RURAL MANAGEMENT OF STROKE

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RURAL MANAGEMENT OF STROKE

• GP TELECONFERENCE Sept 7 2009

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Stroke Demographics

• 48,000 strokes/year in Australia
• 12,000 deaths/year
• Stroke causes 25 of all chronic disability
• Direct and Indirect costs gt 1.75 billion
  annually
• In NSW, Death rates are higher in outer regional
  and remote areas compared to metropolitan areas
• Stroke death rates 2.2 times higher for
  aboriginal population

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Rural/Regional 1,788,000 26 of NSW total
Sydney/Hunter/Wollongong 5,179,000 74 of NSW
total
ABS indicators 12/08 NSW total 6,967,000
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Rural/Regional NSW

• Equivalent populations
• Tasmania x 3.75
• or
• South Australia Geelong
• or
• Brisbane

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Rural/Regional NSW

• Stroke Care Units/Service Enhancement
• Armidale
• Bathurst
• Coffs Harbour
• Dubbo
• Orange
• Port Macquarie
• Tamworth
• Shoalhaven
• Wagga Wagga

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ASSESSING RURAL AWARENESS OF THE NATIONAL FAST
CAMPAIGN

• How effective is a national campaign in a rural
  setting?
• 298 participants at the Henty agricultural field
  days
• Undertaken the week after National Stroke Week
• Awareness of the FAST campaign
• Ability to define the individual FAST acronym
  objects
• Mohr,K Assessing the Awareness of the national
  FAST campaign in a rural setting. Poster
  SmartStrokes 2009

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ASSESSING RURAL AWARENESS OF THE NATIONAL FAST
CAMPAIGN
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ASSESSING RURAL AWARENESS OF THE NATIONAL FAST
CAMPAIGN

• 33 had heard of FAST
• 12 of the surveyed population could define some
  or all of the FAST acronym
• The majority define that initial response to a
  stroke is to call an ambulance
• The minority of patients admitted to WWBH Stroke
  Unit call and ambulance at stroke onset

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Pre-hospital epidemiology of suspected stroke
patients in NSW

• Romesh Markus, Paul Middleton, Sowmya Anand, Mark
  Longworth, Judy Simpson, Julie Newman,
  Mary-Louise McLaws

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AIMS

• Number of 000 calls for potential stroke
• Proportion within one hour of symptom onset
• Agreement between call takers and paramedics
• Is there a difference in prehospital response
  times for Rural and Metro Areas?
• In Metro NSW, proportion of stroke patients taken
  to hospitals with SCUs

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Prehospital response times for potential
strokes Rural versus Metro NSW
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000 calls within 1 hour of onset of suspected
stroke
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Summary

• 000 Call to hospital arrival times
• gt80 transferred within 60 minutes
• Rural median 37.3 (IQR 23.4)
• Metro median 42.7 (IQR 18)
• NSW Metro
• 83 of suspected stroke patients taken to
  hospitals with SCUs

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Acute Access to Stroke Care

• Fewer rural patients call an ambulance within 1
  hour of symptom onset. 6 vs. 17
• Rural patients arrive at hospital faster on
  average. 37 vs. 43 minutes
• 83 of metro patients are taken to a Stroke Care
  Unit
• Where are rural patients taken?

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9
23
86
32
19
8
19
28
20
12
21
187
5
26
3
6
7

• Stroke admissions 1/Jan-3/Dec 2008

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9
23
86
32
19
8
19
28
20
12
21
187
5
26
3
6
7

• Stroke admissions 1/Jan-3/Dec 2008
• No CT access on site

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9
23
86
32
19
8
19
28
20
12
21
187
5
26
3
6
7

• Stroke admissions 1/Jan-3/Dec 2008
• 100km radius from Wagga 187 147

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Effectiveness of Intervention

• INTERVENTION NNT
• Atrial fibrillation anticoagulation
• Apirin
• Carotid stenosis (gt70 symptomatic)
• Clopidogrel/Asasantin
• Hypertension management
• Smoking cessation
• Stroke unit care

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Effectiveness of Intervention

• INTERVENTION NNT
• Apirin 100
• Clopidogrel/Asasantin 80
• Hypertension management 50
• Smoking cessation 43
• Carotid stenosis (gt70 symptomatic) 24
• Stroke unit care 18
• Atrial fibrillation anticoagulation 12

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TIA MANAGEMENT

• 1 year risk of stroke after TIA 10.5
• (50 within the first 2 days)
• TIAs with a worse prognosis
• Increased age
• Duration greater than 10 minutes
• Limb weakness and speech disturbance

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ABCD² Score
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stroke risk based on ABCD² score
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Stroke Unit Management

• Rate of death or dependency reduced from 62.0 to
  56.4
• 1 extra survivor for every 33 patients treated
• 1 extra patient discharged home for every 20
  treated
• Is more effective than management in a rehab
  ward, by a mobile stroke team, or in a general
  medical ward
• Is effective, independent of whether run by
  neurologist, physician, geriatrician or GP, as
  long as expertise in stroke management is present

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Which stroke intervention provides the greatest
community benefit?

• North East Melbourne Stroke Incidence Study
• 306,631 people
• 645 strokes managed in hospital
• For every 1,000 patients treated, the number
  saved from death and dependency
• Stroke Unit Management 46
• Aspirin 6
• tPA (3 hour) 11
• Gilligan et al Cerebrovascular Diseases. 20(4)
  239-244, 2005

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Which stroke intervention provides the greatest
community benefit?

• tPA is the most potent intervention
• Stroke Unit Management is the most broadly
  applicable, and provides the greatest community
  benefit
• Is there any reason to prioritise thrombolysis in
  regional centres?

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Rural tPA implementation

• The case for tPA implementation in rural NSW
• Equity in patient care
• The capacity to deliver tPA drives an upgrade in
  stroke care services generally
• Enables a coordinated message for stroke
  management in the state
• Is politically sexy

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Statewide Comprehensive Stroke Care

• Improve Community Stroke action awareness and
  early ambulance contact
• Ambulance system for diversion of acute stroke
  patients to appropriate centres
• Acute stroke assessment and scoring (NIHSS) by
  local expertise
• Neurologist/Physician/Intensivist where possible
• Metro SCU training for Medical registrars who
  currently provide Statewide medical support
  through IMET
• Imaging assessment and thrombolysis approval via
  PACS/Web based access to local expertise if
  possible, or metro support if necessary
• Continued rural SCU care or transfer via protocol
• Ongoing audit, SITS registration etc.

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Statewide Comprehensive Stroke Care

• Maintains substantial rural independence
• Medical registrar staffing and Web imaging access
  require no significant infrastructure enhancement
• Requires buy in from metro on call system
• Insurance and Liability issues need embedding
• Payment
• May enhance metro lysis rates
• Increases a stroke expert group of medical
  trainees
• Would benefit from more formalised links between
  metro and rural SCUs
• May act as a substrate for other health
  services/disease models

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