Comparison of Provision of Stroke Care in Younger and Older Patients: Findings from the South London Stroke Register

Background. Evidence-based stroke care should be available to all patients. However, evidence exists of inequalities according to age. This study compared access to care for younger adults to that for over 65s. Methods. Using population-based data from 4229 patients with first-ever stroke between 1995 and 2010, associations between age and 21 care indicators were investigated using multivariable logistic regression. Results. Age was not associated with stroke unit admission for ischaemic stroke (P = 0.666). Younger PICH patients were least likely to be admitted to stroke units (P = 0.001), instead treated on neurosurgical or ICU wards. Younger age was also associated with admission to neurosurgery or ICU after SAH (P = 0.006), increased occupational or physiotherapy at 1 year (P = 0.043), and contact with a GP 3 months after stroke (P < 0.001). Conclusion. Younger patients have equal or greater access to evidence-based care. However, there is a need to ensure that services meet the needs of this group

Socioeconomic deprivation and provision of acute and long-term care after stroke: the South London Stroke Register cohort study

Background and aims Socioeconomic deprivation (SED) is associated with increased mortality after stroke, however, its associations with stroke care remains uncertain. We assessed the SED impacts on acute and long-term stroke care, and examined their ethnic differences and secular trends. Methods We used data from 4202 patients with first-ever stroke (mean age 70.1 years, 50.4% male, 20.4% black), collected by a population-based stroke register in South London, England from 1995 to 2010. Carstairs deprivation score was measured for each patient, taking the 1st as the least deprived and the 2nd to 5th quintiles as SED, and was related to 20 indicators of care in multivariate logistic regression models. Results Patients with SED had 29% and 35% statistically significant reductions in odds of being admitted to hospital and having swallow tests, respectively. The multivariate adjusted odds ratio (OR) for receiving five indicators of acute stroke care was 0.81 (95% CI 0.72 to 0.92). It was 0.76 (0.58 to 0.99) in black patients and 0.82 (0.71 to 0.96) in white patients; and 0.70 (0.58 to 0.84) in patients with stroke occurring before 2001 and 0.89 (0.75 to 1.05) since 2001. SED was further associated with receipt of some stroke care during 5 years of follow-up, including atrial fibrillation medication (0.63, 0.48 to 0.83), and in black patients physiotherapy and occupational therapy (0.32, 0.11 to 0.92). Conclusions Stroke healthcare inequalities in England exist for some important indicators, although overall it has improved over time. The impact of SED may be stronger in black patients than in white patients. Further efforts are required to achieve stroke care equality.National Institute for Health Research Programme Grant (RP-PG-0407-10184

Provision of acute stroke care and associated factors in a multiethnic population: prospective study with the South London Stroke Register

Objectives To investigate time trends in receipt of effective acute stroke care and to determine the factors associated with provision of care

Differences in the distribution of stroke subtypes in a UK black stroke population - final results from the South London Ethnicity and Stroke Study.

