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Stroke is the third most common cause of death after heart disease and all cancers combined, and is the major cause of long term adult disability. There were approximately 6000 first ever and 2000 recurrent strokes in New Zealand in 2009. Ninety percent of people with stroke are admitted to hospital.1The annual lifetime costs of stroke to New Zealand is estimated to be $450 million.2 The Diabetes and Cardiovascular Disease Quality Improvement Plan 2008 (QIP) identified improvement of stroke services as a healthcare priority.3 However, there was little information on the provision of stroke services, hampering evaluation and benchmarking of DHB service provision. In 2009, the Ministry of Health contracted the Stroke Foundation of New Zealand (SFNZ) to undertake an audit of all DHBs and we present here the results.4Methods The 2009 National Acute Stroke Services Audit (2009 Audit) was an initiative of the SFNZ and was carried out in collaboration with the Australian National Stroke Foundation (NSF). The audit determined the resources available to support the delivery of evidence-based care and examined conformance of clinical practice with evidence-based best practice recommendations. Audit questions were developed by the Australian National Advisory Committee, on which there were New Zealand representatives, and question terminology was revised to reflect the New Zealand situation. The audit was comprised of two parts: an organisational survey of structural and process elements of acute stroke care service provision; and a clinical audit involving retrospective review, via patient record, of up to 40 consecutive stroke patients admitted, treated and discharged from acute care in individual DHBs. The results of the clinical audit will be reported separately. All 21 DHBs were contacted inviting them to participate in the audit. All 21 DHBs participated in the organisational component of the audit and 20 participated in the audit of acute stroke care delivery. A stroke unit was defined as a discrete ward, or beds within a ward, with a dedicated specialised multi-disciplinary team (MDT) and could include acute stroke units that discharge patients to a rehabilitation service, or an integrated acute and rehabilitation unit. An audit team was established within each DHB and consisted of medical, nursing, and allied health professionals. An hour of on-line training was provided via teleconference, by the NSF National audit program manager and project officer. Responses could only be recorded where there was documented evidence for process of care indicators. Data was entered online by the person carrying out the audit. DHBs were split into three groups on the basis of population served and the predicted number of stroke admissions per year. These groups were: Large, with a population catchment >200,000 people, Medium with a population of 120,000-200,000 and Small with a population of <120,000. Data from DHBs with more than one acute hospital was aggregated and reported for the whole DHB. The audit was conducted in Australia at the same time and was identical with the exception that audits were carried out in individual hospitals and not DHBs with the results reported by hospital size. DHB data sets were de-identified and analysed using PASW Statistics Version 18.0. Organisation data from DHBs was aggregated to provide national estimates with results divided into DHB category (large, medium or small) and stroke unit status. The median (50th percentile) and interquartile (25th percentile) ranges were reported for continuous data. Data collection was carried out from April to August 2009 Results There were 7 large, 6 medium and 8 small DHBs (Table 1). There were 6194 stroke patients admitted in the 12 months prior to the audit and 176 patients in hospital on the day of the audit. Eight of 21 DHBs had stroke units; 5 acute and 3 integrated stroke units. The 8 stroke units were in 5 of 7 large, and 3 of 6 medium DHBs and none of the small DHBs. On the day of the audit, 39% of all New Zealand patients and 51% of all Australian patients were within a stroke unit. Table 1. DHB and stroke unit characteristics Variables Total N Large Medium Small SU No SU Number of DHBs 21 7 6 8 8 13 Stroke admissions 6194 3862 1347 985 3493 2701 DHB stroke admissions* 258 500 256 100 401 116 DHBs with stroke unit 8 5 3 0 8 - Stroke unit beds* 11 (5-15) 12 (10-15) 6 (5-10) - - 11 (5-15) - - Stroke inpatients on audit day 176 121 36 19 107 69 Patients in a stroke unit on audit day 68 (39%) 54 (45%) 14 (39%) 0 (0%) 68 (64%) 0 (0%) *Median; SU: Stroke unit; Large: population catchment > 200,000; Medium : population catchment of 120,000-200,000; Small: population catchment of <120,000. Stroke patients were first admitted to medical assessment units or directly into stroke units in large DHBs, and general medical wards or stroke units in medium DHBs (Table 2). Table 2. Admission ward, transient ischaemic attack (TIA) services and thrombolysis Variables Total Large Medium Small SU No SU (N=21) (N=7) (N=6) (N=8) (N=8) (N=13) Usual admission ward Stroke unit NZ 29% 43% 50% 0% 75% NA Aust 27% 81% 39% 1% 81% NA General medical NZ 52% 0% 50% 100% 0% 85% Aust 54% 13% 42% 81% 13% 75% Medical assessment unit NZ 19% 57% 0% 0% 25% 15% Aust 11% 4% 16% 6% 4% 14% TIA services TIA pathway NZ 67% 71% 83% 50% 75% 62% Aust 42% - - - 76% 25% ‘Admit all’ TIA patients policy NZ 5% 0% 17% 0% 13% 0% Aust 30% - - - 24% 33% Outpatient TIA clinic NZ 43% 57% 50% 25% 50% \r\n\r\

