Age and Ageing Advance Access published online on March 14, 2007
Age and Ageing, doi:10.1093/ageing/afm007
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Access to stroke care in England, Wales and Northern Ireland: the effect of age, gender and weekend admission
1 Stroke Programme Director, Clinical Effectiveness and Evaluation Unit, Royal College of Physicians (London), Consultant Stroke Physician, Guys and St Thomas' Hospitals NHS Trust (London), UK
2 Stroke Programme Coordinator, Clinical Effectiveness and Evaluation Unit, Royal College of Physicians (London), UK
3 Project Coordinator, Clinical Effectiveness and Evaluation Unit, Royal College of Physicians (London), UK
4 Director, Clinical Effectiveness and Evaluation Unit, Royal College of Physicians (London), Consultant Physician Aintree Hospitals NHS Trust (Liverpool), UK
5 Statistician, Clinical Effectiveness and Evaluation Unit, Royal College of Physicians (London), On behalf of the Intercollegiate Working Party for Stroke, UK
Address correspondence to: A. G. Rudd. Tel: +44 20 7935 1174 ext 375; Fax: +44 20 7487 3988. Email: Anthony.rudd{at}kcl.ac.uk
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Abstract |
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Study objectives: to determine whether access to high-quality stroke care is affected by the age or gender of the patient or by weekend admission.
Design: data were collected as part of the National Sentinel Audit of stroke in 2004, both on the organisation of in-patient stroke care and the process of care to hospitals managing stroke patients.
Setting: two hundred and forty-six hospitals from England, Wales and Northern Ireland took part in the 2004 National Stroke Audit, a response rate of 100%. These sites audited te care of 8,718 ptients.
Audit Tool: Royal College of Physicians Intercollegiate Working Party Stroke Audit Tool.
Results: overall standards of care for cases of stroke in England, Wales and Northern Ireland are low. Older patients are less likely to be treated in a stroke unit than younger patients (risk ratio comparing 85 + years with those <65 years 0.82 (95% CI 0.75–0.90). Seventy-one per cent of patients under 65 years were scanned within 24 h compared to 51% aged over 85 years. Older patients were also less likely than younger ones to receive secondary prevention and some aspects of rehabilitation, especially around higher functioning. Standards were consistently better for patients of all ages managed in stroke units compared to general wards. At weekends, patients were less likely to be admitted directly to a stroke unit (risk ratio 0.77 95% CI 0.69–0.86) and brain imaging was performed less often for older (85 + years) patients (weekday 56%, weekend 40%). There was little evidence of differences in standards of care between males and females.
Conclusion: there is clear evidence of an age effect on the delivery of stroke care in England, Wales, and Northern Ireland, with older patients being less likely to receive care in line with current clinical guidelines. Quality of acute care is also less good for patients admitted at weekends. No systematic evidence for sexism was identified.
Keywords: stroke, quality of care, ageism, sexism, elderly
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Introduction |
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The impact of stroke is high, in terms of mortality, morbidity and expenditure. It is the third most common cause of death and one of the most important causes of significant adult disability [1]. A recent estimate is that stroke costs the English economy £7b per annum [2]. Providing specialist care in stroke units is proven to reduce mortality and morbidity regardless of the age of the patient, gender or the severity of the stroke [3] and the National Clinical Guidelines for Stroke recommend that all stroke patients should be admitted under the care of a stroke specialist to a geographically defined unit. And yet the National Sentinel Audit in 2004 showed that less than half of patients in England, Wales and Northern Ireland are managed for the majority of their stay in a stroke unit [4], despite 83% of hospitals having stroke units.
Using data from the 2004 audit, we explore whether access to high-quality care is affected by age, gender or whether the patient is admitted during the weekend or on a weekday. Our initial hypotheses were that:
- acute care (scan, clinical assessment, acute use of aspirin, etc) are less likely to be delivered well at weekends compared to weekdays;
- this weekend effect will be less evident when a patient is admitted directly to a stroke unit;
- there will be evidence of ageism in the delivery of acute assessment investigation and management;
- there may be less ageism or even reverse ageism in aspects of rehabilitation and longer-term care especially when patients are managed in geriatric wards rather than general medical wards;
- ageism will be less evident when patients are managed in a stroke unit.
