Utilisation of diagnostic computerised tomography imaging and immediate clinical outcomes in older people with stroke before and after introduction of the National Service Framework for older people. A comparative study of hospital-based stroke registry data (1997–2003): Norfolk experience
1 Department of Medicine for the Elderly, Norfolk and Norwich University Hospital, Colney Lane, Norwich NR4 7UY, UK
2 School of Medicine, Health Policy and Practice, University of East Anglia, Norwich NR4 7TJ, UK
3 Department of Public Health and Primary Care, Centre for Applied Medical Statistics, University of Cambridge, Robinson Way, Cambridge CB2 2SR, UK
Address correspondence to: P. K. Myint, Clinical Gerontology Unit, Level 2 F&G Block, Box-251, Addenbrooke’s Hospital, Hills Road, Cambridge CB2 2QQ, UK. Tel: (+44) 1223 217292. Fax: (+44) 1223 336928. Email: pkyawmyint{at}aol.com
Received 9 December 2005; accepted in revised form 7 March 2006
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Abstract |
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Introduction: how the National Service Framework (NSF) for older people in England might be associated with changes in clinically relevant stroke outcome has not been investigated. We looked for changes in computerised tomography (CT) scan rate, inpatient case-fatality rate (CFR), length of acute hospital stay and discharge destination for older people with stroke, compared with their younger counterparts, for a period before, and after, the introduction of the NSF.
Methods: two periods, 4 years before and 2 years after the publication of the NSF, were selected to compare the above outcomes between three age categories: <65, 65–84 and 
85 years of age. Annual summary data for these periods were compared for the magnitude of changes in all age categories for all outcomes measured between pre- and post-NSF periods.
Results: n = 5,219. Utilisation of CT imaging had increased in all age groups post-NSF, with the most significant improvement in the oldest group. This change was associated with a greater proportion of people who had CT in this age group being discharged home in the post-NSF period. There was no change in the mortality from stroke in any age group during the study. Although the length of acute hospital stay increased, this was associated with a higher percentage of home discharges particularly in >65-year olds, suggesting better clinical outcome in those who survived.
Conclusions: in this single-centre analysis, the post-NSF period appeared to be associated with improvement in outcome in older people with stroke. Continual monitoring using stroke registry data may help to assess whether these effects are sustained in the longer term.
Keywords: NSF, stroke, older people, elderly
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Introduction |
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The National Service Framework (NSF) for Older People was published in England in March 2001 [1]. It aimed to ‘root out ageism’ and improve health care for older people by setting national standards. Standard 5 ‘Stroke’ included recommendations and milestones for improving stroke care for patients of all ages.
The NSF for older people was generally welcomed by the professionals as well as by the patient and carer groups. Swift [2] thought that there might be problems in operational feasibility, expertise and accountability for standards such as ‘rooting out ageism’. Nevertheless, the NSF should lead to better care for patients with stroke, including the elderly.
Rodgers and colleagues [3] had carried out a survey of stroke services at around the time of the publication of the NSF. The authors highlighted the need for significant development to achieve the NSF target for hospital-based stroke services. Since then, the provision of stroke services has been assessed using performance indicators and national sentinel audits [4–6]. However, whether the NSF has influenced the way in which stroke is managed and whether it has improved the outcome for patients have not previously been studied.
We were particularly interested to know whether the NSF had changed the rate of computerised tomography (CT) scanning in the management of older patients, compared with that of younger patients, and whether this or other factors may have affected clinically relevant outcomes such as inpatient mortality, length of acute hospital stay and discharge destination from an acute hospital admission.
The aims of the current study were to compare the following, before and after the introduction of the NSF for three age groups, younger (<65 years), older (65–84 years) and extreme old age (85 years):
- CT scan rate (confirmation of diagnosis of stroke).
- In-patient case-fatality rate (CFR) (number of deaths per 100 admissions).
- Length of acute hospital stay for those who were discharged alive.
- Discharge destination from the acute setting (home versus elsewhere).
