciplinary input, outpatient and community care: the best performing centres in this paper had strong elements of all of these components of a complete service. Conversely, in countries with lower performance, deficits are found at all levels of the system (3). .... While making acute stroke unit care universal and a radical improvement in provision of thrombolysis is needed in the UK and Ireland, there is also a need to ensure that the full range of needs of patients with high levels of co-morbidity and functional deficits are met, and the template of the American Stroke Association for developing stroke systems is helpful in this regard (4), as is the recognition of the range of skills and care philosophies which can improve stroke care (5). The task of designing and implementing systems for people with such complex needs is likely to be helped by the positive and creative interaction of the key medical disciplines involved in providing specialist stroke care – geriatric medicine, neurology and rehabilitation medicine – and the UK and Ireland are fortunate in this regard that leadership in stroke medicine has developed in an atmosphere of good joint working between the disciplines. ..... 1) Gray LJ, Sprigg N, Bath PM, Sorensen P, Lindenstrom E, Boysen G, De Deyn PP, Friis P, Leys D, Marttila R, Olsson JE, O'Neill D, Ringelstein B, van der Sande JJ, Turpie AG; TAIST Investigators. Significant variation in mortality and functional outcome after acute ischaemic stroke between Western countries: data from the tinzaparin in acute ischaemic stroke trial (TAIST). J Neurol Neurosurg Psychiatry. 2006;77:327-33. 2) Grieve R, Hutton J, Bhalla A, Rastenytë D, Ryglewicz D, Sarti C, et al. A comparison of the costs and survival of hospital-admitted stroke patients across Europe. Stroke 2001;32:1684-91. 3) Horgan F, Hickey A, Murphy S, Wiley M, Conroy R, McGee H, O'Neill D on behalf of the Irish National Audit of Stroke Care. First Irish National Audit of Stroke Care, Cerebrovascular Diseases 2007; 23(Suppl 2):132. 4) Schwamm LH, Pancioli A, Acker JE 3rd, Goldstein LB, Zorowitz RD, Shephard TJ, Moyer P, Gorman M, Johnston SC, Duncan PW, Gorelick P, Frank J, Stranne SK, Smith R, Federspiel W, Horton KB, Magnis E, Adams RJ; American Stroke Association's Task Force on the Development of Stroke Systems. Recommendations for the establishment of stroke systems of care: recommendations from the American Stroke Association's Task Force on the Development of Stroke Systems. Circulation. 2005;111:1078-91. 5) Pound P, Sabin C, Ebrahim S. Observing the process of care: a stroke unit, elderly care unit and general medical ward compared. Age Ageing. 1999;28:433-40. Competing interests: None declared |
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S. Michael Crawford, Consultant Medical Oncologist Airedale General Hospital, Keighley, West Yorkshire. BD20 6TD
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Markus’s editorial[1] on stroke management neatly illustrates one of the points I made in the letter printed immediately after it[2] . He describes the need for thrombolytic therapy to be administered within 3 hours of the onset of symptoms to patients identified as being suitable by CT imaging; this investigation therefore needs to be performed on all cases where acute stroke illness is part of the differential diagnosis. The capacity for such urgent imaging, preceded by minimal clinical assessment as implied by the analogy with the electrocardiogram, needs to accommodate every patient who is thought by the paramedic, general practitioner or accident and emergency doctor to have some possibility of having a stroke. If the capacity is too low, diagnostic discriminants will have to be devised such as those for suspected breast cancer that were previously discussed[2]. In protecting an inadequate service, sensitivity would be sacrificed for specificity; the healthcare worker’s concern for the patient would sacrifice specificity for sensitivity. This is seen not only in referral criteria for suspected cancer but also in the decisions of NHS Direct employees and in the relationships between midwife- and consultant-led obstetric services, for example. The alternative is to provide the service in more hospitals than would be assumed by the instinct of the academic specialist or of the Department of Health official. References 1] Markus H. Improving the outcome of stroke. BMJ 2007;335:359-360 (25 August) 2] Crawford SM, Breast cancer experience has wider implications BMJ.2007; 335: 361 (25 August) Competing interests: I practise in a tertiary referral specialty within a district general hospital. |
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L S Lewis, GP Surgery, Newport, Pembrokeshire SA42 0TJ
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Markus lobbies hard for the reorganisation of UK Stroke Care, and starts from the sensible premise of comparing like-for-like. Given the same acute Stroke case-mix, and the same funds - who/what delivers the most effective outcomes ? Markus contends that the UK fails principally because it is organisationally 'neolistic' ( neologism for 'nihilistic' ? ) and hence cannot provide early thrombolysis. Our spending currently goes on chronic stroke care, which should only be recouped and re-invested into acute stroke care after some NEW development money is injected. I concur with Fisken, in wanting to see more trialled evidence, of exactly what we propose to purchase. I am concerned that if we GPs re- learn to treat every 'suspected Stroke' as an emergency in need of admission and possible thrombolysis , then Markus has grossly underestimated the size of the problem. There are very many 'TIA' cases which UK GPs currently 'thrombolyse' with an Aspirin, after a quick primary care 'bedside brain scan' (which captures the patients' functional loss, social support and home circumstances in a single 3D snapshot). The great majority of my patients eligible for Markus' thrombolysis do not go to hospital, and recover within 24 hours of aspirin ( albeit to go on possibly to a more damaging stroke at a later date ). Won't they all now have to be admitted - and likely get IV thrombolysis ? Maybe acute Clopidogrel should be trialled ?? Competing interests: None declared |
