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Real life v modelling and the case for change
- Nigel Dudley (3 July 2009)
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Nigel Dudley, Consultant in Elderly / Stroke Medicine St James's University Hospital, LEEDS LS9 7TF
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Nick Losseff and colleagues should more accurately portray the London proposal as transforming acute stroke care. Establishing acute primary stroke centres - “hyperacute” units - in a metropolitan area can improve the delivery of thrombolysis as has been shown by the Phoenix Experience in Arizona [1]: 8 stroke centres covering a 3.5 million population (half that of London’s approximate 7 million population) in the 12 month period July 2004 to June 2005 admitted 1800 patients, 1104 (61%) presenting within 3 hours, with 520 (47%) being eligible for thrombolysis and 320 of those - that is 62% of eligible patients or 17.8% of the original 1800 admissions - being given tPA. That real life delivery of tPA to 320 patients in a 3.5 million population in what would appear to be a slick American system of thrombolysis delivery is of interest considering the expectation for London that is based on modelling.[2] Healthcare for London’s own model and underpinning assumptions suggest that 13.4% of all stroke patients in London will receive thrombolysis; the expectation is for 1,616 patients being thrombolysed of 10,775 presenting at hospital. How do Lessoff and colleagues explain the differences between the real-life Arizona achievement - the equivalent of 640 treated with tPA in a London sized 7 million population - and what has been predicted for London’s population? Intensive physiological monitoring may be of benefit as shown by Sulter et al [3] but as with most similar monitoring studies there is the caveat that a larger trial is needed. One has yet to be carried out but this could be undertaken in the new London acute stroke service that offers many research opportunities. There is a balanced argument for and against routine monitoring as made by Steiner and Indredavik, [4,5] with the latter warning “… a general recommendation of continuous monitoring will also have economic consequences. Traditionally “high-tech” medicine has more prestige than rehabilitation and demands great resources. Expensive equipment and monitoring in the early phase may, therefore, drain resources both from evidence-based rehabilitation in the stroke unit and from the further chain of care, which also seems to be very important for stroke patients’ outcome”. If this is the one opportunity that London gets to transform stroke care and “get this right” - as Lessoff and colleagues claim -, then changes are needed. Such changes ought not to be derailed but careful thought is required on how best to use the available resources and to check that the modelling work making the case for change is in fact sound and based on good evidence and not wishful expert thinking or invalid assumptions. Sudlow and Warlow’s call to get the priorities right should not be ignored by those responsible for commissioning stroke services. [1] Demaerschalk BM, Bobrow BJ, Paulsen. Development of a Metropolitan Matrix of Primary Stroke Centers. The Phoenix Experience. Stroke 2008;39:1246 - 1253. [2] Appendix 10. Outline of the modelling approach. www.healthcareforlondon.nhs.uk/stroke-project-documentation/ [3] Sulter G, Elting JW, Langedijk M et al. Admitting Acute Ischemic Stroke Patients to a Stroke Care Monitoring Unit Versus a Conventional Stroke Unit. A Randomized Pilot Study. Stroke 2003;34:101-104 [4] Steiner T. Stroke Unit Design: Intensive Monitoring Should Be a Routine Procedure. Stroke 2004;35:1018 - 1019 [5] Indredavik B. Intensive Monitoring Should Not Be the Routine. Stroke 2004;35:1019 - 1020 Competing interests: None declared |
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