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Methods |
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The 2004 national audit was conducted in two parts. The first part was an audit of organisation of care in sites to coincide with the April 2004 stroke milestones contained within the English National Service Framework for Older People Stroke [5]. The second part was an audit of patients with a primary diagnosis of stroke (ICD10 I61, I63 and I64) admitted from 1 April to 30 June 2004, to assess compliance with evidence-based standards, to define case mix, process of care and outcome. The audit covered the whole inpatient stroke pathway, from admission to the transfer of care back to the community. Sites were asked to audit 40 consecutive admissions. An inter-rater reliability study compared agreement between data for the first five cases from two different auditors. The audit was guided by a multidisciplinary steering group, the Intercollegiate Working Party for Stroke, which is responsible for the whole stroke programme. Further details of audit forms and methodology can be found on http://www.rcplondon.ac.uk/college/ceeu/ceeu_stroke_home.htm.
All available standards from the audit were included, with a total of 45 standards analysed. The first three comprised treatment in a stroke unit; treatment in a stroke unit the same day as being admitted to hospital (or the same day as a stroke in hospital) and treatment in a stroke unit for more than half of the inpatient stay. The other standards were applicable regardless of stroke unit admission and were grouped for analysis in terms of early-care assessments (8 standards) and later care assessments (34 standards). They covered aspects of initial patient assessment, clinical diagnosis, multidisciplinary assessment, screening and functional assessment, management/care planning, communication with patient and carer and the interface between primary and secondary care. Composite patient scores from 0 to 100 were formed from the 42 standards, and separately for the eight early and 34 later standards, where 100 implied all applicable standards met and 0 none. Patient circumstances determined whether or not a standard applied to them, for example, a test of walking or of speech difficulties is not possible if a patient is unconscious. The audit designated a priori specified circumstances for each standard and all relevant patient factors have gone into criteria defining each ‘NO BUT’ classification. The differing denominators reflect this. The NO BUT adjustment is a form of case-mix stratification leaving only those for analysis who are appropriate to receive that particular form of care regardless of age, gender or when they were admitted.
Missing data rates were below 1% for all but two standards (brain scan within 24 h 6%, GP informed of death/discharge 2%). The association of age, gender and ‘admission day to hospital’ (weekday versus weekend/holidays) with composite score, was assessed using multiple linear regression analyses adapted to account for the clustering of patient data within sites (STATA 8 ‘regress’ software). The association with each categorical standard was also assessed using adapted multiple binary regression methods (STATA 8 ‘binreg’ software). Age bracketing of results (<65, 65–74, 75–84 and 85 + y) was determined before analysis. Confidence intervals were computed for the difference between each of three older groups and the youngest age group using the above regression methods, with each interval also adjusted for the other factors under consideration (i.e. gender and admission day to hospital). Analysis was stratified by the stroke unit entry in line with the initial hypotheses. Because of the large number of comparisons made during the analysis of individual early care (Table 4) and later care (Table 5) assessments we have applied more strict individual test criteria (P<0.001) in indicating the most significant comparisons.
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Results |
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All possible acute trusts in England participated in the national audit; 246 sites with 8,718 cases, median 40 per site, inter-quartile range (IQR) 33–40. The inter-rater reliability study included 696 cases from 143 sites. The agreement for the standards covered by this paper was generally good, median kappa 0.70, IQR 0.66–0.75, range 0.52–0.91.