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Methods |
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We retrospectively analysed the data from the Norfolk and Norwich University Hospital Stroke Register, which was set up in late 1996. All patients with stroke admitted to a single large district general hospital, covering a catchment population of 568,000 living in the city of Norwich and surrounding towns and rural areas, were included in the register. The bulk of the data, which is collected prospectively and is vetted by either a specialist nurse or a doctor, specifically excludes patients with transient ischaemic attacks. The patient-related data were collected for the period of acute hospital stay at Norfolk and Norwich District General Hospital (University Hospital since 2002).
For the purpose of this study, we included stroke admissions from 1 April 1997 to the end of March 2003 (a total of 6 years). This allowed us to compare data from the 4 years before and the 2 years after the publication of the NSF in 2001. Patients who had a CT scan confirmed diagnosis of subarachnoid haemorrhage (SAH) (n = 231), and those who were under 17 years of age (n = 3) were excluded. Five patients were excluded because of insufficient data.
The following data were ascertained for 5,219 patients: age, sex, CT (yes/no), discharge status (dead/alive), duration of acute hospital stay (for those who were alive) and discharge destination (home/elsewhere).
Data were analysed using SPSS for Windows Version 12.0 (SPSS, Chicago, IL, USA) and Stat-Xact Version 4.0 (Cytel Software, Cambridge, MA, USA). The Mann–Whitney U test was used to compare median lengths of stay, and confidence intervals on the difference of two proportions were used to compare proportions pre- and post-NSF. Subgroup analysis was performed for those who had estimated Barthel score at discharge to examine whether there was functional improvement at discharge between two periods by different age groups. Data were presented descriptively. For comparative purposes, we categorised the patients into three age groups: younger (<65 years), older (65–84 years) and extreme old age (85 years). The summary data for pre-NSF period are derived from April 1997 to March 2001 data and post-NSF period data from April 2001 to March 2003.
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Results |
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After exclusions mentioned above, 5,219 stroke admissions were included in the analysis. The yearly sex-specific admission rate showed no material difference in year-to-year admission rates and during the pre- and post-NSF period. The nature of case mix in terms of stroke subtype is presented in the Appendix 1 on the journal website (http://www.ageing.oxfordjournals.org/).
Figure 1 shows the rate of CT scanning by age category for each year included in the analysis. There was a 12.4% increase (95% CI 10.0–14.9) in CT scan rate from the pre- to the post-NSF period. There was a 2.0% increase (–2.8 to 6.8) in CT scan rates for the under 65-year olds, a 10.8% rise (7.8–13.8) for the 65- to 84-year olds and a 21.6% increase (16.0–27.2) for those aged 85 years and over.
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Table 1 summarises the annual in-patient CFR for each age group. There was a 2.0% decrease (95% CI –4.5 to 0.6) in CFR between the pre- and the post-NSF period. This breaks down to a 4.7% decrease (–4.5 to 0.6) in fatality rates for the under 65-year olds, a 1.5% decrease (–4.8 to 1.8) for the 65- to 84-year olds and a 1.4% decrease (–7.2 to 4.3) for those aged 85 years and over.
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There was an increase in the length of acute hospital stay for those who were discharged alive, median (range) length of stay pre-NSF was 8 days (0, 123) and post-NSF was 10 days (0, 141). This increase was significant (U = 1,321,497, P < 0.0001). A similar pattern was seen within each age group. For the <65-year olds, the median length of stay increased from 9 (0, 123) to 11 days (0, 141), although this was only of borderline significance (U = 33,927, P = 0.07). More significant was the change for the 65- to 84-year olds, where median length of stay went from 8 (0, 72) to 10 days (0, 112) (U = 545,113.5, P < 0.0001), and for the 85-year olds and over, it went from 8 (1, 58) to 11 days (1, 113) (U = 50,417, P < 0.0001).
Further analyses of the data at day 14 of admission were conducted to see whether the patients with the most severe stroke, who finally died as in-patients after prolonged stay because of medical complications, influenced the above finding regarding the length of stay. For those included in the study, 23.6% (1,230/5,219) who died in hospital died within 14 days, a further 311 died in hospital after 14 days, showing that 79.8% (1,230/1,541) of those who died did so within 14 days of admission. In those who were alive when discharged, the length of stay tended to be longer after the NSF (using the Mann–Whitney U test). In those who died after day 14, there was no evidence of a difference in length of stay before and after the NSF (using the Mann–Whitney U test) (Appendix 3 on the journal website http://www.ageing.oxfordjournals.org/).