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Neville W Goodman, Consultant Anaesthetist Southmead Hospital, Bristol, BS10 5NB
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It is physiological variables, not parameters, that need better monitoring and treatment. Perhaps now that BMJ editorials are misusing the word parameter, it is time to give up trying to save it. But I still ask the question "What idea can scientists who have described their variables (their data) as parameters have" (1) of the distinction between variables that follow parametric and non-parametric distributions? Reference: 1 Goodman NW. Paradigm, parameter, paralysis of mind. BMJ 1993;307:1627-9. Competing interests: None declared |
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Ruth M Kent, Consultant and Senior Lecturer in Neurological Rehabilitation Mid Yorks NHS Hospital Trust WF1 4DG, Professor MA Chamberlain, emeritus Professor of Rehabilitation Medicine University of Leeds
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Professor Markus rightly points out that the outcome of current stroke management in the UK is currently worse than many areas of Europe (1). This may be an argument for greater availability of acute thrombolysis, through the implementation of organised stroke services. This is also a powerful argument for the adequate provision of expert, medically led and interdisciplinary rehabilitation services, available from the first day. Thrombolysis is appropriate to a minority of individuals with stroke, but intensive, organised, and timely rehabilitation has a greater effect on stroke outcomes in most individuals; therefore overall benefit will be significant (2). Neural plasticity needs to be utilised both in the acute and post acute phases of stroke care, and outcomes depend on effective rehabilitation interventions provided at sufficient intensity. Stroke outcome is more than mortality, given that some 50% of survivors remain disabled; the degree of disability and its impact on the family and society is therefore a key outcome. Quality of life after stroke is affected by the level of disability, and dependency on others carries a social and economic cost. A reduction in the cost of dependency is an important outcome, and is shown in the following example of an individual with stroke treated in a specialist rehabilitation service. Calculated care costs per week as evaluated by the Northwick Park Care Needs Assessment Scale (3.4), were shown to have reduced from £1232 per week (Barthel index 55/100), had he been discharged at that point, during the week of admission to £168 seven weeks later (Barthel index 94/100). This individual by virtue of his young age would have an 80% chance of surviving 10 years (5), following the stroke therefore the cumulative cost savings were potentially substantial. Stroke rehabilitation is not available to all stroke survivors, and the organisation of services needs to take this into account. It is perhaps not a coincidence that the UK has the second lowest number of Rehabilitation Medicine Consultants in Europe (6), which gives an indication of the number of medical services dedicated to the rehabilitation of individuals with complex conditions such as stroke. It is also worth noting that in 2006, over 1000 physiotherapists were unemployed in the UK. If we are to respond properly to the needs of a large number of people with stroke, a full spectrum of coordinated clinical services including appropriate, timely and intensive rehabilitation must be provided References 1. Markus H, Improving the outcome of stroke BMJ 2007;335:359-360 (25 August), 2. Stroke Unit Trialists' Collaboration. Organised inpatient (stroke unit) care for stroke. In: The Cochrane Library, Issue 2, 2006. Chichester, UK: John Wiley & Sons, Ltd. Search date 2001 3. L Turner-Stokes K Nyein The Northwick Park Care Needs Assessment (NPCNA): a directly costable outcome measure in rehabilitation Clinical Rehabilitation, Vol. 13, No. 3, 253-267 (1999) 4. L Turner-Stokes, S Paul, and H Williams Efficiency of specialist rehabilitation in reducing dependency and costs of continuing care for adults with complex acquired brain injuries J. Neurol. Neurosurg. Psychiatry, May 1, 2006; 77(5): 634 - 639. 5. . Carter A M, Catto, AJ. Mansfield MW, Bamford JM, and Grant PJ Predictive Variables for Mortality After Acute Ischemic Stroke Stroke 2007 38: 1873 - 1880 6. C Gutenbrunner, AB Ward, MA Chamberlain White book on Physical and Rehabilitation Medicine in Europe. J Rehabil Med. 2007 Jan;(45 Suppl):6- 47. Competing interests: None declared |
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David Barer, Consultant / Professor in Stroke Medicine Queen Elizabeth Hospital, Gateshead NE9 6SX
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While I would not argue with Hugh Markus that much needs to be done to improve acute stroke care in the UK (1), there are dangers in prescribing a remedy based on polemic rather than scientific evidence. Comparative studies over the past 15 years (2) have shown striking and puzzling discrepancies in outcome for patients admitted with acute stroke to hospitals in the British Isles and in other countries, but the evidence is shaky, no convincing explanation has been found and there is nothing to suggest that any of these self-selected centres are representative of their countries as a whole. Markus then makes a dizzying leap from a discussion about outcomes to a plea to reorganise acute stroke care to improve access to thrombolysis. This is a leap of faith: not one patient received thrombolytic treatment in the studies he quotes, but such subtleties will be lost in the political hubbub about the NHS letting us all down yet again. Naturally it is frustrating that after 25 years’ research, we have only one drug treatment, alteplase, which