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Stroke unit care |
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Almost half, 46% (4,018) of patients were treated in a stroke unit during their stay with 40% (3,508) spending most of their stay there. Only 15% (1,328) went to a stroke unit on the same day as being admitted to hospital or on the same day as a stroke if they were already in hospital. Older age, particularly those over the age of 85 years, but not gender or weekend day of admission, reduced the likelihood of stroke unit treatment (Table 1). The risk ratio comparing the oldest (85 + years) with the youngest patients (<65 years) was 0.82 (95% CI 0.75–0.90) with 8.5% fewer patients (95% CI 4.7–12.3%) being treated. Of 7,401 patients alive after 10 days in hospital, 51% (3,769) had been treated in a stroke unit, with a similar deficit noted for the most elderly: 51% (< 65y), 53% (65–74y), 53% (75–84y) and 45% (85 + y). A very similar pattern of results was seen for patients spending most of their time in hospital in a stroke unit, the risk ratio for oldest to youngest being 0.74 (95% CI 0.68–0.82) with 11.2% fewer patients (95% CI 7.6–14.8%). For those treated in a stroke unit, little difference was seen between age groups in the number of days between admission to hospital and entry to the stroke unit (Table 1). However, patients admitted at the weekend had to wait slightly longer, on average, to get into the stroke unit than patients admitted during the working week: 55% (683/1,241) waited more than 1 day compared to 45% (1,216/2,745). Weekend patients were less likely to have same day entry to stroke units, risk ratio 0.77 (95% CI 0.69–0.86), with 3.8% fewer patients (95% CI 2.2–5.4%) than during the working week (Table 2).
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Standards non-specific to stroke unit care |
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 TopAbstractIntroductionMethodsResultsStroke unit care Standards non-specific to stroke... Early-care assessments within 48...Later standards during the...DiscussionKey pointsAcknowledgements and fundingReferences |
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For the 42 standards unrelated to the stroke unit, the median number of standards applicable was 30, IQR 22–34. A higher proportion of the standards were met (75 versus 58%) in patients who were admitted to a stroke unit for some or all of their hospital stay compared to those not so admitted. There was a pattern that fewer standards were met for the older age groups (Table 3). The decrease for oldest to the youngest group was estimated at 3.4% (95% CI 1.4–5.4%) for patients treated in a stroke unit and 1.9% (95% CI –0.3 to 4.1%) not in a stroke unit. Associations with gender or admission day were not found. Binary regression methods indicated higher compliance (at P<0.001) in stroke units for 39 of the 42 standards.
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Early-care assessments within 48 h |
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TopAbstractIntroductionMethodsResultsStroke unit careStandards non-specific to stroke...Early-care assessments within 48...Later standards during the...DiscussionKey pointsAcknowledgements and fundingReferences |
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Older patients were less likely to receive a brain scan within 24 h of stroke, as were patients admitted over the weekend (Table 4). Overall, 71% (809/3,348) of patients under 65 (weekday 72%, weekend 68%) had early brain scans compared to 51% (557/1,087) of those aged 85 and over (weekday 56%, weekend 40%). The proportions scanned were similar whether admitted to a stroke unit on day 1 (58%) or later (62%). For the older patients not in a stroke unit, a clear description of the cerebral lesion was less likely to be present and eye movement assessments, visual field testing and sensory testing were performed less often (Table 4). Also, outside the stroke unit, males were more likely than females to commence on aspirin. Thus, 65% (292/448) of females and 74% (552/747) of males under 75 commenced aspirin, and this was 55% (588/1,015) of females and 67% (450/676) of males amongst older patients. The median percentage of the eight early-care standards being met was higher for those going to a stroke unit on day 1 (86%, IQR 71–100%) compared with those admitted later (75%, IQR 57–88%).
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Later standards during the inpatient stay |
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By discharge, individualised care planning goals for older patients were less likely to include reference to areas of higher level functioning such as leisure pursuits, driving and, return to work (Table 5). Older patients were also less likely to have received dietary advice to reduce fat intake and to have discussed other risk factors such as smoking and alcohol consumption. Diagnosis and prognosis were less likely to be discussed with elderly patients but were more likely to be discussed with their carers. There was a considerable decline with age in performing carotid imaging within 3 months as a check for carotid stenosis. The median per cent of the 34 later care standards being met was similar for those going to a stroke unit on day 1 (75%, IQR 60–87%) as compared with those admitted later (77%, IQR 61–88%).
