THE NEW ZEALAND MEDICAL JOURNAL Journal of the New Zealand Medical Association

Acute stroke services in New Zealand: changes between 2001 and 2007 P Alan Barber, John Gommans, John Fink, H Carl Hanger, Patricia Bennett, Nina Ataman Abstract Aim To determine changes in the organisation of acute stroke management in New Zealand between 2001 and 2007. Method A questionnaire was sent to 58 New Zealand hospitals; it included questions about access to organised stroke care, the presence of designated areas for stroke patient management, guidelines for stroke management, and audit. Results Responses were received from all hospitals surveyed, with 46 admitting stroke patients either acutely or for stroke rehabilitation. Sixteen District Health Boards (DHBs) covering 88% of the population have a physician who provides overall leadership for stroke services. Seven of 46 hospitals, covering 48% of the population, had areas designated for acute management of stroke patients. Rehabilitation for patients older than 65 years was carried out in designated areas for patients with stroke in seven hospitals, covering 49% of the population. Only 13 hospitals (serving 60% of the population) had audited local inpatient stroke care at the patient level and 10 (45% of the population) at the service level. Conclusion While there have been improvements in the development of an organised approach to acute inpatient acute stroke care in New Zealand there remain major variations between different centres. The training of general physicians, geriatricians, and neurologists in stroke medicine must be seen as a priority. Since the early to mid 1990s, overwhelming evidence shows that stroke unit care significantly reduces death and disability after stroke compared with care in general wards.1 However in New Zealand-wide surveys performed in 2001 and 2002, only one large urban and four medium-sized regional hospitals out of 41 had stroke units, and only one hospital had a dedicated stroke rehabilitation unit.2,3 Since this time, New Zealand and international stroke guidelines have clearly stated that all patients admitted to hospital with stroke should expect to be managed in a stroke unit and that the provision of organised stroke care should be seen as a priority.4,5 We have repeated the surveys with the aim of obtaining an overall picture of the provision of stroke services throughout New Zealand and to determine whether or not this has improved in recent years. This report concentrates on the acute management of stroke with the results from the rehabilitation components of the survey published separately.6

Methods We updated and combined the questionnaires used in the original surveys of acute stroke services (2001) and stroke rehabilitation services (2002).2,3 This questionnaire was sent to the medical director or a physician known to have an interest in stroke at each of 58 hospitals thought to admit patients with stroke. These hospitals were identified from a New Zealand hospital directory and covered the whole of the country. The hospitals were divided into three groups according to the population served; large (urban hospitals serving populations

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>180,000), medium (urban or regional hospitals serving populations of 40,000–180,000), and small (regional hospitals serving populations 95% of the population) with transoesophageal echocardiography available in 16 hospitals (90%). Treatment with tissue plasminogen activator—Eleven large or medium-sized hospitals serving 67% of the population had protocols for the use of tissue plasminogen activator (tPA). All but one of these hospitals had treated a patient with tPA in the past 12 months. Seventy-nine patients were thrombolysed in the past 12 months with the numbers of patients treated in each hospital ranging from 1–20 with 5 hospitals treating 5 or more, and 3 hospitals treating 10 or more patients. Comparison with 2001 survey—Comparisons between the results of the 2007 and 2001 surveys are given in Table 1. In the past 6 years there has been an increase in the number of stroke units and approximately half of the population are now admitted to hospitals with acute stroke units. There has also been an increase in patients having rehabilitation in areas for people with stroke, although there remains only one dedicated stroke rehabilitation unit. Table1. Comparison of acute stroke services in 2001 and 2007 Variables Number of hospitals Large urban Medium urban/regional Small regional Lead stroke physician Designated areas for Acute care Rehabilitation 65 years Pathways Guidelines Investigations Thrombolysis Blood pressure Swallow VTE prevention Secondary prevention Audit Patient level Service level

2001/2 N (% Pop) 41 7 17 17 5 (26)

2007 N (% Pop) 46 7 16 23 16 (88)

P value

4 (11) 0 1* (9) 10 (38) 34 (78) 23 (78) 2 (9) 17 (52) 19 (61) 16 (53) 19 (55)

7 (48) 3 7* (49) 16 (47) 27 (83) 19 (71) 11 (67) 19 (73) 22 (73) 21 (73) 21 (73)

0.332 ‡ 0.096 ‡ 0.039 0.290† 0.988† 0.168† 0.007† 0.988† 0.752† 0.829† 0.949†

8 9

13 10 *Only 1 hospital with a dedicated stroke rehabilitation unit; †Chi2 test; ‡Fisher’s exact test.

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0.724† 0.023 ‡

‡

0.242 ‡ 0.592

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Most DHBs now have lead stroke physicians. There have been non-significant increases in the number of hospitals with guidelines or protocols for the management of common problems following stroke, apart from a marked increase in the numbers of hospitals with thrombolysis protocols.

