Stroke audit uncovers alarming variation in medication in UK
pharmafile | March 30, 2005 | News story | |
An in-depth audit of services for stroke patients shows standards of care are generally improving – but progress is slow and there are significant variations across the UK, including the provision of medicines.
The audit is the first of every hospital countrywide but its authors say a dramatic improvement in the provision of specialist stroke services in recent years is nonetheless clear.
It added, however: "There remains a considerable amount of work to do, to ensure that every stroke patient receives the quality of care that will enable maximum recovery. Some hospitals are clearly delivering exceptionally high quality care demonstrating that the standards that have been set for this audit are achievable. There are a few that continue to deliver lamentable care and the task now must be to help raise the standards of all to acceptable levels."
The provision of specialist stroke units, brain scans and simple tests to assess swallowing problems were three key areas the report marked out for particular attention throughout the system.
The prescribing of medicines was also closely monitored, and revealed some alarming variations in treatment. A significant minority of patients were missing out entirely on primary and secondary prevention of strokes with drug treatment.
Antihypertensive medication
- 4,432 (51%) of patients were identified as having hypertension, 1,380 (16%) diabetes and 1,658 (19%) ischaemic heart disease prior to stroke.
- Overall 4,588 patients were taking an antihypertensive drug although only 3,577 of these were identified in the audit as having hypertension.
- 831 patients identified as having hypertension prior to admission were on no antihypertensive treatment.
The report concluded: "These figures suggest considerable under treatment of the most important risk factor for stroke."
It added that there was an increasing use of ACE inhibitors, angiotensin II receptor antagonists and thiazide diuretics after stroke, and that this was justified in view of the latest evidence
Antithrombotic treatment
- Of patients with a pre-stroke co-morbidity of atrial fibrillation, 24% (380 of 1555) were on warfarin before admission.
"This is a much lower figure than one would have hoped, given the clear evidence that anticoagulation of patients in atrial fibrillation is the most effective way of preventing stroke in these patients."
- Aspirin remains by far the most widely used antithrombotic drug, although use of dipyridamole and clopidogrel has increased over the last three years. A quarter of patients with previous stroke were not taking any form of antithrombotic medication. Perhaps half of these would have had previous intracerebral hemorrhage and therefore treatment would have been contraindicated, however that leaves about 15% of patients with previous ischaemic stroke not receiving the most basic form of secondary prevention.
- A key audit standard is commencement of aspirin by 48 hours after stroke. It is of grave concern that only two-thirds of patients achieved this standard.
Thrombolysis
- Thrombolysis was probably given to at most 27 patients (<1%) from 17 sites (<10%).
Management of lipids
- Use of statins has increased dramatically over the last three years. In 2001 only 64% of patients had their cholesterol checked at all and only 64% of those with cholesterol over 5mmol/l were treated. In 2004 80% had their cholesterol checked and 91% of those with raised cholesterol were treated.
- Any patient with hypercholesterolaemia should be given dietary advice in addition to any pharmacological treatment. It is disappointing to see that this has only been documented as being provided in less than half of appropriate patients.
A service is to be made available later this year, jointly run by the Clinical Effectiveness and Evaluation Unit of the Royal College of Physicians, the British Association of Stroke Physicians (with possible input from The Stroke Association) to help raise standards in hospitals.
Trusts will be able to commission visits from a team of specialists to help multi-disciplinary teams overcome problems in improving services.
Jon Barrick, chief executive of The Stroke Association said stroke services had seen vast improvements over the last 20 years, but said it was extremely disappointing to see patients waiting for essential care as set out in existing government standards.
"How can the government possibly achieve their target of reducing deaths from stroke by 40% by 2010 if hospitals are not given the essential resources and support to achieve this? By getting this right, lives could be saved."
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