Summary

Abstract

Aim

To characterise the nature of acute stroke services provided by District Health Boards (DHBs) in New Zealand.

Method

An audit of all 21 DHBs was carried out in 2009 via an online survey examining the structural and process elements of acute stroke service provision. A clinical audit involving a retrospective review of consecutive admitted stroke patients is reported separately.

Results

The organisational survey found that most patients (82%) are admitted to hospitals in the 13 large and medium DHBs. Only 8 DHBs had stroke units and 5 of the large and medium DHBs did not have stroke units. On audit day, only 39% of all New Zealand patients were being managed in a stroke unit, compared with 51% of all Australian patients. Even in the 8 DHBs with stroke units, only 64% of patients were actually being managed in the stroke unit on the day of the audit. New Zealand compared favourably with Australia in aspects of TIA management and in access to brain imaging.

Conclusion

There is significant regional variation in the provision of organised stroke care and the level of stroke unit care is low by international standards. This audit provides a benchmark against which to compare future changes in the delivery of stroke care.

Author Information

Nicholas Child, Registrar, Neurology Department, Auckland City Hospital, Auckland; P Alan Barber, Director of the Auckland City Hospital Stroke Service, Neurology Department, Auckland City Hospital, Auckland; John Fink, Neurologist, Neurology Department Christchurch Hospital, Christchurch; Shelley Jones, Guidelines Project Coordinator, Stroke Foundation of New Zealand; Kevin Voges, Senior Lecturer in Marketing, Department of Management, College of Business and Economics, University of Canterbury, Christchurch; Mark Vivian, Chief Executive Officer, Stroke Foundation of New Zealand

Acknowledgements

Correspondence

Professor Alan Barber, Neurology Department, Auckland City Hospital, Park Road, Grafton, Auckland, New Zealand. Fax :+64 (0)9 3754309

Correspondence Email

a.barber@auckland.ac.nz

Competing Interests

None.

