Improving the outcome of stroke

The outcome of stroke varies markedly between countries. A study of 12 centres in seven European countries found that mortality varied twofold even when adjusted for case mix and use of healthcare resources.1 Similar variation was also found in two large international multicentre trials of acute stroke.2 3 All three studies found the outcome was worst in the United Kingdom; in one study the differences in the proportion of patients dead or dependent between the UK and the other eight countries were between 150 and 300 events per 1000 patients.2

What underlies this variation and why is outcome so poor in the UK compared with countries with similar economies in western Europe? Residual confounding by case mix is difficult to exclude completely, but differences in the process of care are likely to be important.3 In many European countries stroke care is an integral part of neurology. In contrast, in the UK it has, until recently, been a “Cinderella” subject, often falling between neurology and general and geriatric medicine. It is tempting to conclude that this lack of interest has led to underinvestment and a resulting poor outcome. However, the cost of care of stroke patients seems to be as high, …