There was a 9.9% increase (95% CI 6.6–13.3) in the percentage of patients discharged home directly from their acute hospital stay between the pre- and the post-NSF periods. This breaks down to a 2.8% increase (–5.8 to 11.7) in the <65-year olds, an 11.1% increase (6.9–15.3) in the 65- to 84-year olds and a 10.4% increase (4.2–17.2) for 85 years.
Among those who were discharged alive from the acute setting, the estimated Barthel index scores were available in 2,724 patients (74.1%). Comparison of estimated Barthel index showed overall improved functional status at discharge in older age groups. The lower quartile, median and upper quartile values for pre- and post-NSF were 2, 12, 19 and 4, 14, 19 for 65–84 years, respectively, and corresponding values for 85 years and over were 2, 7, 14 and 2, 7, 16, respectively.
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Discussion |
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Our study provides an age-specific comparison of clinically relevant outcomes of stroke between pre- and post-NSF periods in a single unit. As the case mix, in terms of age, sex and stroke subtypes (haemorrhagic and non-haemorrhagic strokes), was comparable between the pre- and the post-NSF periods, the difference in outcomes appears to be related to a change in clinical practice and/or standard of care.
There was an increase in CT scan rate in all age groups. This was most striking in the oldest age group (Figure 1). This might also reflect better access for older people to imaging facilities and/or a lower threshold for investigating older people with a clinical diagnosis of stroke. This in turn may reflect changes in the attitude towards older people with stroke since the introduction of the NSF.
We looked at whether the increase in the rate of CT scanning in older people had any clinical relevance by comparing the proportion of people who were discharged alive with just a clinical diagnosis and no CT scan. The absence of a CT scan may in part be due to the severity of stroke in a frail elderly patient where a decision not to investigate further has been made on clinical grounds. In fact, the increased rate of CT scanning in the post-NSF period in older stroke patients was associated with an increase in the number of patients discharged alive with a diagnosis confirmed on CT (Appendix 2 on the journal website http://www.ageing.oxfordjournals.org/). Despite this, compared with younger patients, the rate of scanning is still relatively low in the oldest age groups.
Regardless of age group, there was no evidence of a change in the fatality rates between the two periods. However, despite an increase in the proportion of patients who were discharged home during this time (Figure 2), the length of hospital stay also increased significantly in the older age groups (65 years) after publication of the NSF. It is possible that the lengthening in the amount of time spent in the acute unit, thereby giving more patients an opportunity to achieve functional recovery, is solely responsible for the increase in the numbers who were discharged home. It was interesting that where the increase in median length of stay did not increase as significantly in the younger patient group, the proportion going home also did not change significantly.
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Given that the case mix and age structure of stroke admissions did not change significantly during the study period, changes in these outcomes (length of stay, case fatality and proportion being discharged home) might relate to other factors than to the rate of CT scanning. The data on case mix and numbers admitted suggest that there has not been a significant change, but without a population-based register, this would be difficult to confirm. However, Wardlaw and others [7] have suggested that performing urgent CT scan on all stroke patients is associated with better clinical outcome and is also cost effective. It is also possible that the rate of scanning is unrelated to the recommendations in the NSF. The rate of CT scanning may have reflected the move to a new, University Hospital, site with increased availability of scanning facilities, in 2001/02.
Moreover, after the publication of the NSF for older people, a few changes occurred in stroke service set up locally. We believe that these changes may be related to the increased awareness of the importance of developing and expanding local stroke services by the local policy makers following the publication of the NSF. Briefly, these changes included (i) appointment of second consultant with special interest in stroke medicine in late 2001; (ii) although a six-bedded stroke unit established before NSF was lost when the hospital moved to the new site in late 2001, a new 28-bedded stroke unit with dedicated staff was opened in the new hospital site in late 2002; (iii) creation of a stroke liaison nurse post-established in 2002 and (iv) a change in admission pattern with regard to stroke patients in late 2001 where the stroke patients were more likely to be managed by a consultant with special interest in stroke.