Tobias M, Cheung J, Carter K, et al. Stroke surveillance: population-based estimates and projections for New Zealand. Australian & New Zealand Journal of Public Health. 2007;31(6):520-525.Brown P. Economic burden of stroke in New Zealand. Three decades of Auckland regional community stroke (ARCOS) studies: What have we learned and what is next for stroke care and stroke research? . AUT University Auckland. 2009.Ministry of Health. Diabetes and Cardiovascular Disease Quality Improvement Plan 2008: Ministry of Health, Wellington; 2007.Stroke Foundation of New Zealand. National Acute Stroke Services Audit: Stroke Foundation of New Zealand;2010.http://www.stroke.org.nz/stroke-health-professionalsStroke Unit Trialists Collaboration. Collaborative systematic review of the randomised trials of organised inpatient (stroke unit) care after stroke. BMJ. April 19, 1997 1997;314(7088):1151.ORourke K, Walsh C. Impact of stroke units on mortality: a Bayesian analysis. European Journal of Neurology. 2010;17(2):247-251.Stroke Unit Trialists' Collaboration. Organised inpatient (stroke unit) care for stroke. The Cochrane Library 2007(4).Hankey GJ, Warlow CP. Treatment and secondary prevention of stroke: evidence, costs, and effects on individuals and populations. The Lancet. 1999;354(9188):1457-1463.New Zealand Stroke Guidelines Development Team. Life after stroke. New Zealand Guideline for the management of stroke. Wellington: Stroke Foundation of New Zealand. 2003.Stroke Foundation of New Zealand and New Zealand Guidelines Group. Clinical Guidelines for Stroke Management 2010. Wellington: Stroke Foundation of New Zealand. 2010.The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. Tissue Plasminogen Activator for Acute Ischemic Stroke. New England Journal of Medicine. 1995;333(24):1581-1588.Kwiatkowski TG, Libman RB, Frankel M, et al. Effects of Tissue Plasminogen Activator for Acute Ischemic Stroke at One Year. New England Journal of Medicine. 1999;340(23):1781-1787.Hacke W, Kaste M, Bluhmki E, et al. Thrombolysis with Alteplase 3 to 4.5 Hours after Acute Ischemic Stroke. New England Journal of Medicine. 2008;359(13):1317-1329.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. February 7, 2004 2004;328(7435):326.Rothwell PM, Giles MF, Chandratheva A, et al. Effect of urgent treatment of transient ischaemic attack and minor stroke on early recurrent stroke (EXPRESS study): a prospective population-based sequential comparison. The Lancet. 2007;370(9596):1432-1442.Lavall 00e9e PC, Meseguer E, Abboud H, et al. A transient ischaemic attack clinic with round-the-clock access (SOS-TIA): feasibility and effects. The Lancet Neurology. 2007;6(11):953-960.New Zealand Guidelines For the Assessment and Management of People with Recent Transient ischaemic Attack (TIA). Stroke Foundation of New Zealand. 2008.Barber PA, Bennett P, Gommans J. Acute stroke services in New Zealand. The New Zealand Medical Journal. 2002;115(1146):3-6.Gommans J, Barber A, McNaughton H, et al. Stroke rehabilitation services in New Zealand. The New Zealand Medical Journal. 2003;116(1174).Barber PA, Gommans J, Fink J, et al. Acute stroke services in New Zealand: changes between 2001 and 2007. The New Zealand Medical Journal. 2008;121(1285). http://journal.nzma.org.nz/journal/121-1285/3343/content.pdfSomerfield 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. Internal Medicine Journal. 2006;36(5):276-280.

