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Associations between the organisation of stroke services, process of care, and mortality in England: prospective cohort study

BMJ 2013; 346 doi: https://doi.org/10.1136/bmj.f2827 (Published 10 May 2013) Cite this as: BMJ 2013;346:f2827
  1. Benjamin D Bray, clinical academic fellow1,
  2. Salma Ayis, lecturer in medical statistics14,
  3. James Campbell, stroke audit development manager2,
  4. Alex Hoffman, stroke programme manager2,
  5. Michael Roughton, medical statistician2,
  6. Pippa J Tyrrell, professor of stroke medicine3,
  7. Charles D A Wolfe, professor of public health medicine14,
  8. Anthony G Rudd, professor of stroke medicine14
  1. 1King’s College London, Division of Health and Social Care Research, London SE13QD, UK
  2. 2Royal College of Physicians, London, UK
  3. 3University of Manchester MAHSC, Salford Royal NHS Foundation Trust, Salford, UK
  4. 4National Institute for Health Research Comprehensive Biomedical Research Centre, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
  1. Correspondence to: B D Bray benjamin.bray{at}kcl.ac.uk
  • Accepted 24 April 2013

Abstract

Objective To estimate the relations between the organisation of stroke services, process measures of care quality, and 30 day mortality in patients admitted with acute ischaemic stroke.

Design Prospective cohort study.

Setting Hospitals (n=106) admitting patients with acute stroke in England and participating in the Stroke Improvement National Audit Programme and 2010 Sentinel Stroke Audit.

Participants 36 197 adults admitted with acute ischaemic stroke to a participating hospital from 1 April 2010 to 30 November 2011.

Main outcome measure Associations between process of care (the assessments, interventions, and treatments that patients receive) and 30 day all cause mortality, adjusting for patient level characteristics. Process of care was measured using six individual measures of stroke care and summarised into an overall quality score.

Results Of 36 197 patients admitted with acute ischaemic stroke, 25 904 (71.6%) were eligible to receive all six care processes. Patients admitted to stroke services with high organisational scores were more likely to receive most (5 or 6) of the six care processes. Three of the individual processes were associated with reduced mortality, including two care bundles: review by a stroke consultant within 24 hours of admission (adjusted odds ratio 0.86, 95%confidence interval 0.78 to 0.96), nutrition screening and formal swallow assessment within 72 hours (0.83, 0.72 to 0.96), and antiplatelet therapy and adequate fluid and nutrition for first the 72 hours (0.55, 0.49 to 0.61). Receipt of five or six care processes was associated with lower mortality compared with receipt of 0-4 in both multilevel (0.74, 0.66 to 0.83) and instrumental variable analyses (0.62, 0.46 to 0.83).

Conclusions Patients admitted to stroke services with higher levels of organisation are more likely to receive high quality care as measured by audited process measures of acute stroke care. Those patients receiving high quality care have a reduced risk of death in the 30 days after stroke, adjusting for patient characteristics and controlling for selection bias.

Footnotes

  • We thank all those who have contributed to the Stroke Improvement National Audit Programme and Sentinel Stroke Audits. The audits would not be possible without their hard work and dedication. We also thank the Intercollegiate Stroke Working Party (see supplementary file for list of members) for their guidance and work to support the audits, and Toby Prevost for his comments on the manuscript.

  • Contributors: BDB designed the study, carried out the analysis, and drafted the initial manuscript. SA and MR carried out statistical analysis and contributed to the drafting of the Methods and Results section. JC, AH, PJT, AGR, and CDAW contributed to drafting and editing the final manuscript and reviewing the results of the statistical analysis. AGR is the guarantor.

  • Funding: The Stroke Improvement National Audit Programme audit is commissioned by the Healthcare Quality Improvement Partnership on behalf of the Department of Health in England. The National Sentinel Stroke Audit 2010 was commissioned by the Healthcare Quality Improvement Partnership on behalf of the Department of Health in England. No specific funding from any source was sought for this study. The research was supported by the National Institute for Health Research Biomedical Research Centre based at Guy’s and St Thomas’ NHS Foundation Trust and King’s College London. The views expressed are those of the author(s) and not necessarily those of the NHS, the National Institute for Health Research, or the Department of Health.

  • Competing interests: AGR is National Clinical Director of Stroke, NHS England. All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

  • Ethical approval: Ethical approval of the Stroke Improvement National Audit Programme audit was granted by the Ethics and Confidentiality Committee of the National Information Governance Board. This included Section 251 (under the NHS Act 2006) approval to collect data without active patient consent and patients are able to request for any identifiable data to not be included. No patient identifiable information is collected in the National Sentinel Stroke Audit. Patients and patient representatives are involved in the design, reporting, and oversight of Stroke Improvement National Audit Programme and Sentinel. Further ethical approval was not sought.

  • Data sharing: No additional data available.

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