Blair says patients will have to travel further for specialist care

Less brains would need mending with tPA (tissue plasminogen
activator) in specialist stroke centres if greater priority was given to
developing TIA (transient ischaemic attack) services and trusts made
greater use of the ABCD scoring system.[1,2] The Department of Health's
latest version of the "Action on Stroke Services: an Evaluation Toolkit"
(ASSET)in the guide to commission stroke services uses Oxford TIA data;
the 87 events in a population of 90,542 translates into 48,000 TIA events
each year in England's 50 million population.[3,4] Early surgical
intervention should prevent strokes - and thereby death and disability -
as documented in recent National Audit Office (NAO) and Committee of
Public Accounts (PAC) reports.[5,6]

The assumptions used in the NAO report's economic research model for
a 29,000 TIA population to arrive at outcome and savings figures of around
250 strokes prevented and £4 million savings were that: 15% have a carotid
stenosis of >50% that could benefit from carotid endarterectomy; 5%
with >50% stenosis are operated on within 2 weeks; the risk of a stroke
without surgery is 30%; surgical intervention reduces the risk by 80% to
6%; each stroke prevented results in care cost savings of £17,000; each
surgical operation costs £786.24 [background information provided by the
NAO]. Of England's 48,000 TIA patients, 7200 have a surgically treatable
carotid lesion; 360 would normally be treated within 2 weeks leaving 6840
untreated. Without surgery 2052 (6840 x .3) would go on to have a stroke
but with surgery this would fall to 410 (6840 x .06). Early carotid
surgery could prevent 1642 stroke episodes; operation costs for 6840
patients would be £5.4 million; savings from preventing 1642 strokes would
be £27.9 million. The net saving is £22.5 million a year. The NAO outcome
and saving figures for a 29,000 population, as they appear in the NAO and
PAC reports, would appear to considerably understate the prevention
benefits of early TIA intervention.

In comparison, the NAO and PAC reports overstate thrombolysis
benefits with unfounded life-saving claims for tPA in the NAO report
(paragraph 13, page 8) and reference to £16 million savings and 1500
patients fully recovering; these figures were based on giving 9900 doses
of tPA (9% of 110,000 strokes); Box Hill hospital, referred to in the NAO
report, delivered just 2.3 doses of tPA a month.[7] Treating 9% of
selected patients in a leading Australian tertiary hospital specialist
stroke unit is not the same as treating 9% of all strokes.

Those commissioing stroke services on behalf of patients and the
public they serve should ignore the NAO and PAC reports' outcomes and
savings figures when choosing between stroke funding and development
priorities.

[1] Kmietowicz Z. Blair says patients will have to travel further for
specialist care. BMJ 2006; 333:1187

[2] Rothwell PM, Giles MF, Flossman E et al. A simple score (ABCD) to
identify individuals at high early risk of stroke after transient
ischaemic attack. Lancet 2005;366:29-36

[3] Department of Health. Improving Stroke Services: a guide for
commissioners. December 2006

[4] Coull AJ, Lovett JK, Rothwell PM. Population based study of early
risk of stroke after transient ischaemic attack or minor stroke:
implications for public education and organisation of services. BMJ
2004;328:326-8

[5] Report by the Comptroller and Auditor General. Reducing brain
damage: faster access to better stroke care. National Audit Office,
London. HC 452 Session 2005 - 2006. 16 November 2005

[6] House of Commons Committee of Public Accounts. REducing brain
damage: faster access to better stroke care. Fifty-second Report of
Session 2005-06. July 200. HC 911

[7] Bray JE, Coughlan K, Bladin C. Thrombolytic therapy for acute
ischaemic stroke: succesful implementation in an Australian tertiary
hospital. Internal Medicine Journal 36 (2006) 483-488.

Competing interests:
None declared