Discussion The major finding of this study is that there have been improvements in the provision of organised acute in patient stroke care since 2001. There has been an increase in the number of acute stroke units from 4 to 7. Half of the population are now admitted to hospitals with a stroke unit compared to only 11% in 2001. Similarly the number of stroke rehabilitation units has increased from one to seven. Access to brain and vascular imaging has improved. There has been a slow increase in the numbers of patients treated with tPA. There is greater use of guidelines and protocols for the management of common problems following stroke. What are the likely reasons for this improvement? There is no doubt that the evidence that stroke units are effective has been accepted. In a 2004 survey of New Zealand physicians, almost all respondents thought that stroke units and stroke rehabilitation units were beneficial.7 All but 5 of the 21 DHBs now have identified lead physicians, an increase from only 5 in 2001. A number of these physicians have formed the Stroke Unit Network of New Zealand (SUNNZ), an alliance that shares practical guidelines and protocols for the management of common problems after stroke (see http://www.stroke.org.nz/pdfs/SUNNZguidelines.pdf). Further improvements are likely to be driven by lead clinicians adapting guidelines and protocols for local circumstances and driving the development of organised stroke services within their DHB. Conversely, it is unlikely that organised stroke care will develop in other hospitals until physicians with a special interest and expertise in stroke are identified. However, there are still major discrepancies between the evidence base and practice. Just under half of New Zealanders do not have access to organised inpatient stroke care and there are still major teaching hospitals without organised stroke care. A meta-analysis of all randomised and quasi-randomised studies demonstrated a reduction in the odds of death or institutionalised care for patients receiving some form of specialised inpatient stroke care compared with conventional care.1 Only 18 patients need to receive organised inpatient stroke care to prevent one from dying or being dependent at 1 year.8 Organised inpatient stroke care does not increase (and possibly decreases) length of hospital stay and is not more expensive than care in a general ward.1,8,9 The introduction of a stroke rehabilitation unit in Christchurch resulted in an 8-day reduction in length of stay.10 There are also concerns about the quality of the services provided. Only two of the stroke units are stand alone units with the remainder in designated areas of general medical, neurology or AT&R wards. There is still no comprehensive stroke unit in New Zealand where acute management and rehabilitation occur in the same ward, although some of the stroke units transfer patients to designated stroke rehabilitation areas. The use of guidelines was more widespread, but 20–30% of the population is served by hospitals where there were no guidelines for the management of common complications following stroke or for the secondary prevention of a further stroke. This, in conjunction with the limited use of audit, suggests that there is an ad hoc approach to the care of many stroke patients, and that the opportunity to identify and address local deficiencies in stroke care is missed.

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Only 79 patients were treated with intravenous rt-PA in the preceding year, representing about 1% of all acute stroke patients. 4 This is despite the fact that 67% of the population are admitted to hospitals with protocols for the use of rt-PA. It is now 12 years after the National Institute of Neurological Disorders and Stroke (NINDS) trial found that patients treated with rt-PA within 3 hours of symptom onset were approximately one-third more likely to have complete or near complete recovery compared to those receiving placebo.11,12 Only 16 patients need to be treated with rt-PA to prevent one from dying or becoming dependent,8 and for every 7 patients treated, neurological improvement is seen in one. Treatment with rtPA is cost effective.13 Without organised acute stroke care the numbers of patients receiving stroke thrombolysis is likely to remain small. In the previous surveys, the care of stroke patients in medium sized urban and regional hospitals was similar to large urban hospitals. Indeed, care in some regional hospitals was “better” than most of the large hospitals. However, since this time most of the larger urban hospitals have developed stroke units, while there has been no corresponding increase in the number of stroke units in the medium and smaller-sized hospitals. This is likely to reflect the presence of lead clinicians being early adopters of organised stroke care. Without the training of general physicians, geriatricians and neurologists in stroke medicine these numbers are likely to remain small. There remain variations in the nature of care received depending on place of residence. These discrepancies may be addressed with the development and implementation of Ministry of Health stroke service specifications which are based on population size.14 These specifications suggest that hospitals serving more than 180,000 people should aim to have a lead stroke physician, an acute or comprehensive stroke unit, and an expert, stroke-dedicated multidisciplinary team. Smaller hospitals serving fewer than 80,000 people should still have a lead physician but are not necessarily expected to have a stroke unit. Rather, patients should be aggregated within a general ward with an MDT team expert in rehabilitation. Medium-sized hospitals should have a combination of these approaches. However, these are recommendations only with no requirement for these specifications to be met and without DHB and MOH commitment the further development of organised stroke services will remain patchy. So what is the way forward? The ongoing work of individual lead clinicians and SUNNZ will have some effect but this study has shown that this approach has been slow and is dependent on the drive of clinicians and acceptance by hospital managers of the need for organised stroke services. A formalised and compulsory national audit programme of stroke services could be considered by the Ministry of Health, as in England. This would ensure regular audit and enable the comparison of service provision between DHBs. This study has a number of limitations. Questionnaires offer a convenient means of surveying clinical practice in a large number of hospitals. However, the most appropriate individual within an institution may not be targeted and responses to a survey may not reflect actual practice. Attempts were made to contact physicians with a known interest in stroke at each institution. We did not systematically attempt to verify responses but made clear it that no hospital would be identified. It is reasonable to assume that the responses reflect the state of stroke management in New Zealand. There has been a failure to implement best practice guidelines in New Zealand for the care of patients admitted with stroke. The evidence in favour of organised inpatient care is overwhelming, and achieving this goal should be the highest priority. The situation in New Zealand is unlikely to change without training more general physicians, geriatricians, and NZMJ 7 November 2008, Vol 121 No 1285; ISSN 1175 8716 URL: http://www.nzma.org.nz/journal/121-1285/3343/

