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NIHR Signal Centralising stroke services can save lives

Published on 28 May 2019

doi: 10.3310/signal-000770

Changing access to more specialised stroke centre care in one city (London) was estimated to save an additional 96 lives per year (1%) compared to the reductions occurring in the rest of England. These improvements were sustained over time. Other cities did well on quality of care indicators, including time to admission in a stroke unit and length of stay. Patients and carers reported good experiences despite slightly increased travel times to the central stroke units.

A stroke can have devastating consequences, but these can be lessened if patients receive the right care quickly. The traditional service model usually involves patients being admitted to the nearest hospital able to offer acute stroke care, but some patients fail to receive optimal treatment or face delays to transfer.

This NIHR funded study adds to previous research evaluating centralisation of stroke units in London and Manchester that were initiated in 2010. Results show that centralised stroke services such as these can be cost effective and reduce mortality and length of hospital stay. However, performance varied between sites depending on factors such as the admission criteria and whether quality standards were linked with payments.

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Why was this study needed?

There are over 100,000 strokes in the UK each year, and it is the fourth commonest cause of death. Strokes happen when the blood supply to part of the brain is cut off, causing brain cell damage or death. This can affect people in different ways, both physically and emotionally. Almost two-thirds of survivors leave hospital with a disability.

In 2010, London opted for a fully centralised model, opening specialist hyperacute stroke units for all people with acute stroke. Manchester restricted centralised care to people within four hours of having a stroke, the time limit for effective clot-busting treatment (the Greater Manchester A model).

Earlier NIHR evidence published in 2014 showed that the London model appears to perform better on key indicators such as mortality. This study adds to this by evaluating longer-term results as well as the subsequent reconfiguration of Manchester services. In this, any stroke patient became eligible for centralised care without a time threshold (the Greater Manchester B model). The aim was to develop a more detailed understanding of which aspects of reorganisation were successful, and why, to guide wider implementation.

What did this study do?

This mixed-methods study compared the effectiveness of the different models of stroke service centralisation implemented in London and Manchester with the rest of England.

Data was obtained from several sources including Hospital Episode Statistics, mortality data from the Office for National Statistics, national stroke audits as well as earlier project research outputs. Qualitative data from patients, carers and staff was also gathered to help assess the development, implementation and sustainability of changes.

The lack of information about stroke severity upon admission is a limitation of the study that may have had a bearing on results. As well as this, only urban areas were studied, which limits generalisability to all parts of the country.

What did it find?

  • The London centralisation performed better than the rest of England in terms of mortality with an estimated 96 additional lives saved per year (–1.1%, 95% confidence interval [CI] –2.1% to –0.1%). Length of stay was reduced by a day and a half (–1.4 days, 95% CI –2.3 to –0.5 days).
  • The delivery of necessary clinical interventions within four hours was also higher with London’s rate running at 66.3% (95% CI 65.6% to 67.1%); compared with 54.4% (95% CI 53.6% to 55.1) in the rest of England. Later analyses show that these findings have been sustained.
  • The initial service redesign in Manchester (Greater Manchester A) reduced the length of stay by two days (–2.0 days, 95% CI –2.8 to –1.2 days), but did not have any impact on mortality or clinical interventions – only 39% of people received an intervention within four hours.
  • The subsequent reconfiguration (Greater Manchester B) reduced the length of stay by a day and a half (–1.5 days, 95% CI –2.5 to –0.4 days) as well as increasing the delivery of clinical interventions within four hours to 79.1% of patients. It did not have an effect on mortality overall (–1.3%, 95% CI –2.7% to 0.01%), taking into account reductions observed in the rest of England.
  • The London and Greater Manchester A services were judged to be cost-effective at 10 years and the Greater Manchester B service at 90 days.
  • When asked, patients and carers said that the better care received outweighed any concerns about longer travel times.

What does current guidance say on this issue?

While there is a lack of specific guidance on implementing changes to stroke services, the National Stroke Strategy of 2007 set new standards by recommending specialist treatment in the aftermath of stroke and auditing of stroke services.

Subsequent guidance from NICE in 2008 and the Royal College of Physicians in 2012 reinforced this by recommending that people with suspected stroke are admitted to and treated in, a specialist stroke ward or centre.