Conversely, there were patterns to indicate better provision for older patients in screening of swallowing disorders within 24 h (Table 4), in being assessed for swallowing by a speech and language therapist within 72 h (Table 5), and in being assessed by a physiotherapist within 72 h (Table 5).
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Discussion |
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Overall, the standards of care for stroke patients of all ages are often far from ideal. Older patients with stroke are even less likely to receive high-quality care whether they are managed in a stroke unit or general ward, particularly when over the age of 85 years. Stroke units have been shown previously to provide higher standards of care for all patients regardless of age or stroke severity and these data strongly confirm that, by demonstrating that 41/42 standards of care are performed better for patients managed in a stroke unit. Access to stroke unit care and urgent brain imaging is less for older than younger people and this is probably responsible for a large part of the difference in quality between the ages. Part of the reason for the lower stroke unit admission rates for the older patients may result from the higher levels of multiple pathology and greater degrees of frailty, leading to a belief that admission to a geriatric ward is more appropriate than a stroke unit. The evidence on which to base decisions around the ideal organisation of care for these patients is not strong, and despite the evidence from the Stroke Unit Triallists that all patients with stroke do better in stroke units than general wards there may be subgroups where alternative models of care are preferable. This audit did not collect sufficient information on co-morbidities to identify if there were systematic explicable reasons for non-admission to stroke unit care. Further research is required in this area. Early access to brain imaging is essential to the delivery of appropriate acute stroke care. The demonstration that admission at weekends reduces the chances of brain scanning within 24 h reinforces the need to develop a Health Service that operates on a 7-day week rather than the current 5-day week. Secondary prevention also appears to receive less attention in older patients. However, access to rehabilitation seems to be influenced by age less often with some aspects of rehabilitation being provided more effectively to older patients than the younger ones. These data show some evidence that female patients have less access to appropriate care than men adjusting for age, but the data is less strong than for age.
Little has been written about inequalities in access to care after stroke. It has been reported that older patients are less likely to be transferred to neurosurgical centres and had poorer outcomes with subdurals and extradurals. However, once transferred, there was no evidence that age influenced interventions [6]. A recent paper has shown that patients over the age of 80 years with symptomatic carotid stenosis are less likely to be investigated and treated than their younger counterparts [7]. There is a wealth of evidence in cardiology that similar age discrimination is prevalent, both in the United Kingdom and around the rest of the world [8–10]. It has been shown that access to thrombolysis after acute myocardial infarction, interventional cardiology as well as the use of statins and other secondary prevention measures are often rationed by age [11–13. Large age differences in lung cancer management were also found in an audit of care in the United Kingdom in the late 1990s [14].
The reasons for the apparent ageism are likely to be multiple. The evidence base for treatment is often less robust in the elderly, mainly because few randomised controlled trials include sufficient numbers of old people to provide an evidence base; there is still a prevalent belief among health professionals that if resources are scarce then the younger patient should be given them rather than the old, ignoring the fact that the older patient is more likely to have complex disease and therefore more likely to benefit from specialist expertise, and there is the straightforward age bias with the belief that older people are less worthy of expert care than younger patients.
The National Service Framework for Older People [5] devoted an entire chapter to ageism and set as one of its main targets the elimination of discrimination on the basis of age. These data show that this target has yet to be achieved and confirms data from a study of secondary prevention of coronary heart disease [15, [16]. The most effective way of eliminating selection to stroke units would be to provide sufficient capacity so that clinicians do not have to choose which patient receives the highest level of care. Ensuring that accessing brain imaging and other specialist investigations and rooting out bias in the delivery of expert secondary prevention may be more difficult to solve because it requires a fundamental change in attitude among many healthcare staff who often appear to view a year of life in old age as being of less value than a year of life earlier in life.
