Letters
Letters Stroke care in Australia: why is it still the poor cousin of health care?
TO THE E DITOR : We concur with Hoffman and Lindley that dedicated funding for implementation of a comprehensive stroke strategy is TO THE EDITOR: In their editorial on overdue.1 The importance of funding stroke care in Australia, Hoffman and the implementation of evidenceLindley state “only 7% of ischaemic based care has been recognised by the stroke patients received thrombolysis New South Wales Agency for Clinical treatment, yet for every 100 patients Innovation (ACI). Two key projects are who receive it, there are up to 10 extra currently putting high-level evidence independent survivors”,1 citing the into practice in NSW. The first is the most recent meta-analysis.2 This Quality in Acute Stroke Care (QASC) research also found a significant Implementation Project, a statewide increase in the risk of early death with translational quality improvement thrombolysis, mostly from intracranial activity implementing evidence-based haemorrhage. For the individual clinical protocols to manage fever, Medical final Journal of Australia ISSN: 0025patient,The predicting neurological hyperglycaemia and swallowing,2 in 729X 5 August 199 3hours 318-319 outcome is difficult in 2013 the early all 36 NSW stroke services during ©The 2013 after the onsetMedical of stroke.Journal Patientsof Australia 2013.3 The second is the NSW Stroke www.mja.com.au considering Reperfusion Service,4 which aims to Lettersthrombolysis treatment must weigh up an increased risk of decrease treatment delays using an early death against possible evidence-based pathway involving improvement in final function if they paramedic rapid transfer to the closest survive. In addition, any benefits from acute stroke thrombolysis centre.5 thrombolysis appear modest at best. This service was introduced in 20 The third International Stroke Trial NSW hospitals in 2012. Both projects (IST-3), the most recently published are translating evidence into practice, and largest randomised trial of and are prime examples showing how thrombolysis in stroke, in fact showed the NSW Ministry of Health and its no improvement in the proportion key pillars such as the ACI are of patients alive and independent at enabling clinicians to close evidence– 6 months.3 Hoffman and Lindley practice gaps. Rigorous evaluations describe a number of evidence–practice of both these initiatives are being gaps, including early assessment for undertaken, examining patient transient ischaemic attack and access outcomes and clinician practiceto multidisciplinary stroke unit care. change measures, and will be Patients and the community may be completed in the first half of 2014. better served by directing resources to These projects are examples of such areas where stronger evidence of funded, evidence-based activities that overall benefit exists. show how research can be translated in the real world and on a large scale. Stephen PJ Macdonald Emergency Physician Initiatives such as these are critical; Armadale Health Service, Perth, WA. they require dedicated funding [email protected] thereby demonstrating a serious Competing interests: No relevant disclosures. commitment to closing evidence– doi: 10.5694/mja13.10419 practice gaps. 1 Hoffman TC, Lindley RI. Stroke care in Australia: why is it still the poor cousin of health care? Med J Aust 2013; 198: 246-247. 2 Wardlaw JM, Murray V, Berge E, et al. Recombinant tissue plasminogen activator for acute ischaemic stroke: an updated systematic review and meta-analysis. Lancet 2012; 379: 2364-2372. 3 Sandercock P, Wardlaw JM, Lindley RI, et al; IST-3 collaborative group. The benefits and harms of intravenous thrombolysis with recombinant tissue plasminogen activator within 6 h of acute ischaemic stroke (the third international stroke trial [IST-3]): a randomised controlled trial. Lancet 2012; 379: 2352-2363. ❏
166
MJA 199 (3) · 5 August 2013
Sandy Middleton Professor of Nursing and Director, Nursing Research Institute1 Nigel Lyons Chief Executive2 1 Nursing Research Institute, St Vincents and Mater Health and Australian Catholic University, Sydney, NSW. 2 NSW Agency for Clinical Innovation, Sydney, NSW.
