CONTEXTUALISING NATIONAL LEVEL RESULTS WITHIN A PUBLIC REPORT ON THE CLINICAL COMPONENT OF STROKE CARE IN ENGLAND, WALES AND NORTHERN IRELAND

Introduction Previous studies showed insufficient control of cardiovascular risk factors (CVRF) and high stroke recurrence rates among ischemic stroke patients in Germany. Currently, no structured secondary prevention program exists in clinical routine. We present the trial design and pilot phase results of a complex intervention to improve stroke care after hospital discharge in Germany. Patients and methods SANO is a cluster-randomized trial with 30 participating regions across Germany aiming to enrol 2,790 patients (drks.de, DRKS00015322). Study intervention combines both structural and patient-centred elements. Study development was based on the Medical Research Council framework for complex interventions. In 15 intervention regions, a cross-sectoral multidisciplinary network is established to enhance CVRF control as well as detection and treatment of post-stroke complications. Recommendations on CVRF are based on high-quality secondary prevention guidelines. Study physicians use motivational interviewing and agree with patients on therapeutic targets. While hospitalised, patients also receive dietary counselling and a health-passport to track their progress. During regular visits, CVRF management and potential complications are monitored. The intervention is compared to 15 regions providing usual care. The primary endpoint is the combination of recurrent stroke, myocardial infarction and death assessed 12 months after enrolment and adjudicated in a blinded manner. Results Eighteen patients were enrolled in a pilot phase that demonstrated feasibility of patient recruitment and study procedures. Conclusion SANO is investigating a program to reduce outcome events after ischemic stroke by implementing a complex intervention. If successful, the program may be implemented in routine care on national level in Germany.

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Abstract P863: Did Covid 19 Highlight Disparities in Stroke Care: A Real-World Study of Telehealth Utilization Between Urban and Suburban Populations in a Health Care System

Stroke ◽

10.1161/str.52.suppl_1.p863 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

Maryika I Gibson ◽

Ruchi Wanchoo

Keyword(s):

Health Care ◽

Health Care System ◽

Care Delivery ◽

Small Sample Size ◽

National Level ◽

Stroke Care ◽

Small Sample ◽

Acute Stroke Care ◽

Significant Difference ◽

Care System

A viable alternative to in person assessments, telemedicine offered providers cost effective and safe alternative to patient care delivery during COVID19. Resource limitations, state and organizational safety precautions accelerated our system adoption of video visits for stroke post hospitalization assessments. Utilizing mixed methods we aimed to investigate an association between patients characteristics (age, gender, race, Modified Rankin Score-mRS, residence) and their choice for post-acute care during a five-month period. The subset selecting in-person visits was further interviewed regarding perceptions of barriers to telehealth. We analyzed data from 85 patients’ records (45 in the urban telehealth and 40 in the suburban clinic visit groups) according to ICD10 codes. While total volume of televisits increased during COVID 19, stroke accounted for <1% of them. There was no significant difference in the mean age between the two groups-68.5 years in the clinic and 64.4 in the tele. The clinic subset had 42% of patients age greater than 75 years. Significant difference was detected in disabilities (t=3.5, p<.001) with one-point higher mean mRS (1.7 vs .7) and stronger positive correlation of age to disabilities in the suburban group (r2=.26 vs r2=.16). Patients selecting in-person care outlined as barriers to telehealth a lack of technology, poor connectivity, no caregiver availability for tele exam, inability to communicate or other major co-morbidities, family’s perception of complexity of patient’s condition, fragmentation of care during the period. Patients selecting video assessment were more connected with a health care system and from the urban center. Strengths of the study are the application of mix methods and investigation of suburban patients’ perceptions of barriers to telehealth. Limitations consist of small sample size and 90% Caucasian population. Current technology advancements, software applications, and the goal of Healthy People 2030 of removing disparities in heart and stroke disease will require a new multipronged approach to improving stroke telehealth at population level. Further studies at national level including social determinates of health need to examine barriers to telemedicine in post-acute stroke care.