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Stroke is the third most common cause of death after heart disease and all cancers combined, and is the major cause of long term adult disability. There were approximately 6000 first ever and 2000 recurrent strokes in New Zealand in 2009. Ninety percent of people with stroke are admitted to hospital.1The annual lifetime costs of stroke to New Zealand is estimated to be $450 million.2 The Diabetes and Cardiovascular Disease Quality Improvement Plan 2008 (QIP) identified improvement of stroke services as a healthcare priority.3 However, there was little information on the provision of stroke services, hampering evaluation and benchmarking of DHB service provision. In 2009, the Ministry of Health contracted the Stroke Foundation of New Zealand (SFNZ) to undertake an audit of all DHBs and we present here the results.4Methods The 2009 National Acute Stroke Services Audit (2009 Audit) was an initiative of the SFNZ and was carried out in collaboration with the Australian National Stroke Foundation (NSF). The audit determined the resources available to support the delivery of evidence-based care and examined conformance of clinical practice with evidence-based best practice recommendations. Audit questions were developed by the Australian National Advisory Committee, on which there were New Zealand representatives, and question terminology was revised to reflect the New Zealand situation. The audit was comprised of two parts: an organisational survey of structural and process elements of acute stroke care service provision; and a clinical audit involving retrospective review, via patient record, of up to 40 consecutive stroke patients admitted, treated and discharged from acute care in individual DHBs. The results of the clinical audit will be reported separately. All 21 DHBs were contacted inviting them to participate in the audit. All 21 DHBs participated in the organisational component of the audit and 20 participated in the audit of acute stroke care delivery. A stroke unit was defined as a discrete ward, or beds within a ward, with a dedicated specialised multi-disciplinary team (MDT) and could include acute stroke units that discharge patients to a rehabilitation service, or an integrated acute and rehabilitation unit. An audit team was established within each DHB and consisted of medical, nursing, and allied health professionals. An hour of on-line training was provided via teleconference, by the NSF National audit program manager and project officer. Responses could only be recorded where there was documented evidence for process of care indicators. Data was entered online by the person carrying out the audit. DHBs were split into three groups on the basis of population served and the predicted number of stroke admissions per year. These groups were: Large, with a population catchment >200,000 people, Medium with a population of 120,000-200,000 and Small with a population of <120,000. Data from DHBs with more than one acute hospital was aggregated and reported for the whole DHB. The audit was conducted in Australia at the same time and was identical with the exception that audits were carried out in individual hospitals and not DHBs with the results reported by hospital size. DHB data sets were de-identified and analysed using PASW Statistics Version 18.0. Organisation data from DHBs was aggregated to provide national estimates with results divided into DHB category (large, medium or small) and stroke unit status. The median (50th percentile) and interquartile (25th percentile) ranges were reported for continuous data. Data collection was carried out from April to August 2009 Results There were 7 large, 6 medium and 8 small DHBs (Table 1). There were 6194 stroke patients admitted in the 12 months prior to the audit and 176 patients in hospital on the day of the audit. Eight of 21 DHBs had stroke units; 5 acute and 3 integrated stroke units. The 8 stroke units were in 5 of 7 large, and 3 of 6 medium DHBs and none of the small DHBs. On the day of the audit, 39% of all New Zealand patients and 51% of all Australian patients were within a stroke unit. Table 1. DHB and stroke unit characteristics Variables Total N Large Medium Small SU No SU Number of DHBs 21 7 6 8 8 13 Stroke admissions 6194 3862 1347 985 3493 2701 DHB stroke admissions* 258 500 256 100 401 116 DHBs with stroke unit 8 5 3 0 8 - Stroke unit beds* 11 (5-15) 12 (10-15) 6 (5-10) - - 11 (5-15) - - Stroke inpatients on audit day 176 121 36 19 107 69 Patients in a stroke unit on audit day 68 (39%) 54 (45%) 14 (39%) 0 (0%) 68 (64%) 0 (0%) *Median; SU: Stroke unit; Large: population catchment > 200,000; Medium : population catchment of 120,000-200,000; Small: population catchment of <120,000. Stroke patients were first admitted to medical assessment units or directly into stroke units in large DHBs, and general medical wards or stroke units in medium DHBs (Table 2). Table 2. Admission ward, transient ischaemic attack (TIA) services and thrombolysis Variables Total Large Medium Small SU No SU (N=21) (N=7) (N=6) (N=8) (N=8) (N=13) Usual admission ward Stroke unit NZ 29% 43% 50% 0% 75% NA Aust 27% 81% 39% 1% 81% NA General medical NZ 52% 0% 50% 100% 0% 85% Aust 54% 13% 42% 81% 13% 75% Medical assessment unit NZ 19% 57% 0% 0% 25% 15% Aust 11% 4% 16% 6% 4% 14% TIA services TIA pathway NZ 67% 71% 83% 50% 75% 62% Aust 42% - - - 76% 25% ‘Admit all’ TIA patients policy NZ 5% 0% 17% 0% 13% 0% Aust 30% - - - 24% 33% Outpatient TIA clinic NZ 43% 57% 50% 25% 50% \r\n\r\

Summary

Abstract

Aim

To characterise the nature of acute stroke services provided by District Health Boards (DHBs) in New Zealand.

Method

An audit of all 21 DHBs was carried out in 2009 via an online survey examining the structural and process elements of acute stroke service provision. A clinical audit involving a retrospective review of consecutive admitted stroke patients is reported separately.

