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28.05.19

How are we improving outcomes for those affected by stroke?

Professor Gillian Leng, deputy chief executive at the National Institute for Health and Care Excellence (NICE), provides her view on the newly published NICE impact report on stroke.

Stroke is one of the greatest health challenges of our time. There are a reported 38,000 deaths occurring every year in the UK from more than 100,000 strokes. Without better access to treatment and rehabilitation, more people will lose their lives or be left with very serious life-impacting disabilities. The cost of stroke to health and social care is also rising and is predicted to reach as much as £91bn by 2035.

NICE has an important role in producing high quality, evidence-based recommendations for those who are at risk of or who have had a stroke. We published our first guideline on the diagnosis and initial management of stroke in 2008 and since then we have developed 2 guidelines covering stroke rehabilitation and stroke and transient ischaemic attack in over 16s, a quality standard on stroke in adults to drive improvements, and we have recommended two new drugs; alteplase and clopidogrel.

To bring together NICE’s guidance and to show how our recommendations are making a difference in priority areas of stroke care, we have published a new impact report on stroke. The report looks at where improvements have been made in health and social care but also identifies areas where more progress is needed.

One area the impact report considers is how we are working together to prevent stroke. In 2014, NICE updated its guideline on the prevention of stroke in people with atrial fibrillation (AF) to include a new risk assessment tool. The tool identifies those with AF who are at a high risk of stroke and need anticoagulation, and those with a lower risk who do not. The updated recommendations subsequently became part of the Quality and Outcomes Framework (QOF) and by 2017-18, 94% of people with atrial fibrillation were risk assessed using this tool.

Another area the report highlights is the impact of NICE’s recommendations on improving outcomes for those receiving acute care. In NICE’s guideline on the diagnosis and initial management of stroke, we focus on the importance of performing brain imaging as soon as possible. The evidence shows that by performing brain imaging within one hour, we can determine the most effective treatment for those with acute stroke. Since 2013/14, there have been improvements in the number of people who are scanned within 1 hour from 42% to 53% in 2017/18.

This is further evidence of how important implementation of NICE recommendations is in improving care for those who need it the most. However, there is more that needs to be done.

For example, an area that requires specific attention is waiting times for admissions to acute stroke units. NICE’s recommendations state that admissions must be within four hours to speed up treatment and to help prevent complications. However data from SSNAP shows that only 58% of patients overall across the UK were admitted to a stroke unit within four hours. Worryingly, this figure has not changed over the last five years, which could be due to long waiting times in Accident and Emergency and the availability of beds.

A new development in stroke treatment is another important focus of our impact report. Thrombectomy involves using a device to remove the blood clot directly from the blocked artery and restore blood flow, thus preventing a stroke. NICE guidance produced in 2016 on mechanical clot retrieval for treating acute ischaemic stroke provides evidence of its safety and efficacy.

SSNAP analysis indicates that in trials the procedure has shown real improvement in eligible patient outcomes, if performed within a few hours of a stroke. In March 2018, NHS England commissioned mechanical thrombectomy for acute ischaemic stroke and the NHS Long Term Plan aims to increase availability of mechanical thrombectomy from 1% to 10% of stroke patients. The updated NICE stroke guideline, which published this month, includes recommendations on the use of thrombectomy.

Our impact report clearly demonstrates that we are making significant strides in improving the lives of those affected by, or at risk of, stroke. However, there is still room for improvement. We need to work together to implement our evidence-based recommendations, to reduce the ‘postcode lottery’ of access to rehabilitation services, and to provide better support for people once they leave hospital. We will then be able to see a brighter, healthier future for all of those who have been affected by stroke, alongside significant advances in the health and social care services that support them.

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