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Stroke - a chronic disease with acute events
- Desmond O'Neill, Frances Horgan, Anne Hickey, Hannah McGee (19 February 2008)
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Inadequate adjustments for stroke severity and comorbidity
- Philip C Haycock, Hiroyuki Hori , Aju Mathew, Weerasak Muangpaisan, Georgios Lyratzopoulos (2 March 2008)
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Author`s reply to comments by Haycock and colleagues
- Karsten Bruins Slot, Peter Sandercock, Steff Lewis (6 March 2008)
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Desmond O'Neill, Principal Investigator Irish National Audit of Stroke Care, Trinity College Dublin, Dublin 2. Ireland, Frances Horgan, Anne Hickey, Hannah McGee
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This paper and accompanying editorial (1) on stroke care make a compelling case for reviewing conventional policy approaches to stroke (2), which often show a dysequilibrium towards the (very important) front end of stroke, and a relative agnosia for (equally important) after-care. While it is clearly very important that all should have access to stroke unit care (and thrombolysis for those for whom it is indicated) , the majority of patients will still have residual disability after both of these interventions, and will be more prone to further stroke than the rest of the population. Comprehensive national audits of stroke care show alarming levels of neglect in terms of chronic disease management (3), and seem to indicate a collective nihilism about the potential for altering function and well-being after the early treatment of stroke, despite evidence of the effectiveness of continuing therapy and support at long intervals after stroke (4). We need to ensure that the potential for altering functional status and wellbeing is maximized at six months (and beyond). Highlighting the chronic disease aspect of stroke care may best serve this aspiration by promoting a timely focus on preventive, care and support needs through patient education and empowerment (5) as well as the development of models of care which bring together primary and secondary care (6). This may require a reorientation of practice and training for stroke physicians (7), which do not currently emphasize the chronic course of the illness, nor models of chronic disease management which promote the role of the patient as partner. 1) Bruins Slot K, Berge E, Dorman P, Lewis S, Dennis M, Sandercock P on behalf of the Oxfordshire Community Stroke Project, the International Stroke Trial (UK), and the Lothian Stroke Register Collaborative Groups. Impact of functional status at six months on long term survival in patients with ischaemic stroke: prospective cohort studies. BMJ 2008;336:376-379. 2) Kjellström T, Norrving B, Shatchkute A. Helsingborg Declaration 2006 on European stroke strategies. Cerebrovasc Dis. 2007;23(2-3):231-41. 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, 23, (Suppl 2), 2007, 132 4) Ouellette MM, LeBrasseur NK, Bean JF, Phillips E, Stein J, Frontera WR, Fielding RA. High-intensity resistance training improves muscle strength, self-reported function, and disability in long-term stroke survivors. Stroke. 2004 Jun;35(6):1404-9. 5) Jones F. Strategies to enhance chronic disease self-management: how can we apply this to stroke? Disabil Rehabil. 2006 Jul 15-30;28(13-14): 841-7. 6) Allen KR, Hazelett S, Jarjoura D, et al. Effectiveness of a post- discharge care management model for stroke and transient ischemic attack: a randomised trial. J Stroke Cerebrovasc Dis. 2002;11(2):88–98. 7) Joint Royal Colleges of Physicians Training Board. Stroke Specialist Training. London, Joint Royal Colleges of Physicians Training Board, 2007. Competing interests: None declared |
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Philip C Haycock, MPhil Candidate Department of Public Health and Primary Care, University of Cambridge, CB2 0SR, Hiroyuki Hori , Aju Mathew, Weerasak Muangpaisan, Georgios Lyratzopoulos
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Slot and colleagues' study about the relationship between functional status at 6 months after ischaemic stroke and subsequent long-term survival, provides important new evidence about the burden of disease associated with stroke, and can be used to inform future healthcare planning and health economic research. However, given that functional dependency at 6 months and 'stroke severity' are likely to be highly related to one another, it is important that this relationship be taken into account in the statistical analyses. Although the authors partly address this issue by adjusting for subtype of stroke, the reported association between 'functional status' and long-term survival may simply be a reflection of stroke severity at case presentation. Moreover, except for atrial fibrillation, no adjustments were made for comorbidity: a potentially important contributor to both functional status and long-term survival. Thus, the relationship between functional status at 6 months and long-term survival is possibly confounded by stroke severity and/or comorbidity. Alternatively, functional status may be a mediator of the relationship between stroke severity/comorbidity and long-term survival. Competing interests: None declared |
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Karsten Bruins Slot, Clinical research fellow Ullevaal University Hospital, NO-0407, Oslo, Norway, Peter Sandercock, Steff Lewis
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We agree with Haycock and colleagues that both stroke severity and (pre-stroke) comorbidity could influence functional status after stroke. However, it is important to emphasize that we restricted the analyses to patients who were alive at 6 months after stroke; patients with severe strokes and comorbidities are more likely to have died during the first 6 months. The severity of stroke at onset in the three cohorts was graded according to the OCSP-classification, which has been shown to have prognostic validity and to agree well with other measures of stroke severity, such as the Scandinavian Stroke Scale (1). In a sensitivity analysis we also entered the Glasgow Coma Score at baseline (which was only collected in the OCSP and LSR cohorts) in multivariate Cox regression models. The GCS was not a significant variable and these analyses did not change our findings. The NIHSS-scale, which nowadays is the most widely used assessment tool for stroke severity, was not used in any of the three cohorts. Unfortunately, the only baseline data on comorbidity was the modified Rankin Score prior to the index stroke for patients in the OCSP and LSR cohorts. We entered this variable in multivariate Cox regression models and did this not change our findings. We have chosen not to present the above-mentioned separate analyses in our paper, as these baseline variables were only available in two of the studied cohorts and did not change our principal findings in any way. Functional status at 6 months after ischaemic stroke onset is a clinically relevant and robust indicator of subsequent survival. References 1. N. Sprigg, L. Gray, P. Bath, E. Lindenstrøm, G. Boysen, P. De Deyn, et al. Stroke severity, early recovery and outcome are each related with clinical classification of stroke: Data from the ‘Tinzaparin in Acute Ischaemic Stroke Trial’ (TAIST). J Neurol Sci 2007:254(1-2):54-59. Competing interests: None declared |
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