Results

The organisational survey found that most patients (82%) are admitted to hospitals in the 13 large and medium DHBs. Only 8 DHBs had stroke units and 5 of the large and medium DHBs did not have stroke units. On audit day, only 39% of all New Zealand patients were being managed in a stroke unit, compared with 51% of all Australian patients. Even in the 8 DHBs with stroke units, only 64% of patients were actually being managed in the stroke unit on the day of the audit. New Zealand compared favourably with Australia in aspects of TIA management and in access to brain imaging.

Conclusion

There is significant regional variation in the provision of organised stroke care and the level of stroke unit care is low by international standards. This audit provides a benchmark against which to compare future changes in the delivery of stroke care.

Author Information

Nicholas Child, Registrar, Neurology Department, Auckland City Hospital, Auckland; P Alan Barber, Director of the Auckland City Hospital Stroke Service, Neurology Department, Auckland City Hospital, Auckland; John Fink, Neurologist, Neurology Department Christchurch Hospital, Christchurch; Shelley Jones, Guidelines Project Coordinator, Stroke Foundation of New Zealand; Kevin Voges, Senior Lecturer in Marketing, Department of Management, College of Business and Economics, University of Canterbury, Christchurch; Mark Vivian, Chief Executive Officer, Stroke Foundation of New Zealand

Acknowledgements

Correspondence

Professor Alan Barber, Neurology Department, Auckland City Hospital, Park Road, Grafton, Auckland, New Zealand. Fax :+64 (0)9 3754309

Correspondence Email

a.barber@auckland.ac.nz

Competing Interests

None.

Tobias M, Cheung J, Carter K, et al. Stroke surveillance: population-based estimates and projections for New Zealand. Australian & New Zealand Journal of Public Health. 2007;31(6):520-525.Brown P. Economic burden of stroke in New Zealand. Three decades of Auckland regional community stroke (ARCOS) studies: What have we learned and what is next for stroke care and stroke research? . AUT University Auckland. 2009.Ministry of Health. Diabetes and Cardiovascular Disease Quality Improvement Plan 2008: Ministry of Health, Wellington; 2007.Stroke Foundation of New Zealand. National Acute Stroke Services Audit: Stroke Foundation of New Zealand;2010.http://www.stroke.org.nz/stroke-health-professionalsStroke Unit Trialists Collaboration. Collaborative systematic review of the randomised trials of organised inpatient (stroke unit) care after stroke. BMJ. April 19, 1997 1997;314(7088):1151.ORourke K, Walsh C. Impact of stroke units on mortality: a Bayesian analysis. European Journal of Neurology. 2010;17(2):247-251.Stroke Unit Trialists' Collaboration. Organised inpatient (stroke unit) care for stroke. The Cochrane Library 2007(4).Hankey GJ, Warlow CP. Treatment and secondary prevention of stroke: evidence, costs, and effects on individuals and populations. The Lancet. 1999;354(9188):1457-1463.New Zealand Stroke Guidelines Development Team. Life after stroke. New Zealand Guideline for the management of stroke. Wellington: Stroke Foundation of New Zealand. 2003.Stroke Foundation of New Zealand and New Zealand Guidelines Group. Clinical Guidelines for Stroke Management 2010. Wellington: Stroke Foundation of New Zealand. 2010.The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. Tissue Plasminogen Activator for Acute Ischemic Stroke. New England Journal of Medicine. 1995;333(24):1581-1588.Kwiatkowski TG, Libman RB, Frankel M, et al. Effects of Tissue Plasminogen Activator for Acute Ischemic Stroke at One Year. New England Journal of Medicine. 1999;340(23):1781-1787.Hacke W, Kaste M, Bluhmki E, et al. Thrombolysis with Alteplase 3 to 4.5 Hours after Acute Ischemic Stroke. New England Journal of Medicine. 2008;359(13):1317-1329.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. February 7, 2004 2004;328(7435):326.Rothwell PM, Giles MF, Chandratheva A, et al. Effect of urgent treatment of transient ischaemic attack and minor stroke on early recurrent stroke (EXPRESS study): a prospective population-based sequential comparison. The Lancet. 2007;370(9596):1432-1442.Lavall 00e9e PC, Meseguer E, Abboud H, et al. A transient ischaemic attack clinic with round-the-clock access (SOS-TIA): feasibility and effects. The Lancet Neurology. 2007;6(11):953-960.New Zealand Guidelines For the Assessment and Management of People with Recent Transient ischaemic Attack (TIA). Stroke Foundation of New Zealand. 2008.Barber PA, Bennett P, Gommans J. Acute stroke services in New Zealand. The New Zealand Medical Journal. 2002;115(1146):3-6.Gommans J, Barber A, McNaughton H, et al. Stroke rehabilitation services in New Zealand. The New Zealand Medical Journal. 2003;116(1174).Barber PA, Gommans J, Fink J, et al. Acute stroke services in New Zealand: changes between 2001 and 2007. The New Zealand Medical Journal. 2008;121(1285). http://journal.nzma.org.nz/journal/121-1285/3343/content.pdfSomerfield 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. Internal Medicine Journal. 2006;36(5):276-280.