The solution to these issues may lie in better education of healthcare professionals, development of research programmes that test interventions in sufficiently large numbers of older people to provide clear evidence for treatment and continuing audit that can identify where ageism persists. Regulatory bodies monitoring the quality of healthcare systems should identify ageism as a key target for urgent attention and where necessary apply sanctions to organisations that persistently offend. The failure to include sufficient numbers of old patients in trials has led to an evidence gap for these patients. This is sometimes used as justification to limit treatment. For example, trials of thrombolysis for stroke have included few patients over 80 years and the drug is therefore appropriately not licensed in Europe for patients over 80 years. Similarly, drugs for secondary prevention of stroke, such as antihypertensives and statins, which may take several years to achieve full benefit may not be prescribed because life expectancy is insufficient to justify treatment, and for frail patients, some of the drugs recommended in stroke guidelines such as antihypertensives will be inappropriate. This audit, however, overcomes this issue by offering the auditor the opportunity to identify a particular intervention as being contraindicated for the patient in which case the analysis records the patient as having received appropriate care. A recent article [17] argues that the current recommendations in stroke guidelines to lower blood pressure after stroke should be reviewed because the trials demonstrating the benefits were conducted on populations that are not typical of those seen, in general, practice, particularly in terms of age structure. These data are unlikely to be available in the near future. Do we, therefore, adopt a policy of not delivering any care that has not been tested in the specific type of patient under consideration, or do we adopt a more pragmatic approach?
We have demonstrated few differences in the care provided to men and women. Gender inequalities have been demonstrated in ischaemic heart disease secondary prevention [18] and also, possibly, in access to cardiac catheterisation [19]; however, other papers have been unable to show any gender differences [20].
These data do confirm that the health service is ill-equipped to provide high-quality emergency stroke care at weekends. Stroke presents at any time and there is no justification to provide high-quality care only during ‘normal’ working hours. Scanners often lie idle at night and weekends while patients suffer from a failure to establish an accurate diagnosis. Rehabilitation is rarely provided, except for emergency problems, at weekends. A radical change in working practices is needed to deliver specialist care at all times. There is evidence that there is a dose response to rehabilitation. It may well be that providing a greater intensity of treatment would shorten lengths of stay and result in significant savings overall. These changes will require a major reconfiguration of services but is something that must not be ignored any longer
The strengths of the study are that it included a large unselected sample of patients from all hospitals providing stroke care in England, Wales and Northern Ireland, and there are, therefore, unlikely to be significant biases in the data. Data completeness was extremely high and collecting data using a Web-based tool enabled extensive internal validation to be undertaken resulting in a remarkably clean dataset. The weaknesses are intrinsic to any retrospective audit. Only information in the case record can be included, although data items such as day of admission, time of scan and type of ward are likely to be reliably recorded. One of the limitations of this study was that local clinicians completed the data without any external validation, although it might be expected that, if anything, this would result in over-optimistic descriptions of the service.
We have shown that the quality of stroke care is influenced by age but not gender, with older patients being less likely to receive high-quality care particularly in the acute phase, than younger patients. We have also shown the related consequences of a stroke at weekends, as it is less likely that the essential investigations will be completed inside the times recommended within the National Clinical Guidelines for Stroke [21].
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Key points |
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- Older patients are admitted less often to stroke unit care than younger patients
- In both, outside stroke units and to a lesser extent inside stroke units, the quality of care provided to older patients is of lower quality than that available to younger patients
- Immediate admission to a stroke unit and emergency brain imaging is less likely to happen for patients admitted at weekends
Conflict of interests statement
Competing Interests: All authors declare that they have no competing interests.
Authors contributions
All authors were involved in the design of the study, data analysis and in the drafting of the paper and there is no one else who fulfils the criteria but has not been included as an author.
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Acknowledgements and funding |
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Thanks are due to the many organisations and individuals who have participated in the National Sentinel Audit of Stroke 2004, not least the clinicians and audit staff from all the hospitals that participated. The audit was funded by the Healthcare Commission.
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