Naturally, there are limitations in our study. One of the limitations is the retrospective nature of the study. Data collection was limited to acute hospital admissions, and therefore some of the outcomes measured, such as length of stay and discharge destinations, are immediate post-stroke outcomes rather than intermediate or long-term outcomes. In fact, there was an implementation of an intermediate services strategy in 2002, with an associated loss of community hospital beds, shortly after the publication of the NSF. However, our data are based on the acute hospital stay, and therefore, it is possible that an even higher number of people returned home after a period of further rehabilitation in both periods. Our subgroup analysis also showed that among those who were discharged alive from the acute unit, there appeared to be an improvement in functional outcome from pre- to post-NSF period in older age groups.
We did not adjust for the risk-factor profile and other possible confounders such as socioeconomic status of stroke patients before and after the NSF period included in our study. However, Norfolk has a stable population, and it is very unlikely that these factors would have changed over a couple of years to an extent that would influence the outcome.
In summary, our findings suggest that the NSF for older people appeared to be associated with an increase in CT imaging in acute stroke, particularly in older patients, and in turn, there were reductions in case fatality and an increase in those going home. Although we cannot establish the causal relationship, it raises the intriguing possibility that increased awareness of better care for older people driven by publication of NSF may have some positive influence locally. We have shown that by utilising local stroke register data, the changing pattern of clinical practice and outcomes can be monitored. If these changes are attributable to the NSF, it is likely to be associated with better outcome in future with the development of NSF milestones.
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Key points |
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TopAbstractIntroductionMethodsResultsDiscussionKey pointsEthicsContributorsConflict of interestReferences |
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- How the NSF for older people in England might be associated with changes in clinically relevant stroke outcome has not been investigated.
- Our findings suggest that the NSF for older people appeared to be associated with an increase in CT imaging in acute stroke, particularly in older patients, and in turn, there were reductions in case fatality and an increase in those going home.
- The changing pattern of clinical practice and outcomes can be monitored by utilising local stroke register data.
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Ethics |
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The data were collected as part of European Basic Stroke Register (Trust R&D registration number-95 ME175). Data presented were aggregated and anonymised. Therefore, Local Research Ethics Committee (LREC) approval was not sought.
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Contributors |
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O.R. collected data. S.L.V. analysed the data. P.K.M. wrote the paper with S.L.V. All authors contributed in preparation of the manuscript. R.A.F. is the guarantor.
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Conflict of interest |
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TopAbstractIntroductionMethodsResultsDiscussionKey pointsEthicsContributorsConflict of interestReferences |
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None.
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References |
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- Department of Health. National Service Framework (NSF) for Older People. London: Department of Health, 2001.
- Swift CG. The NHS English National Service Framework for older people: opportunities and risks. Clin Med 2002; 2: 139–43.[Web of Science][Medline]
- Rodgers H, Dennis M, Cohen D et al. British Association of Stroke Physicians: benchmarking survey of stroke services. Age Ageing 2003; 32: 211–7.
[Abstract/Free Full Text] - Rudd AG, Hoffman A, Irwin P, Pearson M, Lowe D, Intercollegiate Working Party for Stroke. Stroke units: research and reality. Results from the National Sentinel Audit of Stroke. Qual Saf Health Care 2005; 14: 7–12.
[Abstract/Free Full Text] - Rudd AG, Irwin P, Rutledge Z, Lowe D, Wade DT, Pearson M. Regional variations in stroke care in England, Wales and Northern Ireland: results from the National Sentinel Audit of Stroke. Royal College Physicians Intercollegiate Stroke Working Party. Clin Rehabil 2001; 15: 562–72.
[Abstract/Free Full Text] - Rudd AG, Hoffman A, Irwin P, Lowe D, Pearson MG. Stroke unit care and outcome results from the 2001 National Sentinel Audit of Stroke (England, Wales, and Northern Ireland). Stroke 2005; 36: 103–6.
[Abstract/Free Full Text] - Wardlaw JM, Seymour J, Cairns J, Keir S, Lewis S, Sandercock P. Immediate computed scanning acute stroke is cost effective and improves quality of life. Stroke 2004; 35: 2477–83.
[Abstract/Free Full Text]
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