BACKGROUND: Stroke incidence is increased in Black individuals but the reasons for this are poorly understood. Exploring the differences in aetiological stroke subtypes, and the extent to which they are explained by conventional and novel risk factors, is an important step in elucidating the underlying mechanisms for this increased stroke risk. METHODS: Between 1999 and 2010, 1200 black and 1200 white stroke patients were prospectively recruited from a contiguous geographical area in South London in the UK. The Trial of Org 10172 (TOAST) classification was used to classify stroke subtype. Age- and sex-adjusted comparisons of socio-demographics, traditional vascular risk factors and stroke subtypes were performed between black and white stroke patients and between Black Caribbean and Black African stroke patients using age-, sex-, and social deprivation-adjusted univariable and multivariable logistic regression analyses. RESULTS: Black stroke patients were younger than white stroke patients (mean (SD) 65.1 (13.7) vs. 74.8 (13.7) years). There were significant differences in the distribution of stroke subtypes. Small vessel disease stroke was increased in black patients versus white patients (27 % vs. 12 %; OR, 2.74; 95 % CI, 2.19-3.44), whereas large vessel and cardioembolic stroke was less frequent in black patients (OR, 0.59; 95 % CI, 0.45-0.78 and OR, 0.61; 95 % CI, 0.50-0.74, respectively). These associations remained after controlling for traditional vascular risk factors and socio-demographics. Black Caribbean patients appeared to have an intermediate risk factor and stroke subtype profile between that found in Black African and white stroke patients. Cardioembolic stroke was more strongly associated with Black Caribbean ethnicity versus Black African ethnicity (OR, 1.48; 95 % CI, 1.04-2.10), whereas intracranial large vessel disease was less frequent in Black Caribbean patients versus Black African subjects (OR, 0.44; 95 % CI, 0.24-0.83). CONCLUSIONS: Clear differences exist in stroke subtype distribution between black and white stroke patients, with a marked increase in small vessel stroke. These could not be explained by differences in the assessed traditional risk factors. Possible explanations for these differences might include variations in genetic susceptibility, differing rates of control of vascular risk factors, or as yet undetermined environmental risk factors.This work was supported by a Stroke Association (UK) Programme Grant (PROG 3) (www.stroke.org.uk) and the National Institute for Health Research (NIHR) Biomedical Research Centre based at Guy's and St Thomas' NHS Foundation Trust and King's College London (http://www.guysandstthomasbrc.nihr.ac.uk). The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health. Loes Rutten-Jacobs was supported by a British Heart Foundation Immediate Research Fellowship (FS/15/61/31626) (www.bhf.org.uk). Hugh Markus is supported by an NIHR Senior Investigator award (www.nihr.ac.uk) and his work is supported by the NIHR Cambridge University Hospital Trusts Comprehensive BRC (www.cambridge-brc.org.uk)

What does it take to provide clinical interventions with temporal consistency? A qualitative study of London hyperacute stroke units.

OBJECTIVES: Seven-day working in hospitals is a current priority of international health research and policy. Previous research has shown variability in delivering evidence-based clinical interventions across different times of day and week. We aimed to identify factors influencing such variations in London hyperacute stroke units (HASUs). DESIGN: Interview and observation study to explain patterns of variation in delivery and outcomes of care described in a quantitative partner paper (Melnychuk et al). SETTING: Eight HASUs in London. PARTICIPANTS: We interviewed HASU staff (n=76), including doctors, nurses, therapists and administrators. We also conducted non-participant observations of delivery of care at different times of the day and week (n=45; ~102 hours). We analysed the data for thematic content relating to the ability of staff to provide evidence-based interventions consistently at different times of the day and week. RESULTS: Staff were able to deliver 'front door' interventions consistently by taking on additional responsibilities out of hours (eg, deciding eligibility for thrombolysis); creating continuities between day and night (through, eg, governance processes and staggering rotas); building trusting relationships with, eg, Radiology and Emergency Departments and staff prioritisation of 'front door' interventions. Variations by time of day resulted from reduced staffing in HASUs and elsewhere in hospitals in the evenings and at the weekend. Variations by day of week (eg, weekend effect) resulted from lack of therapy input and difficulties repatriating patients at weekends, and associated increases in pressure on Fridays and Mondays. CONCLUSIONS: Evidence-based service standards can facilitate 7-day working in acute stroke services. Standards should ensure that the capacity and capabilities required for 'front door' interventions are available 24/7, while other services, for example, therapies are available every day of the week. The impact of standards is influenced by interdependencies between HASUs, other hospital services and social services

Associations Between 30-Day Mortality, Specialist Nursing, and Daily Physician Ward Rounds in a National Stroke Registry