The RCP guidance also makes specific reference to the London and Manchester service restructuring and suggests that services should follow the more inclusive admission criteria of the London model.

What are the implications?

While the feasibility of centralised stroke services has already been established, this study helps clarify what aids successful implementation. Centralised service models where all stroke patients are eligible for treatment in a hyperacute stroke unit (such as London and Greater Manchester B) seem to perform better than those with more selective admission criteria (Greater Manchester A).

This should guide other urban regions looking to reconfigure their stroke care so that the changes can be made as effectively as possible.

Citation and Funding

Fulop N J, Ramsay A I G, Hunter R M et al. Evaluation of reconfigurations of acute stroke services in different regions of England and lessons for implementation: a mixed-methods study. Health Services and Delivery Research. 2019;7(7).

This project was funded by the NIHR Health Research and Delivery Research programme (project number 10/1009/09).

Bibliography

Intercollegiate Stroke Working Party. National clinical guideline for stroke, 5th edition. London: Royal College of Physicians; 2016.

Morris S, Hunter RM, Ramsay AI et al. Impact of centralising acute stroke services in English metropolitan areas on mortality and length of hospital stay: difference-in-differences analysis. BMJ. 2014;349:g4757.

NICE. Stroke: diagnosis and initial management of acute stroke and transient ischaemic attack (TIA). CG68. London: National Institute for Health and Care Excellence; 2008.

Ramsay AI, Morris S, Hoffman A, et al. Effects of centralizing acute stroke services on stroke care provision in two large metropolitan areas in England. Stroke. 2015;46(8):2244-51.

Stroke Association. State of the nation stroke statistics. London: Stroke Association; 2018.

Why was this study needed?

There are over 100,000 strokes in the UK each year, and it is the fourth commonest cause of death. Strokes happen when the blood supply to part of the brain is cut off, causing brain cell damage or death. This can affect people in different ways, both physically and emotionally. Almost two-thirds of survivors leave hospital with a disability.

In 2010, London opted for a fully centralised model, opening specialist hyperacute stroke units for all people with acute stroke. Manchester restricted centralised care to people within four hours of having a stroke, the time limit for effective clot-busting treatment (the Greater Manchester A model).

Earlier NIHR evidence published in 2014 showed that the London model appears to perform better on key indicators such as mortality. This study adds to this by evaluating longer-term results as well as the subsequent reconfiguration of Manchester services. In this, any stroke patient became eligible for centralised care without a time threshold (the Greater Manchester B model). The aim was to develop a more detailed understanding of which aspects of reorganisation were successful, and why, to guide wider implementation.

What did this study do?

This mixed-methods study compared the effectiveness of the different models of stroke service centralisation implemented in London and Manchester with the rest of England.

Data was obtained from several sources including Hospital Episode Statistics, mortality data from the Office for National Statistics, national stroke audits as well as earlier project research outputs. Qualitative data from patients, carers and staff was also gathered to help assess the development, implementation and sustainability of changes.

The lack of information about stroke severity upon admission is a limitation of the study that may have had a bearing on results. As well as this, only urban areas were studied, which limits generalisability to all parts of the country.

What did it find?

  • The London centralisation performed better than the rest of England in terms of mortality with an estimated 96 additional lives saved per year (–1.1%, 95% confidence interval [CI] –2.1% to –0.1%). Length of stay was reduced by a day and a half (–1.4 days, 95% CI –2.3 to –0.5 days).
  • The delivery of necessary clinical interventions within four hours was also higher with London’s rate running at 66.3% (95% CI 65.6% to 67.1%); compared with 54.4% (95% CI 53.6% to 55.1) in the rest of England. Later analyses show that these findings have been sustained.
  • The initial service redesign in Manchester (Greater Manchester A) reduced the length of stay by two days (–2.0 days, 95% CI –2.8 to –1.2 days), but did not have any impact on mortality or clinical interventions – only 39% of people received an intervention within four hours.
  • The subsequent reconfiguration (Greater Manchester B) reduced the length of stay by a day and a half (–1.5 days, 95% CI –2.5 to –0.4 days) as well as increasing the delivery of clinical interventions within four hours to 79.1% of patients. It did not have an effect on mortality overall (–1.3%, 95% CI –2.7% to 0.01%), taking into account reductions observed in the rest of England.
  • The London and Greater Manchester A services were judged to be cost-effective at 10 years and the Greater Manchester B service at 90 days.
  • When asked, patients and carers said that the better care received outweighed any concerns about longer travel times.