[email protected] Competing interests: Sandy Middleton is a member of the ACI, the NSW Stroke Services Coordinating Committee and the ACI Research Committee.
doi: 10.5694/mja13.10476
1 Hoffman TC, Lindley RI. Stroke care in Australia:
“
2
predicting final neurological outcome is difficult in the early hours after the onset of stroke
”
4
Macdonald
“
Two key projects are currently putting highlevel evidence into practice in NSW
”
3
Middleton et al
5
why is it still the poor cousin of health care? Med J Aust 2013; 198: 246-247. QASC Implementation Project 2013. http:// www.acu.edu.au/about_acu/faculties,_ institutes_and_centres/health_sciences/ research/quality_in_acute_stroke_care/qasc_ implementation_project_2013 (accessed Jul 2013). Middleton S, McElduff P, Ward J, et al. Implementation of evidence-based treatment protocols to manage fever, hyperglycaemia, and swallowing dysfunction in acute stroke (QASC): a cluster randomised controlled trial. Lancet 2011; 378: 1699-1706. Agency for Clinical Innovation. NSW Stroke Reperfusion Service. www.aci.health.nsw.gov.au/ networks/stroke/priorities/stroke-reperfusion 2013 (accessed Jul 2013). Hacke W, Kaste M, Bluhmki E, et al. Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke. N Engl J Med 2008; 359: 1317-1329. ❏
IN REPLY: In response to Macdonald’s letter, we agree there are many effective interventions for stroke that should be routinely available, including stroke units and early coordinated care for minor strokes and transient ischaemic attacks (early care is particularly neglected in Australia). However, thrombolysis is one of the interventions that should be more widely available. Australian and international guidelines (the National Health and Medical Research Council [NHMRC]-approved clinical guidelines for stroke management, the United Kingdom Royal College of Physicians stroke guidelines and the American Heart Association/ American Stroke Association guidelines) recommend thrombolysis with alteplase for acute ischaemic stroke.1-3 While there is a risk of early death from intracranial haemorrhage, long-term outcomes are significantly improved with thrombolysis. Although the primary outcome of the third international stroke trial (IST-3) was not significant, there was a significant improvement in 6-month disability (a prespecified secondary outcome) in the alteplase group, and no difference in number of deaths by 6 months (as the alteplase group had a lower death rate from 7 days to 6 months).4 It is on the basis of all of this evidence, confirming that
Letters treatment is beneficial, that guidelines consistently recommend thrombolysis as the standard of care for those who are eligible.5 We thank Middleton and Lyons for their letter highlighting real-world examples of how organisations can fund and facilitate health service redesign to address identified evidence–practice gaps. We commend the NSW Ministry of Health’s Agency for Clinical Innovation for showing leadership with these projects and encourage other organisations to select priority evidence–practice gaps and provide dedicated funding and planning to tackle them. Without the step of implementation, evidence of effective interventions is of no benefit to patients. Tammy C Hoffmann Associate Professor of Clinical Epidemiology, 1 and NHMRC/PHCRED Research Fellow 2 Richard I Lindley Professor of Geriatric Medicine, 3 and Professorial Fellow 4 1 Centre for Research in Evidence-Based Practice, Bond University, Gold Coast, QLD. 2 School of Health and Rehabilitation Sciences, University of Queensland, Brisbane, QLD. 3 University of Sydney, Sydney, NSW. 4 George Institute for Global Health, Sydney, NSW.
[email protected] Acknowledgements: Tammy Hoffmann is supported by an NHMRC/Primary Health Care Research, Evaluation and Development (PHCRED) Career Development Fellowship (1033038), with funding provided by the Department of Health and Ageing. Competing interests: Tammy Hoffmann is a member of the National Stroke Foundation Clinical Council, but does not receive payment for this involvement. Richard Lindley is Chair of the Clinical Council and Board Member for the National Stroke Foundation, but does not receive payment for these positions.
doi: 10.5694/mja13.10551 1 National Stroke Foundation. Clinical guidelines
2
3
4
5
for stroke management 2010. http:// strokefoundation.com.au/health-professionals/ tools-and-resources/clinical-guidelines-forstroke-prevention-and-management (accessed Apr 2013). Royal College of Physicians Intercollegiate Stroke Working Party. National clinical guideline for stroke. 4th ed. London: RCP, 2012. http:// www.rcplondon.ac.uk/publications/nationalclinical-guidelines-stroke (accessed Apr 2013). Jauch EC, Saver JL, Adams HP Jr, et al. Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2013; 44: 870-947. Wardlaw JM, Murray V, Berge E, et al. Recombinant tissue plasminogen activator for acute ischaemic stroke: an updated systematic review and meta-analysis. Lancet 2012; 379: 2364-2372. Sandercock P, Wardlaw JM, Lindley RI, et al; IST-3 collaborative group. The benefits and harms of intravenous thrombolysis with recombinant tissue plasminogen activator within 6 h of acute ischaemic stroke (the third international stroke trial [IST-3]): a randomised controlled trial. Lancet 2012; 379: 2352-2363. ❏
168
MJA 199 (3) · 5 August 2013
Letters Stroke care in Australia: why is it still the poor cousin of health care?