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neurologists as stroke physicians. In the interim, there is a need to identify physicians in each hospital who will be responsible for stroke services. Competing interests: Four authors work in an honorary capacity for the Stroke Foundation of New Zealand; as national medical director (JF) or regional medical advisors (PAB Northern, JG Central, CH Southern). All four were also members of the Ministry of Health’s Stroke Advisory Committee 2002–4.

Author information: P Alan Barber, Neurologist, Auckland City Hospital, Auckland; John Gommans, Physician, Hawke’s Bay Hospital, Hastings; John Fink, Neurologist, Christchurch Hospital, Christchurch; H Carl Hanger, Geriatrician, Princess Margaret Hospital, Christchurch; Patricia Bennett, Stroke Research Nurse, Auckland City Hospital, Auckland; Nina Ataman, House Officer, Neurology Department, Auckland City Hospital, Auckland Acknowledgement: This study was supported by the Julius Brendel Trust (PB). Correspondence: Prof P Alan Barber, Director of Auckland Hospital Stroke Service, Park Rd, Grafton, Auckland 1001, New Zealand. Email [email protected] References: 1. 2. 3. 4. 5. 6.

7.

8. 9. 10. 11. 12.

13. 14.

Stroke Unit Trialists Collaboration. Organised inpatient (stroke unit) care for stroke (Cochrane Review). The Cochrane Library. Vol Issue 2, Update Software. Oxford; 2001. Barber A, Anderson NE, Bennett P, Gommans J. Acute stroke services in New Zealand. N Z Med J. Jan 25 2002;115(1146):3–6. http://www.nzmj.com/journal/114-1146/2224/content.pdf Gommans J, Barber A, McNaughton H, et al. Stroke rehabilitation services in New Zealand. N Z Med J. May 16 2003;116(1174). http://www.nzmj.com/journal/116-1174/435 . New Zealand Stroke Guidelines Development Team. Life after stroke. New Zealand Guideline for the management of stroke. Wellington: Stroke Foundation of New Zealand; 2003. National Stroke Foundation of Australia. Clinical guidelines for the acute management of stroke: National Health and Medical Research Council; 2007. Gommans J, Barber A, Hanger HC, Bennett P. Rehabilitation after stroke: changes between 2002 and 2007 in services provided by District Health Boards in New Zealand. N Z Med J. 2008;121(1274):26– 33. http://www.nzma.org.nz/journal/121-1274/3066/ Somerfield J, Barber PA, Anderson NE, et al. Changing attitudes to the management of ischaemic stroke between 1997 and 2004: a survey of New Zealand physicians. Intern Med J. May 2006;36(5):276–280. Hankey GJ, Warlow CP. Treatment and secondary prevention of stroke: evidence, costs, and effects on individuals and populations. Lancet. 1999;354(9188):1457–63. Bergman L, van der Meulen JH, Limburg M, Habbema JD. Costs of medical care after first-ever stroke in The Netherlands. Stroke. 1995;26(10):1830–6. Hanger HC. Implementing a stroke rehabilitation area: the first six months. N Z Med J. 2002;115(1158). http://www.nzmj.com/journal/115-1158/110 The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke. N Engl J Med. 1995;333(24):1581–7. Kwiatkowski TG, Libman RB, Frankel M, et al. Effects of tissue plasminogen activator for acute ischemic stroke at one year. National Institute of Neurological Disorders and Stroke Recombinant Tissue Plasminogen Activator Stroke Study Group. N Engl J Med. 1999;340(23):1781–7. Fagan SC, Morgenstern LB, Petitta A, et al. Cost-effectiveness of tissue plasminogen activator for acute ischemic stroke. NINDS rt-PA Stroke Study Group. Neurology. 1998;50(4):883–90. Guidelines for the delivery of an organised stroke service. New Zealand Ministry of Health and DHBNZ. http://www.nsfl.health.govt.nz/apps/nsfl.nsf/menumh/Service+Specifications

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