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Access to stroke care in England, Wales and Northern Ireland: the effect of age, gender and weekend admission

Age and Ageing ◽

10.1093/ageing/afm007 ◽

2007 ◽

Vol 36 (3) ◽

pp. 247-255 ◽

Cited By ~ 81

Author(s):

A. G. Rudd ◽

A. Hoffman ◽

C. Down ◽

M. Pearson ◽

D. Lowe

Keyword(s):

Northern Ireland ◽

Stroke Care ◽

Effect Of Age

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Abstract 115: Current Status of Acute Stroke Management in Korea: A Nationwide Report Based on 19,608 Patients Treated in 216 Hospitals

Stroke ◽

10.1161/str.51.suppl_1.115 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Jun Yup Kim ◽

Keon-Joo Lee ◽

Jihoon Kang ◽

Beom Joon Kim ◽

Seong-Eun Kim ◽

...

Keyword(s):

Acute Stroke ◽

Stroke Unit ◽

National Level ◽

Stroke Care ◽

Current Status ◽

Endovascular Coiling ◽

Stroke Management ◽

Acute Stroke Care ◽

Survey Period ◽

Stroke Units

Introduction: There have been few reports on status of acute stroke management at a national level worldwide, and none in Korea. This study is aimed to describe the current status and disparities of acute stroke management in Korea. Methods: Data from 5th (2013) and 6th (2014) national surveys for assessing quality of acute stroke care were used. Patients with principal diagnosis codes indicating subarachnoid hemorrhage (SAH), intracerebral hemorrhage (ICH), ischemic stroke (IS), who were admitted via emergency rooms within 7 days of onset at hospitals treating 10 or more stroke cases during the each 3-month survey period were selected. Results: A total of 19,608 stroke cases (age, 67.7±13.5years; female, 45%; IS, 76%; ICH, 15%; SAH, 9%) treated in 216 hospitals were analyzed. Thirty-one percent of hospitals had stroke units and 41% of stroke cases were treated at hospitals without stroke units. In IS, IV thrombolysis (IVT) and endovascular treatment (EVT) rates were 10.7% and 3.6%, respectively. Thirty-nine percent of IVT and fifty-two percent of EVT cases were performed in hospitals with annual volume of <25 IVT and <15 EVT. Centralization of EVT showed disparities by region (Figure). Carotid endarterectomy, carotid artery stenting, decompressive, bypass surgery was conducted in 0.2%, 1.4%, 1.0%, 0.2% of IS cases; decompressive surgery was done in 28.1% of ICH cases; surgical clipping, endovascular coiling was done in 17.2%, 14.3% of SAH cases, respectively. There were noticeable regional disparities in various interventions, use of ambulance, arrival time and provision of stroke unit service. Conclusions: This study is the first report on the status of acute stroke care in Korea on a national level. Large number of recanalization therapies were performed in low-volume-hospitals. Expansion of stroke unit service, stroke center certification or accreditation, and connections between stroke centers and EMS are highly recommended.

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Variations in hospital resource use across stroke care teams in England, Wales and Northern Ireland: a retrospective observational study

BMJ Open ◽

10.1136/bmjopen-2019-030426 ◽

2019 ◽

Vol 9 (9) ◽

pp. e030426 ◽

Cited By ~ 1

Author(s):

David G Lugo-Palacios ◽

Brenda Gannon ◽

Matthew Gittins ◽

Andy Vail ◽

Audrey Bowen ◽

...

