Organisational interventions for stroke

Stroke is a major cause of death and disability among older adults. It is one of the top three causes of death in England and Scotland and a leading cause of disability among older adults. Approximately 130,000 strokes and an additional 20,000 transient ischaemic attacks (TIAs) occur in England every year, and at least 300,000 people live with moderate or severe disability resulting from a stroke (National Audit Office, 2005). In addition to stroke’s impact on mortality and morbidity, it is also costly: stroke care costs the National Health Service (NHS) about £2.8 billion a year in direct costs, with an additional £1.8 billion in lost productivity and disability (National Audit Office, 2005).

A stroke, also known as a cerebrovascular accident, is ‘the brain equivalent of a heart attack’ (National Audit Office, 2005). A stroke occurs when a blood vessel that carries oxygen and nutrients to the brain either gets blocked by a clot or, less commonly, bursts and bleeds. As a result, the part of the brain affected becomes damaged or dies. The severity of strokes varies from one that gets better within 24 hours, known as transient ischaemic attack (TIA), or a ‘mini stroke’, to one that can cause severe brain damage or even death.

The underlying causes of and effective treatments for strokes and TIAs are well understood. This information has underpinned the development of multiple evidence-based guidelines for the treatment of this serious condition. These include guidelines concerning prevention, acute care and post-acute care (Intercollegiate Stroke Working Party, 2004). Nevertheless, patients with TIAs continue to suffer strokes in high proportions, and the condition continues to cause significant morbidity and mortality. The imbalance between our knowledge of stroke care and effective delivery of guideline-concordant care suggests a lack of fidelity in the stroke care system. Fidelity in this context refers to the ‘extent to which the system provides patients the precise interventions they need, delivered properly, precisely when they need them’ (Woolf and Johnson, 2005, p 545).

In this review, we focus on the evidence related to health care delivery models that can support timely diagnosis, treatment and rehabilitation of stroke. Evidence is also presented on delivery models for the treatment of TIAs to reduce the risk of stroke. The emphasis, therefore, is not on amassing evidence about effective clinical treatments per se, but rather on health system delivery modalities related to the care of stroke patients.

Project overview

What works to improve quality in health care is a perennial issue. Health services research, clinical medicine and social science literature all contain a huge number of articles that discuss interventions designed to improve quality. The interventions vary widely in terms of design, underlying assumptions, and the context in which they have been implemented. However, although the number of publications that discuss quality improvement is unwieldy and ever-increasing, the empirical evidence about the effects such interventions have on health care processes and outcomes is sparse and difficult to access. The Quality Enhancing Interventions (QEI) project seeks to address these difficulties and will gather available evidence on a range of interventions designed to improve quality of care (see Figure 1).

Our findings will form the basis of a searchable resource that will allow decision-makers to find relevant research evidence on particular interventions to improve quality and the context in which those interventions have been implemented, as well as access to information on different approaches applied to a particular disease or population group.

Within each of the major themes, sub-categories and clusters of specific interventions are developed, building a taxonomy of QEIs. Clinical healthcare delivery models are the focus topics for this report.

Clinical care delivery models vary for different diseases. Effective care processes will reflect the predisposing factors, the cause (aetiology), course and consequences of a particular disease, as well as available therapy options and their cost. Depending on the nature of the disease, care may most appropriately be delivered in primary, emergency or palliative care settings; it may be focused to different extents on prevention as well as management or cure; it may be characterised by an acute episode or by chronic symptoms. The focus of this report is on the care for stroke patients in three settings – emergency, acute and post-acute. In addition, we examine evidence of care delivery models for TIAs, or ‘mini strokes’. This falls under the topic of preventive care for stroke, since a large portion of TIAs are followed by strokes, and care often takes place in the primary care setting.

Methods

We used a ‘best evidence’ approach to conduct our literature review. We focused primarily on evidence from review articles and guidelines issued by national professional organisations. We conducted electronic searches of MEDLINE®, focusing on articles classified as ‘review articles’, and included systematic evidence reviews issued by the Cochrane Collaboration. We conducted our searches using a series of steps to identify articles related to the following four main topic areas: stroke, health systems, health care quality, and health care outcomes. Search strategies are provided in the full report. The review includes a range of research designs: systematic reviews, randomised controlled trials, and quasi-experimental and observational studies. Broad inclusion criteria were adopted owing to the methodological challenges inherent in assessing organisational and delivery models for chronic illness in general and stroke in particular.

Findings

In this review we focused primarily on the following areas related to the organisation and delivery of health care for patients with stroke:

• stroke risk reduction: treatment of TIA

• adequate access to emergency services for diagnosis and timely initiation of appropriate treatment

• inpatient treatment for acute care

• post-acute rehabilitation services.

Table 1: Summary of evidence: health delivery models for stroke

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