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Better organised stroke services linked to reduced risk of death

Posted on 20/05/2013

Researchers have found that patients admitted to more organised stroke services are more likely to receive high quality care, and have a reduced risk of death in the 30 days following stroke.

Every year, an estimated 110,000 people in the UK have a stroke. It is a leading cause of death and disability in the UK. Prompt and effective treatment of stroke can prevent long-term disability and save lives.

Clinical audit is used in health systems throughout the world to measure quality of care. The audit of stroke care in the UK has previously largely focused on process measures of quality such as access to thrombolysis or admission to stroke units, rather than patient outcomes. There is limited evidence that associates measures of stroke care quality with patient outcomes.

The study, led by researchers in the Division of Health & Social Care Research at King’s College London and the Royal College of Physicians London, investigated associations between process of care (the assessments, interventions and treatments that patients receive) and 30 day mortality, adjusted for patient level characteristics. 

Process of care was measured using six individual measures of stroke care (see below) and summarised into an overall quality score. Data was obtained from over 36,000 adults admitted with acute ischaemic stroke to over 100 hospitals in England.

The study, published in the British Medical Journal, found that patients admitted to more organised stroke services (based on a score of their staffing, facilities, and service level) are more likely to receive high quality care defined by process measures of care quality.

Patients receiving high quality care have a reduced risk of death in the 30 days following stroke, after adjusting for patient characteristics and controlling for selection bias.

One care bundle of antiplatelet therapy, hydration, and nutrition was strongly associated with reduced mortality, suggesting that controlled studies of fluid therapy and nutrition in acute stroke are warranted. 

The six care processes measured were:

• Seen by a stroke consultant or associate specialist within 24 hours of admission

• Brain scan within 24 hours of admission

• Seen by nurse and one therapist within 24 hours and all relevant therapists within 72 hours

• Nutrition screening and formal swallow assessment within 72 hours where appropriate

• Patient’s first ward of admission was stroke unit and they arrived within four hours of hospital admission

• Patient given antiplatelet therapy where appropriate and had adequate fluid and nutrition for first 72 hours

While further studies are required to evaluate the findings, these results have important implications for quality improvement in stroke services and also contribute more generally to the evidence base for quality measures in healthcare. 

The authors of the study are:

• Benjamin Bray, Clinical Academic Fellow, King’s College London

• Salma Ayis, Lecturer in Medical Statistics, King’s College London

• James Campbell, Stroke Audit Development Manager, Royal College of Physicians

• Alex Hoffman, Stroke Programme Manager, Royal College of Physicians

• Michael Roughton, Medical Statistician, Royal College of Physicians

• Pippa Tyrrel, Professor of Stroke Medicine, University of Manchester

• Charles Wolfe, Professor of Public Health Medicine, King’s College London

• Anthony Rudd, Professor of Stroke Medicine, King’s College London

Read the full BMJ article here

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