Contact diana@nzma.org.nz
for the PDF of this article

View Article PDF

Stroke is the third most common cause of death after heart disease and all cancers combined, and is the major cause of long term adult disability. There were approximately 6000 first ever and 2000 recurrent strokes in New Zealand in 2009. Ninety percent of people with stroke are admitted to hospital.1The annual lifetime costs of stroke to New Zealand is estimated to be $450 million.2 The Diabetes and Cardiovascular Disease Quality Improvement Plan 2008 (QIP) identified improvement of stroke services as a healthcare priority.3 However, there was little information on the provision of stroke services, hampering evaluation and benchmarking of DHB service provision. In 2009, the Ministry of Health contracted the Stroke Foundation of New Zealand (SFNZ) to undertake an audit of all DHBs and we present here the results.4Methods The 2009 National Acute Stroke Services Audit (2009 Audit) was an initiative of the SFNZ and was carried out in collaboration with the Australian National Stroke Foundation (NSF). The audit determined the resources available to support the delivery of evidence-based care and examined conformance of clinical practice with evidence-based best practice recommendations. Audit questions were developed by the Australian National Advisory Committee, on which there were New Zealand representatives, and question terminology was revised to reflect the New Zealand situation. The audit was comprised of two parts: an organisational survey of structural and process elements of acute stroke care service provision; and a clinical audit involving retrospective review, via patient record, of up to 40 consecutive stroke patients admitted, treated and discharged from acute care in individual DHBs. The results of the clinical audit will be reported separately. All 21 DHBs were contacted inviting them to participate in the audit. All 21 DHBs participated in the organisational component of the audit and 20 participated in the audit of acute stroke care delivery. A stroke unit was defined as a discrete ward, or beds within a ward, with a dedicated specialised multi-disciplinary team (MDT) and could include acute stroke units that discharge patients to a rehabilitation service, or an integrated acute and rehabilitation unit. An audit team was established within each DHB and consisted of medical, nursing, and allied health professionals. An hour of on-line training was provided via teleconference, by the NSF National audit program manager and project officer. Responses could only be recorded where there was documented evidence for process of care indicators. Data was entered online by the person carrying out the audit. DHBs were split into three groups on the basis of population served and the predicted number of stroke admissions per year. These groups were: Large, with a population catchment >200,000 people, Medium with a population of 120,000-200,000 and Small with a population of <120,000. Data from DHBs with more than one acute hospital was aggregated and reported for the whole DHB. The audit was conducted in Australia at the same time and was identical with the exception that audits were carried out in individual hospitals and not DHBs with the results reported by hospital size. DHB data sets were de-identified and analysed using PASW Statistics Version 18.0. Organisation data from DHBs was aggregated to provide national estimates with results divided into DHB category (large, medium or small) and stroke unit status. The median (50th percentile) and interquartile (25th percentile) ranges were reported for continuous data. Data collection was carried out from April to August 2009 Results There were 7 large, 6 medium and 8 small DHBs (Table 1). There were 6194 stroke patients admitted in the 12 months prior to the audit and 176 patients in hospital on the day of the audit. Eight of 21 DHBs had stroke units; 5 acute and 3 integrated stroke units. The 8 stroke units were in 5 of 7 large, and 3 of 6 medium DHBs and none of the small DHBs. On the day of the audit, 39% of all New Zealand patients and 51% of all Australian patients were within a stroke unit. Table 1. DHB and stroke unit characteristics Variables Total N Large Medium Small SU No SU Number of DHBs 21 7 6 8 8 13 Stroke admissions 6194 3862 1347 985 3493 2701 DHB stroke admissions* 258 500 256 100 401 116 DHBs with stroke unit 8 5 3 0 8 - Stroke unit beds* 11 (5-15) 12 (10-15) 6 (5-10) - - 11 (5-15) - - Stroke inpatients on audit day 176 121 36 19 107 69 Patients in a stroke unit on audit day 68 (39%) 54 (45%) 14 (39%) 0 (0%) 68 (64%) 0 (0%) *Median; SU: Stroke unit; Large: population catchment > 200,000; Medium : population catchment of 120,000-200,000; Small: population catchment of <120,000. Stroke patients were first admitted to medical assessment units or directly into stroke units in large DHBs, and general medical wards or stroke units in medium DHBs (Table 2). Table 2. Admission ward, transient ischaemic attack (TIA) services and thrombolysis Variables Total Large Medium Small SU No SU (N=21) (N=7) (N=6) (N=8) (N=8) (N=13) Usual admission ward Stroke unit NZ 29% 43% 50% 0% 75% NA Aust 27% 81% 39% 1% 81% NA General medical NZ 52% 0% 50% 100% 0% 85% Aust 54% 13% 42% 81% 13% 75% Medical assessment unit NZ 19% 57% 0% 0% 25% 15% Aust 11% 4% 16% 6% 4% 14% TIA services TIA pathway NZ 67% 71% 83% 50% 75% 62% Aust 42% - - - 76% 25% ‘Admit all’ TIA patients policy NZ 5% 0% 17% 0% 13% 0% Aust 30% - - - 24% 33% Outpatient TIA clinic NZ 43% 57% 50% 25% 50% \r\n\r\

