Streamlined stroke services in London save lives and money, study findsBMJ 2013; 347 doi: http://dx.doi.org/10.1136/bmj.f4954 (Published 06 August 2013) Cite this as: BMJ 2013;347:f4954
The reorganisation of stroke care in London has saved more than 400 lives since it was implemented in 2010, and costs less per patient than the old arrangements, a new study has found.1
Charles Davie, consultant neurologist at the Royal Free Hospital in London, and a member of the research team behind the study, said, “A system directing patients to high quality stroke units in the first 72 hours following stroke saves lives and money.”
London introduced a “hub and spoke” stroke service in 2010, with care in the first 72 hours after stroke concentrated in eight hyper-acute stroke units rather than 30 hospitals in the capital. The changes modestly increased the time it took to get patients to hospital, from 50 minutes before the changes to 62 minutes afterwards, but the proportion still alive at 90 days increased from 81.5% (95% confidence interval 76.0-85.9%) to 88.7% (87.4% to 89.9%).
This was achieved, however, against a background of improvement in stroke care elsewhere in England. When this underlying improvement is accounted for, the benefits of the London model are more modest, but still significant. The team estimated that there was a net reduction in deaths of 12% (8% to 16%). This represents 400 deaths avoided since 2010.
The changes in the pattern of care were considerable. Before, about half the patients were admitted to a stroke unit, and 10% were still in the unit or stroke rehabilitation after 90 days. After, three quarters were admitted first to a hyper-acute stroke unit and less than 1% were still in this unit or in a stroke unit at 90 days. Intravenous thrombolysis increased from 5% of patients before to 13% after the changes.
The new model provides more intensive and expensive care in the immediate aftermath of a stroke, but saves money in the longer run, largely by reducing length of stay. Before, it cost £14 117 (€16 000; $22 000) to treat a stroke to 90 days; after, the figure fell to £13 306. This represents a saving of £5.2m for the almost 6500 stroke patients treated annually in London. Setting up the new system cost about £10m, which the authors estimated was recouped within two years.
Writing in PLoS One, the team, led by health economist Rachael Hunter, of University College London, said that the new system worked well in London because of high population density and a distribution of hospitals that enabled ambulance travel times to remain within viable limits. Other places planning changes in stroke services would require additional research to determine whether the model was appropriate for them.
There are some limitations to the study, the authors acknowledged, but a randomised controlled trial was impossible because the changes were being implemented London-wide. They said that they attempted to account for potential confounders in their “before and after” design, using conservative estimates and testing assumptions in sensitivity analyses.
Cite this as: BMJ 2013;347:f4954