What does current guidance say on this issue?

While there is a lack of specific guidance on implementing changes to stroke services, the National Stroke Strategy of 2007 set new standards by recommending specialist treatment in the aftermath of stroke and auditing of stroke services.

Subsequent guidance from NICE in 2008 and the Royal College of Physicians in 2012 reinforced this by recommending that people with suspected stroke are admitted to and treated in, a specialist stroke ward or centre.

The RCP guidance also makes specific reference to the London and Manchester service restructuring and suggests that services should follow the more inclusive admission criteria of the London model.

What are the implications?

While the feasibility of centralised stroke services has already been established, this study helps clarify what aids successful implementation. Centralised service models where all stroke patients are eligible for treatment in a hyperacute stroke unit (such as London and Greater Manchester B) seem to perform better than those with more selective admission criteria (Greater Manchester A).

This should guide other urban regions looking to reconfigure their stroke care so that the changes can be made as effectively as possible.

Citation and Funding

Fulop N J, Ramsay A I G, Hunter R M et al. Evaluation of reconfigurations of acute stroke services in different regions of England and lessons for implementation: a mixed-methods study. Health Services and Delivery Research. 2019;7(7).

This project was funded by the NIHR Health Research and Delivery Research programme (project number 10/1009/09).

Bibliography

Intercollegiate Stroke Working Party. National clinical guideline for stroke, 5th edition. London: Royal College of Physicians; 2016.

Morris S, Hunter RM, Ramsay AI et al. Impact of centralising acute stroke services in English metropolitan areas on mortality and length of hospital stay: difference-in-differences analysis. BMJ. 2014;349:g4757.

NICE. Stroke: diagnosis and initial management of acute stroke and transient ischaemic attack (TIA). CG68. London: National Institute for Health and Care Excellence; 2008.

Ramsay AI, Morris S, Hoffman A, et al. Effects of centralizing acute stroke services on stroke care provision in two large metropolitan areas in England. Stroke. 2015;46(8):2244-51.

Stroke Association. State of the nation stroke statistics. London: Stroke Association; 2018.

Evaluation of reconfigurations of acute stroke services in different regions of England and lessons for implementation: a mixed-methods study

Published on 25 February 2019

Fulop N J, Ramsay A I G, Hunter R M, McKevitt C, Perry C, Turner S J, Boaden R, Papachristou I, Rudd A G, Tyrrell P J, Wolfe C D A & Morris S.