TO THE E DITOR : We concur with Hoffman and Lindley that dedicated funding for implementation of a comprehensive stroke strategy is TO THE EDITOR: In their editorial on overdue.1 The importance of funding stroke care in Australia, Hoffman and the implementation of evidenceLindley state “only 7% of ischaemic based care has been recognised by the stroke patients received thrombolysis New South Wales Agency for Clinical treatment, yet for every 100 patients Innovation (ACI). Two key projects are who receive it, there are up to 10 extra currently putting high-level evidence independent survivors”,1 citing the into practice in NSW. The first is the most recent meta-analysis.2 This Quality in Acute Stroke Care (QASC) research also found a significant Implementation Project, a statewide increase in the risk of early death with translational quality improvement thrombolysis, mostly from intracranial activity implementing evidence-based haemorrhage. For the individual clinical protocols to manage fever, Medical final Journal of Australia ISSN: 0025patient,The predicting neurological hyperglycaemia and swallowing,2 in 729X 5 August 199 3hours 318-319 outcome is difficult in 2013 the early all 36 NSW stroke services during ©The 2013 after the onsetMedical of stroke.Journal Patientsof Australia 2013.3 The second is the NSW Stroke www.mja.com.au considering Reperfusion Service,4 which aims to Lettersthrombolysis treatment must weigh up an increased risk of decrease treatment delays using an early death against possible evidence-based pathway involving improvement in final function if they paramedic rapid transfer to the closest survive. In addition, any benefits from acute stroke thrombolysis centre.5 thrombolysis appear modest at best. This service was introduced in 20 The third International Stroke Trial NSW hospitals in 2012. Both projects (IST-3), the most recently published are translating evidence into practice, and largest randomised trial of and are prime examples showing how thrombolysis in stroke, in fact showed the NSW Ministry of Health and its no improvement in the proportion key pillars such as the ACI are of patients alive and independent at enabling clinicians to close evidence– 6 months.3 Hoffman and Lindley practice gaps. Rigorous evaluations describe a number of evidence–practice of both these initiatives are being gaps, including early assessment for undertaken, examining patient transient ischaemic attack and access outcomes and clinician practiceto multidisciplinary stroke unit care. change measures, and will be Patients and the community may be completed in the first half of 2014. better served by directing resources to These projects are examples of such areas where stronger evidence of funded, evidence-based activities that overall benefit exists. show how research can be translated in the real world and on a large scale. Stephen PJ Macdonald Emergency Physician Initiatives such as these are critical; Armadale Health Service, Perth, WA. they require dedicated funding [email protected] thereby demonstrating a serious Competing interests: No relevant disclosures. commitment to closing evidence– doi: 10.5694/mja13.10419 practice gaps. 1 Hoffman TC, Lindley RI. Stroke care in Australia: why is it still the poor cousin of health care? Med J Aust 2013; 198: 246-247. 2 Wardlaw JM, Murray V, Berge E, et al. Recombinant tissue plasminogen activator for acute ischaemic stroke: an updated systematic review and meta-analysis. Lancet 2012; 379: 2364-2372. 3 Sandercock P, Wardlaw JM, Lindley RI, et al; IST-3 collaborative group. The benefits and harms of intravenous thrombolysis with recombinant tissue plasminogen activator within 6 h of acute ischaemic stroke (the third international stroke trial [IST-3]): a randomised controlled trial. Lancet 2012; 379: 2352-2363. ❏
166
MJA 199 (3) · 5 August 2013
Sandy Middleton Professor of Nursing and Director, Nursing Research Institute1 Nigel Lyons Chief Executive2 1 Nursing Research Institute, St Vincents and Mater Health and Australian Catholic University, Sydney, NSW. 2 NSW Agency for Clinical Innovation, Sydney, NSW.