Summary

Abstract

Aim

To characterise the nature of acute stroke services provided by District Health Boards (DHBs) in New Zealand.

Method

An audit of all 21 DHBs was carried out in 2009 via an online survey examining the structural and process elements of acute stroke service provision. A clinical audit involving a retrospective review of consecutive admitted stroke patients is reported separately.

Results

The organisational survey found that most patients (82%) are admitted to hospitals in the 13 large and medium DHBs. Only 8 DHBs had stroke units and 5 of the large and medium DHBs did not have stroke units. On audit day, only 39% of all New Zealand patients were being managed in a stroke unit, compared with 51% of all Australian patients. Even in the 8 DHBs with stroke units, only 64% of patients were actually being managed in the stroke unit on the day of the audit. New Zealand compared favourably with Australia in aspects of TIA management and in access to brain imaging.

Conclusion

There is significant regional variation in the provision of organised stroke care and the level of stroke unit care is low by international standards. This audit provides a benchmark against which to compare future changes in the delivery of stroke care.

Author Information

Nicholas Child, Registrar, Neurology Department, Auckland City Hospital, Auckland; P Alan Barber, Director of the Auckland City Hospital Stroke Service, Neurology Department, Auckland City Hospital, Auckland; John Fink, Neurologist, Neurology Department Christchurch Hospital, Christchurch; Shelley Jones, Guidelines Project Coordinator, Stroke Foundation of New Zealand; Kevin Voges, Senior Lecturer in Marketing, Department of Management, College of Business and Economics, University of Canterbury, Christchurch; Mark Vivian, Chief Executive Officer, Stroke Foundation of New Zealand

Acknowledgements

Correspondence

Professor Alan Barber, Neurology Department, Auckland City Hospital, Park Road, Grafton, Auckland, New Zealand. Fax :+64 (0)9 3754309

Correspondence Email

a.barber@auckland.ac.nz

Competing Interests

None.

