The UK urgently needs to reorganise stroke services to improve outcomes for patients, argues a senior doctor in this week's BMJ.
Studies have found that the UK has the worst outcome in western Europe. In one study the differences in the proportion of patients dead or dependent between the UK and eight other European countries were between 150 and 300 events per 1000 patients.
What underlies this variation and why is outcome so poor in the UK, asks Professor Hugh Markus at St George's University of London"
Differences in the process of care are likely to be important, he writes. In many European countries stroke care is an integral part of neurology. In contrast, in the UK it has, until recently, been a "Cinderella" subject, often falling between neurology and general and geriatric medicine.
It is tempting to conclude that this lack of interest has led to underinvestment and a resulting poor outcome, he says. Yet the cost of care of stroke patients seems to be as high, if not higher, in the UK than in European countries with better outcomes.
He suggests several organisational and structural problems, such as poor focus on acute stroke care.
This has become even more important now that there are specific treatments for acute stroke, such as thrombolysis (giving anti-clotting drugs to patients within three hours of a stroke), he says. Effective thrombolysis services exist in many countries in Europe, North America, and Australia, where in some centres as many as 20-30% of eligible patients receiving thrombolytic therapy. Currently less than 1% receive such therapy in the UK.
These deficiencies have already been recognised in England in a 2005 National Audit Office report, he writes. The report concluded that if care was better organised, every year £20m could be saved, 550 deaths could be avoided, and 1700 patients would recover fully who would not otherwise do so. In response, England's Department of Health National Stroke Strategy is due to publish its recommendations in autumn 2007.
A major challenge is to change the perception of stroke among both health professionals and the public, so that stroke is viewed as a condition that requires emergency action. The UK also has a severe shortage of specialists trained in acute stroke care and access to imaging technology, says Markus.
For example, in many European countries, brain scans are performed on admission in the accident and emergency department, while in the UK many units struggle to provide it within 24 hours, despite research showing that scanning patients immediately is the most cost effective strategy.
Improved early diagnosis with imaging, together with improved monitoring and treatment of physiological parameters, will improve outcome independent of administration of thrombolysis, he concludes. If we can set such acute systems in place they will also facilitate implementation of other new treatments.