Keyword(s):

Northern Ireland ◽

Resource Use ◽

Stroke Care ◽

Relative Performance ◽

Stroke Severity ◽

Main Driver ◽

Team Characteristics ◽

Or Team ◽

Stroke Register ◽

Care Performance

ObjectiveTo identify the main drivers of inpatient stroke care resource use, estimate the influence of stroke teams on the length of stay (LoS) of its patients and analyse the variation in relative performance across teams.DesignFor each of four types of stroke care teams, a two-level count data model describing the variation in LoS and identifying the team influence on LoS purged of patient and treatment characteristics was estimated. Each team effect was interpreted as a measure of stroke care relative performance and its variation was analysed.SettingThis study used data from 145 396 admissions in 256 inpatient stroke care teams between June 2013 and July 2015 included in the national stroke register of England, Wales and Northern Ireland—Sentinel Stroke National Audit Programme.ResultsThe main driver of LoS, and thus resource use, was the need for stroke therapy even after stroke severity was taken into account. Conditional on needing the therapy in question, an increase in the average amount of therapy received per inpatient day was associated with shorter LoS. Important variations in stroke care performance were found within each team category.ConclusionsResource use was strongly associated with stroke severity, the need for therapy and the amount of therapy received. The variations in stroke care performance were not explained by measurable patient or team characteristics. Further operational and financial analyses are needed to unmask the causes of this unexplained variation.

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Clinical and budget impacts of changes in oral anticoagulation prescribing for atrial fibrillation

Heart ◽

10.1136/heartjnl-2020-317006 ◽

2020 ◽

Vol 107 (1) ◽

pp. 47-53 ◽

Cited By ~ 4

Author(s):

Andi Orlowski ◽

Chris P Gale ◽

Rachel Ashton ◽

Bruno Petrungaro ◽

Ruth Slater ◽

...

Keyword(s):

Atrial Fibrillation ◽

Oral Anticoagulation ◽

Oral Anticoagulants ◽

Direct Oral Anticoagulants ◽

National Level ◽

Stroke Care ◽

Published Data ◽

Stroke Incidence ◽

Number Of Patients ◽

National Databases

ObjectiveTo assess temporal clinical and budget impacts of changes in atrial fibrillation (AF)-related prescribing in England.MethodsData on AF prevalence, AF-related stroke incidence and prescribing for all National Health Service general practices, hospitals and registered patients with hospitalised AF-related stroke in England were obtained from national databases. Stroke care costs were based on published data. We compared changes in oral anticoagulation prescribing (warfarin or direct oral anticoagulants (DOACs)), incidence of hospitalised AF-related stroke, and associated overall and per-patient costs in the periods January 2011–June 2014 and July 2014–December 2017.ResultsBetween 2011–2014 and 2014–2017, recipients of oral anticoagulation for AF increased by 86.5% from 1 381 170 to 2 575 669. The number of patients prescribed warfarin grew by 16.1% from 1 313 544 to 1 525 674 and those taking DOACs by 1452.7% from 67 626 to 1 049 995. Prescribed items increased by 5.9% for warfarin (95% CI 2.9% to 8.9%) but by 2004.8% for DOACs (95% CI 1848.8% to 2160.7%). Oral anticoagulation prescription cost rose overall by 781.2%, from £87 313 310 to £769 444 028, (£733,466,204 with warfarin monitoring) and per patient by 50.7%, from £293 to £442, giving an incremental cost of £149. Nevertheless, as AF-related stroke incidence fell by 11.3% (95% CI −11.5% to −11.1%) from 86 467 in 2011–2014 to 76 730 in 2014–2017 with adjustment for AF prevalence, the overall per-patient cost reduced from £1129 to £840, giving an incremental per-patient saving of £289.ConclusionsDespite nearly one million additional DOAC prescriptions and substantial associated spending in the latter part of this study, the decline in AF-related stroke led to incremental savings at the national level.

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Regional variations in stroke care in England, Wales and Northern Ireland: results from the National Sentinel Audit of Stroke

Clinical Rehabilitation ◽

10.1191/026921501680425289 ◽

2001 ◽

Vol 15 (5) ◽

pp. 562-572 ◽

Cited By ~ 39

Author(s):

Anthony G Rudd ◽

P Irwin ◽

Z Rutledge ◽

D Lowe ◽

D T Wade ◽

...

