Functional status and long term outcome of stroke

Abstract

Despite undoubted progress, we still have much to do

Despite advances in prevention, acute care, and rehabilitation the prognosis after acute stroke remains poor: 20-30% of patients die within a month and 13% of survivors are discharged to institutional care.^{1 2} In the accompanying prospective cohort study, Bruin Slot and colleagues report that functional status at six months after stroke is associated with long term survival.³ The median survival of patients who were independent at this stage was 9.7 years compared with 6.0 years for those who were dependent. The effect of functional outcome at six months on mortality was independent of age and stroke subtype. The study gives no details about the causes of death or whether secondary prevention was optimised, but these survival data again emphasise the impact of stroke. They also suggest that early treatment known to reduce dependency at six months may have a substantial longer term effect.

Stroke care and the evidence base on which services are developed have improved considerably since 1981, when one of the cohorts described in the study (the Oxfordshire community stroke project) was established.⁴ In the past, people with stroke were too often discharged without consideration for their ongoing needs and carer support.

Most acute trusts in the United Kingdom now have a stroke unit and in the United States the Brain Attack Coalition recommended similar primary stroke centres in 2000; at that time only 7% of hospitals surveyed met all recommended elements, although 44% provided most services. Furthermore, many shortcomings still need to be resolved. The UK 2006 national sentinel stroke audit found that although all eligible patients with ischaemic stroke received antiplatelet drugs, only 70% received blood pressure lowering drugs, only 78% received cholesterol lowering drugs, and only 34% of patients in atrial fibrillation were anticoagulated at discharge. Thus, secondary prevention could be improved and mortality and morbidity after stroke could be reduced if these highly effective treatments were more widely implemented.² These problems in implementation of the evidence base are not unique to the UK.

Stroke units improve independence and survival at six months, but in 2006 only 62% of patients in the UK were admitted to a stroke unit and only 54% spent more than half of their inpatient stay on one.² Thrombolysis given within the first three hours of ischaemic stroke reduces death and disability at three to six months,⁵ yet only 30 trusts in the UK provide this service, and even fewer provide it at all hours of the day.² Up to 20% of stroke patients may be eligible for thrombolytic treatment, yet in 2006 only 218 patients—less than 0.5% of patients with acute ischaemic stroke in England, Wales, and Northern Ireland—received thrombolysis.² In a large study in the US the equivalent rate was 1.12%. Early supported discharge by a specialist stroke team can also improve outcome, yet provision of this service is limited.⁶ All of this emphasises the problem of translating research into practice, which was highlighted by the recent Cooksey report.⁷

Service development and research have focused on prevention and care soon after stroke. Relatively few studies, however, have looked at interventions for improving longer term outcomes for survivors of stroke and their carers.⁸ Service provision focusing on long term needs is also sparse. Patients with stroke and their carers often report feeling abandoned after discharge and that they are badly informed and supported, both practically and emotionally.^{1 9}

Even less is known about how to minimise the long term effects of stroke. The 2001 national service framework for older people suggested that patients with stroke and severe disability should be reviewed at six months.¹⁰ One of the purposes of the review would be to deal with patients’ and carers’ concerns. Bruin Slot and colleagues suggest that prognostic information could be given to patients and their relatives at six months.³ Arguably, before providing more information about risks and prognosis at six months, much could be done to improve communicationsoon after a stroke. The information needs and priorities of patients and their carers change over time, and it is important for the right information to be provided in the right way, at the right time, and in the right format.^{11 12}

It is increasingly acknowledged that patients and carers should be active participants in decisions about the care they receive. Enabling patients and carers to have meaningful input into service development and to be actively involved with clinicians about deciding treatment options will result in care that is responsive to their needs and likely to lead to better outcomes.

The national stroke strategy, published by the UK Department of Health in early December 2007, once again emphasises the importance of implementing evidence based practice as well as involving patients, carers, health professionals, social services, and charities in shaping local stroke services.¹ Let us hope that these admirable aims will become the template for both commissioners and providers of care to seize the opportunity to enhance the health and wellbeing of a substantial and, to date, underserved group of patients.