Urgent Assessment And Treatment Of Stroke Patients Reduces Disability, Hospital Bed-Days, And Costs, Lancet Neurology
April 02, 2017
Urgent assessment and treatment of patients who have had a minor stroke or transient ischaemic attack (TIA)* in a specialist emergency outpatient clinic reduces disability, hospital bed-days and costs. These are the conclusions of the second part of the EXPRESS study, reported in an Article published Online First and in the March edition of The Lancet Neurology. The study was done by Professor Peter Rothwell and colleagues, Stroke Prevention Research Unit, John Radcliffe Hospital, Oxford, and University of Oxford, UK.
The risk of recurrent stroke in the first few days after a minor stroke or TIA is around 8-10%. The first part of the EXPRESS study reported in October 2007, that urgent assessment and immediate treatment at a specialist clinic (phase 2) reduced the risk of recurrent stroke within the first 90 days by 80%, compared with patients treated at a standard referral appointment-based clinic (phase 1). This second paper aimed to compare the effects of phase 2 versus phase 1 with regard to hospital admissions, cost, and disability after 6 months.
The authors found that phase 2 patients had a lower 90-day risk of fatal or disabling stroke-this occurred in only 1 of 281 (0.3%) phase 2 patients compared with 16 of 310 (5.1%) in phase 1. Hospital admissions in phase 2 were much lower (five admissions) than in phase 1 (25). Hospital bed-days used due to stroke and other cardiovascular causes were also much lower in phase 2 (427 days) than phase 1 (1365 days). This generated savings of an average of £624 per patient referred to the phase 2 clinic.
The authors conclude: "In the UK, most patients with TIA or minor stroke are managed in weekly outpatient clinics after referral by a primary-care physician. This system results in about half of all patients waiting for more than 14 days to be assessed and treated, during which time the risk of recurrent stroke is at its highest. The EXPRESS study showed that urgent assessment of TIA and minor stroke in combination with early initiation of preventive treatment reduced the risk of early recurrent stroke by about 80%. This further analysis shows that, for patients referred to the EXPRESS study outpatient clinic, there were also reductions in fatal or disabling recurrent strokes, 90-day hospital bed-days, costs of admission to hospital, and overall disability levels at 6 months' follow-up.
"The extrapolation of these results [for the UK as a whole] would prevent about 10,000 strokes annually, and would generate savings of 290 000 hospital bed-days and monetary savings of £68 million in acute care costs alone. In addition, the reductions in disability rates at 6 months might lead to a reduction in the long-term usage of the health service in the community."
In an accompanying Reflection and Reaction comment Dr Naeem Dean and Professor Ashfaq Shuaib, Royal Alexandra Hospital and University of Alberta, Edmonton, Canada, say: "The care of patients with stroke, and the prevention of further events in patients who present with TIAs, will, unfortunately, always be suboptimum, as long as we fail to equate TIA and stroke care in line with the way we manage patients with acute coronary disorders. We hope that the research work emanating from several stroke centres, including those in Oxfordshire, will bring awareness to this under-recognised and poorly treated but common condition."
"Effect of urgent treatment for transient ischaemic attack and minor stroke on disability and hospital costs (EXPRESS study): a prospective population-based sequential comparison."
Ramon Luengo-Fernandez MSc, Alastair M Gray PhD, Peter M Rothwell FMedSci
The Lancet Neurology, Early Online Publication, 5 February 2009
doi:10.1016/S1474-4422(09)70019-5
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