Keyword(s):

Northern Ireland ◽

Stroke Care ◽

Regional Variations

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Culture, Rhetoric, and Reconciliation: The Place of Language in the Northern Irish Conflict and Peace Process (1998-2002)

Peace and Conflict Studies ◽

10.46743/1082-7307/2006.1068 ◽

2006 ◽

Author(s):

Jennifer Dougherty

Keyword(s):

Northern Ireland ◽

Public Discourse ◽

National Level ◽

Peace Process ◽

Seamus Heaney ◽

Northern Irish ◽

Potential Conflict ◽

Positive Role ◽

Language Play ◽

The Troubles

Alterations in public discourse towards multiculturalism, reconciliation and liberal democracy at the national level in Northern Ireland are evident from 1998 - 2002, but to what end? To what extent did language play a positive role in the Northern Ireland peace process? Recognizing that language does not tell the whole story of the Northern Irish experience of the Troubles or current peace process, the author highlights how language, as a transmitter and constitutor of culture, has played a role as a signifier of potential conflict, peace and progress (or lack thereof). In particular, the author considers several texts including excerpts from speeches given by Noble Prize Winners—the former First Minister David Trimble and former SDLP leader, John Hume; an IRA apology, Bloody Sunday Inquiry and the Belfast Agreement; and several selections from the work of Northern Irish poets Seamus Heaney and Eavan Boland.

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20 years of researching stroke through audit

Clinical Rehabilitation ◽

10.1177/0269215518784645 ◽

2018 ◽

Vol 32 (8) ◽

pp. 997-1006 ◽

Cited By ~ 9

Author(s):

Anthony G Rudd ◽

Alex Hoffman ◽

Lizz Paley ◽

Benjamin Bray

Keyword(s):

Northern Ireland ◽

Institutional Care ◽

Stroke Care ◽

Routine Practice ◽

Processes Of Care ◽

Patient Reported ◽

Clinical Benefits ◽

Using Data ◽

Patient Reported Measures

Over the last 20 years, England, Wales and Northern Ireland have developed an audit programme that now encompasses nearly all patients admitted to hospital with a stroke. This article records and reviews some questions that have been answered using data from the audit: Is the rate of institutional care after rehabilitation a possible measure of outcome? Does stroke unit care in routine practice give the benefits shown in randomized controlled trials? How is the quality of stroke care affected by a patient’s age and the time of their stroke? Do patient-reported measures match those obtained from the professionals recording of processes of care? How do the processes of care after stroke affect mortality? Is thrombolysis safe to use in patients over the age of 80? Do staffing levels matter? Does assessing the safety of swallowing really make a difference? Do clinicians make rational decisions about end-of-life care in patients with haemorrhage? Does socioeconomic status influence the risk of stroke, outcome after stroke and the quality of stroke care? How much does stroke really cost in England, Wales and Northern Ireland? The article concludes that this national audit has improved stroke care across the United Kingdom, has given answers to important questions that could not be answered in any other way and has shown that benefits found in research do generalize into real clinical benefits in day-to-day practice.

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Britain and Ireland

The Oxford Handbook of Ecumenical Studies ◽

10.1093/oxfordhb/9780199600847.013.35 ◽

2017 ◽

Author(s):

Paul Avis

Keyword(s):

United Kingdom ◽

Northern Ireland ◽

National Level ◽

The Political ◽

England And Wales ◽

Republic Of Ireland ◽

Ecumenical Movement ◽

The United Kingdom ◽

The Republic

This chapter begins by noting the contribution of British ecumenists to the ecumenical movement and then proceeds to survey the ecumenical scene in Britain and Ireland against the political and constitutional background of the United Kingdom—comprising England, Scotland, Wales, and Northern Ireland—and the separate jurisdiction of the Republic of Ireland. It notes the favourable ecumenical climate in England and Wales and goes on to outline local ecumenical relationships, including Local Ecumenical Partnerships, the ecumenical instruments for each nation and for all four, and various forms of cooperation at the national level. The chapter then turns to examples of theological dialogue, proposals for closer unity, and the problems of their reception and implementation, with a particular focus on the Anglican-Methodist Covenant.

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