Background and Purpose- Well-organized stroke care is associated with better patient outcomes, but the most important organizational factors are unknown. Methods- Data were extracted from the Sentinel Stroke National Audit Programme of adults with acute stroke treated in stroke hospitals in England and Wales between April 2013 and March 2015. Multilevel models with random intercepts for hospitals were used to estimate the association of each variable with 30-day mortality to estimate the impact of admission to differently organized hospitals. Results- Of the 143 578 patients with acute stroke admitted to 154 hospitals, 14.4% died within 30 days of admission. In adjusted analyses, admission to hospitals with higher ratios of nurses trained in swallow screening was associated with reduced odds of death ( P=0.004), and admission to hospitals with daily physician ward rounds was associated with 10% lower odds of mortality compared with less-frequent ward rounds (95% CI, 0.82-0.98; P=0.013). Number of stroke admissions and overall ratio of registered nurses on duty at weekends were not found to be independently associated with mortality after adjustment for other factors. Conclusions- If these associations are causal, an extra 1332 deaths annually in England and Wales could be saved by hospitals providing care associated with a ratio of nurses trained in swallow screening of at least 3 per 10 beds and daily stroke physician ward rounds

Impact of centralising acute stroke services in English metropolitan areas on mortality and length of hospital stay: difference-in-differences analysis

Objective: To investigate whether centralisation of acute stroke services in two metropolitan areas of England was associated with changes in mortality and length of hospital stay. Design: Analysis of difference-in-differences between regions with patient level data from the hospital episode statistics database linked to mortality data supplied by the Office for National Statistics. Setting: Acute stroke services in Greater Manchester and London, England. Participants: 258 915 patients with stroke living in urban areas and admitted to hospital in January 2008 to March 2012. Interventions “Hub and spoke” model for acute stroke care. In London hyperacute care was provided to all patients with stroke. In Greater Manchester hyperacute care was provided to patients presenting within four hours of developing symptoms of stroke. Main outcome measures Mortality from any cause and at any place at 3, 30, and 90 days after hospital admission; length of hospital stay. Results: In London there was a significant decline in risk adjusted mortality at 3, 30, and 90 days after admission. At 90 days the absolute reduction was −1.1% (95% confidence interval −2.1 to −0.1; relative reduction 5%), indicating 168 fewer deaths (95% confidence interval 19 to 316) during the 21 month period after reconfiguration in London. In both areas there was a significant decline in risk adjusted length of hospital stay: −2.0 days in Greater Manchester (95% confidence interval −2.8 to −1.2; 9%) and −1.4 days in London (−2.3 to −0.5; 7%). Reductions in mortality and length of hospital stay were largely seen among patients with ischaemic stroke. Conclusions: A centralised model of acute stroke care, in which hyperacute care is provided to all patients with stroke across an entire metropolitan area, can reduce mortality and length of hospital stay

Clinical risk scores for predicting stroke-associated pneumonia: A systematic review:A systematic review

Purpose Several risk stratification scores for predicting stroke-associated pneumonia have been derived. We aimed to evaluate the performance and clinical usefulness of such scores for predicting stroke-associated pneumonia. Method A systematic literature review was undertaken in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement, with application of the Quality Assessment of Diagnostic Accuracy-2 tool. Published studies of hospitalised adults with ischaemic stroke, intracerebral haemorrhage, or both, which derived and validated an integer-based clinical risk score, or externally validated an existing score to predict occurrence of stroke-associated pneumonia, were considered and independently screened for inclusion by two reviewers. Findings We identified nine scores, from eight derivation cohorts. Age was a component of all scores, and the NIHSS score in all except one. Six scores were internally validated and five scores were externally validated. The A2DS2 score (Age, Atrial fibrillation, Dysphagia, Severity [NIHSS], Sex) was the most externally validated in 8 independent cohorts. Performance measures were reported for eight scores. Discrimination tended to be more variable in the external validation cohorts (C statistic 0.67–0.83) than the derivation cohorts (C statistic 0.74–0.85). Discussion Overall, discrimination and calibration were similar between the different scores. No study evaluated influence on clinical decision making or prognosis. Conclusion The clinical prediction scores varied in their simplicity of use and were comparable in performance. Utility of such scores for preventive intervention trials and in clinical practice remains uncertain and requires further study