Tobias M, Cheung J, Carter K, et al. Stroke surveillance: population-based estimates and projections for New Zealand. Australian & New Zealand Journal of Public Health. 2007;31(6):520-525.Brown P. Economic burden of stroke in New Zealand. Three decades of Auckland regional community stroke (ARCOS) studies: What have we learned and what is next for stroke care and stroke research? . AUT University Auckland. 2009.Ministry of Health. Diabetes and Cardiovascular Disease Quality Improvement Plan 2008: Ministry of Health, Wellington; 2007.Stroke Foundation of New Zealand. National Acute Stroke Services Audit: Stroke Foundation of New Zealand;2010.http://www.stroke.org.nz/stroke-health-professionalsStroke Unit Trialists Collaboration. Collaborative systematic review of the randomised trials of organised inpatient (stroke unit) care after stroke. BMJ. April 19, 1997 1997;314(7088):1151.ORourke K, Walsh C. Impact of stroke units on mortality: a Bayesian analysis. European Journal of Neurology. 2010;17(2):247-251.Stroke Unit Trialists' Collaboration. Organised inpatient (stroke unit) care for stroke. The Cochrane Library 2007(4).Hankey GJ, Warlow CP. Treatment and secondary prevention of stroke: evidence, costs, and effects on individuals and populations. The Lancet. 1999;354(9188):1457-1463.New Zealand Stroke Guidelines Development Team. Life after stroke. New Zealand Guideline for the management of stroke. Wellington: Stroke Foundation of New Zealand. 2003.Stroke Foundation of New Zealand and New Zealand Guidelines Group. Clinical Guidelines for Stroke Management 2010. Wellington: Stroke Foundation of New Zealand. 2010.The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. Tissue Plasminogen Activator for Acute Ischemic Stroke. New England Journal of Medicine. 1995;333(24):1581-1588.Kwiatkowski TG, Libman RB, Frankel M, et al. Effects of Tissue Plasminogen Activator for Acute Ischemic Stroke at One Year. New England Journal of Medicine. 1999;340(23):1781-1787.Hacke W, Kaste M, Bluhmki E, et al. Thrombolysis with Alteplase 3 to 4.5 Hours after Acute Ischemic Stroke. New England Journal of Medicine. 2008;359(13):1317-1329.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. February 7, 2004 2004;328(7435):326.Rothwell PM, Giles MF, Chandratheva A, et al. Effect of urgent treatment of transient ischaemic attack and minor stroke on early recurrent stroke (EXPRESS study): a prospective population-based sequential comparison. The Lancet. 2007;370(9596):1432-1442.Lavall 00e9e PC, Meseguer E, Abboud H, et al. A transient ischaemic attack clinic with round-the-clock access (SOS-TIA): feasibility and effects. The Lancet Neurology. 2007;6(11):953-960.New Zealand Guidelines For the Assessment and Management of People with Recent Transient ischaemic Attack (TIA). Stroke Foundation of New Zealand. 2008.Barber PA, Bennett P, Gommans J. Acute stroke services in New Zealand. The New Zealand Medical Journal. 2002;115(1146):3-6.Gommans J, Barber A, McNaughton H, et al. Stroke rehabilitation services in New Zealand. The New Zealand Medical Journal. 2003;116(1174).Barber PA, Gommans J, Fink J, et al. Acute stroke services in New Zealand: changes between 2001 and 2007. The New Zealand Medical Journal. 2008;121(1285). http://journal.nzma.org.nz/journal/121-1285/3343/content.pdfSomerfield 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. Internal Medicine Journal. 2006;36(5):276-280.

Contact diana@nzma.org.nz
for the PDF of this article

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