Health Services and Delivery Research Volume 7 Issue 7 , 2019

Background Centralising acute stroke services is an example of major system change (MSC). ‘Hub and spoke’ systems, consisting of a reduced number of services providing acute stroke care over the first 72 hours following a stroke (hubs), with a larger number of services providing care beyond this phase (spokes), have been proposed to improve care and outcomes. Objective To use formative evaluation methods to analyse reconfigurations of acute stroke services in different regions of England and to identify lessons that will help to guide future reconfigurations, by studying the following contrasting cases: (1) London (implemented 2010) – all patients eligible for Hyperacute Stroke Units (HASUs); patients admitted 24 hours a day, 7 days a week; (2) Greater Manchester A (GMA) (2010) – only patients presenting within 4 hours are eligible for HASU treatment; one HASU operated 24/7, two operated from 07.00 to 19.00, Monday to Friday; (3) Greater Manchester B (GMB) (2015) – all patients eligible for HASU treatment (as in London); one HASU operated 24/7, two operated with admission extended to the hours of 07.00–23.00, Monday to Sunday; and (4) Midlands and East of England – planned 2012/13, but not implemented. Design Impact was studied through a controlled before-and-after design, analysing clinical outcomes, clinical interventions and cost-effectiveness. The development, implementation and sustainability of changes were studied through qualitative case studies, documentation analysis (n = 1091), stakeholder interviews (n = 325) and non-participant observations (n = 92; ≈210 hours). Theory-based framework was used to link qualitative findings on process of change with quantitative outcomes. Results Impact – the London centralisation performed significantly better than the rest of England (RoE) in terms of mortality [–1.1%, 95% confidence interval (CI) –2.1% to –0.1%], resulting in an estimated additional 96 lives saved per year beyond reductions observed in the RoE, length of stay (LOS) (–1.4 days, 95% –2.3 to –0.5 days) and delivering effective clinical interventions [e.g. arrival at a Stroke Unit (SU) within 4 hours of ‘clock start’ (when clock start refers to arrival at hospital for strokes occurring outside hospital or the appearance of symptoms for patients who are already in-patients at the time of stroke): London = 66.3% (95% CI 65.6% to 67.1%); comparator = 54.4% (95% CI 53.6% to 55.1%)]. Performance was sustained over 6 years. GMA performed significantly better than the RoE on LOS (–2.0 days, 95% CI –2.8 to –1.2 days) only. GMB (where 86% of patients were treated in HASU) performed significantly better than the RoE on LOS (–1.5 days, 95% CI –2.5 to –0.4 days) and clinical interventions [e.g. SU within 4 hours: GMB = 79.1% (95% CI 77.9% to 80.4%); comparator = 53.4% (95% CI 53.0% to 53.7%)] but not on mortality (–1.3%, 95% CI –2.7% to 0.01%; p = 0.05, accounting for reductions observed in RoE); however, there was a significant effect when examining GMB HASUs only (–1.8%, 95% CI –3.4% to –0.2%), resulting in an estimated additional 68 lives saved per year. All centralisations except GMB were cost-effective at 10 years, with a higher net monetary benefit than the RoE at a willingness to pay for a quality-adjusted life-year (QALY) of £20,000–30,000. Per 1000 patients at 10 years, London resulted in an additional 58 QALYs, GMA resulted in an additional 18 QALYs and GMB resulted in an additional 6 QALYs at costs of £1,014,363, –£470,848 and £719,948, respectively. GMB was cost-effective at 90 days. Despite concerns about the potential impact of increased travel times, patients and carers reported good experiences of centralised services; this relied on clear information at every stage. Planning change – combining top-down authority and bottom-up clinical leadership was important in co-ordinating multiple stakeholders to agree service models and overcome resistance. Implementation – minimising phases of change, use of data, service standards linked to financial incentives and active facilitation of changes by stroke networks was important. The 2013 reforms of the English NHS removed sources of top-down authority and facilitative capacity, preventing centralisation (Midlands and East of England) and delaying implementation (GMB). Greater Manchester’s Operational Delivery Network, developed to provide alternative network facilitation, and London’s continued use of standards suggested important facilitators of centralisation in a post-reform context. Limitations The main limitation of our quantitative analysis was that we were unable to control for stroke severity. In addition, findings may not apply to non-urban settings. Data on patients’ quality of life were unavailable nationally, clinical interventions measured changed over time and national participation in audits varied. Some qualitative analyses were retrospective, potentially influencing participant views. Conclusions Centralising acute stroke services can improve clinical outcomes and care provision. Factors related to the service model implemented, how change is implemented and the context in which it is implemented are influential in improvement. We recommend further analysis of how different types of leadership contribute to MSC, patient and carer experience during the implementation of change, the impact of change on further clinical outcomes (disability and QoL) and influence of severity of stroke on clinical outcomes. Finally, our findings should be assessed in relation to MSC implemented in other health-care specialties. Funding The National Institute for Health Research Health Services and Delivery Research programme.

Expert commentary

This study looked at how major changes to emergency stroke services were undertaken in several regions of England, and whether these changes improved care and provided value for money.

Where the largest numbers of people were treated on central 'Hyperacute Stroke Units' this saved lives (London, 2010; Manchester, 2015), but where this wasn’t achieved (Manchester, 2010), lives weren’t saved, though people spent slightly less time in hospital. Where changes failed to happen at all, this was put down to less strong leadership and weaker involvement of people affected by the changes.

This study is important as other regions are currently planning major changes to stroke services. These changes can be disruptive and costly, so it’s vital that they produce the intended benefits.

 Dr Phil Clatworthy, Consultant Stroke Neurologist, North Bristol NHS Trust; Stroke Association Thompson Family Senior Clinical Lecturer, University of Bristol

The commentator declares no conflicting interests