[email protected] Competing interests: Sandy Middleton is a member of the ACI, the NSW Stroke Services Coordinating Committee and the ACI Research Committee.
doi: 10.5694/mja13.10476
1 Hoffman TC, Lindley RI. Stroke care in Australia:
“
2
predicting final neurological outcome is difficult in the early hours after the onset of stroke
”
4
Macdonald
“
Two key projects are currently putting highlevel evidence into practice in NSW
”
3
Middleton et al
5
why is it still the poor cousin of health care? Med J Aust 2013; 198: 246-247. QASC Implementation Project 2013. http:// www.acu.edu.au/about_acu/faculties,_ institutes_and_centres/health_sciences/ research/quality_in_acute_stroke_care/qasc_ implementation_project_2013 (accessed Jul 2013). Middleton S, McElduff P, Ward J, et al. Implementation of evidence-based treatment protocols to manage fever, hyperglycaemia, and swallowing dysfunction in acute stroke (QASC): a cluster randomised controlled trial. Lancet 2011; 378: 1699-1706. Agency for Clinical Innovation. NSW Stroke Reperfusion Service. www.aci.health.nsw.gov.au/ networks/stroke/priorities/stroke-reperfusion 2013 (accessed Jul 2013). Hacke W, Kaste M, Bluhmki E, et al. Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke. N Engl J Med 2008; 359: 1317-1329. ❏
IN REPLY: In response to Macdonald’s letter, we agree there are many effective interventions for stroke that should be routinely available, including stroke units and early coordinated care for minor strokes and transient ischaemic attacks (early care is particularly neglected in Australia). However, thrombolysis is one of the interventions that should be more widely available. Australian and international guidelines (the National Health and Medical Research Council [NHMRC]-approved clinical guidelines for stroke management, the United Kingdom Royal College of Physicians stroke guidelines and the American Heart Association/ American Stroke Association guidelines) recommend thrombolysis with alteplase for acute ischaemic stroke.1-3 While there is a risk of early death from intracranial haemorrhage, long-term outcomes are significantly improved with thrombolysis. Although the primary outcome of the third international stroke trial (IST-3) was not significant, there was a significant improvement in 6-month disability (a prespecified secondary outcome) in the alteplase group, and no difference in number of deaths by 6 months (as the alteplase group had a lower death rate from 7 days to 6 months).4 It is on the basis of all of this evidence, confirming that
Letters treatment is beneficial, that guidelines consistently recommend thrombolysis as the standard of care for those who are eligible.5 We thank Middleton and Lyons for their letter highlighting real-world examples of how organisations can fund and facilitate health service redesign to address identified evidence–practice gaps. We commend the NSW Ministry of Health’s Agency for Clinical Innovation for showing leadership with these projects and encourage other organisations to select priority evidence–practice gaps and provide dedicated funding and planning to tackle them. Without the step of implementation, evidence of effective interventions is of no benefit to patients. Tammy C Hoffmann Associate Professor of Clinical Epidemiology, 1 and NHMRC/PHCRED Research Fellow 2 Richard I Lindley Professor of Geriatric Medicine, 3 and Professorial Fellow 4 1 Centre for Research in Evidence-Based Practice, Bond University, Gold Coast, QLD. 2 School of Health and Rehabilitation Sciences, University of Queensland, Brisbane, QLD. 3 University of Sydney, Sydney, NSW. 4 George Institute for Global Health, Sydney, NSW.
[email protected] Acknowledgements: Tammy Hoffmann is supported by an NHMRC/Primary Health Care Research, Evaluation and Development (PHCRED) Career Development Fellowship (1033038), with funding provided by the Department of Health and Ageing. Competing interests: Tammy Hoffmann is a member of the National Stroke Foundation Clinical Council, but does not receive payment for this involvement. Richard Lindley is Chair of the Clinical Council and Board Member for the National Stroke Foundation, but does not receive payment for these positions.
doi: 10.5694/mja13.10551 1 National Stroke Foundation. Clinical guidelines
2
3
4
5
for stroke management 2010. http:// strokefoundation.com.au/health-professionals/ tools-and-resources/clinical-guidelines-forstroke-prevention-and-management (accessed Apr 2013). Royal College of Physicians Intercollegiate Stroke Working Party. National clinical guideline for stroke. 4th ed. London: RCP, 2012. http:// www.rcplondon.ac.uk/publications/nationalclinical-guidelines-stroke (accessed Apr 2013). Jauch EC, Saver JL, Adams HP Jr, et al. Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2013; 44: 870-947. Wardlaw JM, Murray V, Berge E, et al. Recombinant tissue plasminogen activator for acute ischaemic stroke: an updated systematic review and meta-analysis. Lancet 2012; 379: 2364-2372. Sandercock P, Wardlaw JM, Lindley RI, et al; IST-3 collaborative group. The benefits and harms of intravenous thrombolysis with recombinant tissue plasminogen activator within 6 h of acute ischaemic stroke (the third international stroke trial [IST-3]): a randomised controlled trial. Lancet 2012; 379: 2352-2363. ❏
168
MJA 199 (3) · 5 August 2013