seems to work, and we only manage to give it to 2% of our patients, but we should not put all our eggs in this basket. About 1 in 8 patients would expect to obtain major benefit from thrombolytic treatment, so even if we could increase the proportion treated to 20%, about 1 in 40 patients would benefit overall. To achieve this, Markus suggests that patients should receive “rapid ambulance assessment” and perhaps half would be transferred to “specialised stroke centres”, some distance away (1). What of the patients not transferred and condemned to “second class care” in their local hospital? This would presumably include anyone over 80 (over 30% of acute stroke patients) as there is insufficient evidence of benefit for alteplase to be licensed in this agegroup. What of the many patients rushed to the specialist hospital in the hope of getting clot-busting treatment but found to be unsuitable? The logistics are nightmarish and the sense of frustration among those whose hopes are dashed would be fertile soil for media mischief. Inevitably, the risks and limitations of alteplase would be ignored and it would become yet another wonder drug, being denied to thousands of NHS patients. We should not forget that the only proven effective treatment for the majority of stroke patients is specialist, multidisciplinary team-based, stroke unit care (3). While we have no magic formula for this, there is no doubt that good coordination, communication and continuity of care are essential ingredients, and these would be put at risk if large numbers of patients received acute care and rehabilitation in different trusts, looked after by different teams. There is no reason why patients with acute stroke, admitted to any reasonably-sized hospital, should not have access to immediate brain scanning and expert assessment, if necessary via telemedicine links, but we need to develop these services quickly and quietly, without hyperbole and fuss. Our impatience with the inadequacies of current services should not lead us to develop a two-tier elitist system, which could let down the majority of stroke patients, or to unleash a political storm which we will certainly not be able to control. 1. Marcus H. Improving the outcome of stroke. BMJ 2007;335:359-60. 2. European Stroke Database Acute Stroke Management Study Group. Case-mix, management and outcome of acute stroke care in different European regions. http://www.ncl.ac.uk/stroke-research- unit/esdb/postpap.htm 1997. Accessed 27/8/07 3. Stroke Unit Trialists' Collaboration. Organised inpatient (stroke unit) care for stroke. Cochrane Database of Systematic Reviews 2001, Issue 3. Art. No.: CD000197. Competing interests: None declared |
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Philip L Clatworthy, Honorary Registrar Neurology Cambridge University Hospitals NHS Foundation Trust, CB2 2QQ, Diana J. Day, Jean-Claude Baron, Elizabeth A. Warburton
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We write in support of Professor Markus’ letter published on 25 August (BMJ 335; 359-360). We agree that stroke care should be organised to maximise the potential for recovery from the very first minutes of a stroke. In 2002 we restructured our stroke care pathway to reflect this ethos. This involved many of the changes Professor Markus describes in his letter; they are detailed below. Local paramedics have been trained to recognise clinical features of stroke and transfer patients urgently, diverting them from district general hospitals to our specialist centre if appropriate. A stroke team specialist nurse is informed while the patient is in transit and assesses the patient on arrival in the Emergency Department (ED), without the need for a thorough assessment by an ED physician. Imaging is immediately available and CT scanning lists are routinely interrupted for acute stroke patients. Medical cover twenty-four hours a day has been achieved by collaboration between the stroke medicine department and neurology department, with out of hours calls from the ED being directed to the on call neurology registrar. Once imaging has been performed stroke patients are treated with thrombolysis if appropriate and transferred immediately to a bay within the stroke unit with basic monitoring facilities. Care is focussed on early identification and management of physiological instability and other complications. Other therapies such as physiotherapy and speech therapy are started at the earliest possible opportunity. This year we performed a retrospective analysis of data from our stroke database for the period encompassing the changes to our stroke service. After restructuring our service the proportion of stroke patients reaching the stroke unit increased from 54% to 85%. On average we now thrombolyse 4.5% of our stroke patients. Based on an estimated 20% of stroke patients being eligible for thrombolysis this equates to more than 20% of eligible patients. Rapid (<24 hours) admission to the stroke unit resulted in reduced mortality compared with delayed (>48 hours) admission (16% compared with 25%; p=0.05). Outcome, measured as discharge destination, was also significantly better with rapid admission (72% went home compared with 61%; 28% were discharged to continuing care compared with 39%; p=0.02, Pearson’s Chi-square). Finally, since introducing these changes the average length of stay in hospital for our stroke patients has fallen from 27 days to 19 days (p<0.05). Using an accepted figure of £134 per patient per day for hotel costs only, this results in an average saving of £1072 per patient admitted. This has allowed us to introduce these changes to our service without any overall increase in expenditure. This letter is not intended as a catalogue of our achievements. Rather we aim to illustrate the returns to be gained by implementing the sort of changes Professor Markus describes, and to further dispel the myth that poor outcome from stroke in the UK is beyond our control. Competing interests: None declared |
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