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Centralised stroke services saving lives – UCL report

Centralised stroke services in highly specialised hospitals can help save lives and reduce the average amount of time a patient has to stay in hospital, new research has confirmed.

The University College London-led study, published in the BMJ, investigated the impact of centralising acute stroke services in London and Greater Manchester, which happened in 2010, on mortality and the length of hospital stay.

Despite fears that the changes could lead to the demise of local hospitals, the research authors stated that the eight hyper-acute stroke units in London save around 96 stroke patients every year who would likely have died under a non-centralised system.

Additionally, the capital’s centralised system has reduced the average hospital stay by around a day and a half.

In Greater Manchester, although the system change has had no effect on mortality, it has reduced the average hospital stay by two days.

The authors say there was less compliance with the new system in Greater Manchester, where, in its first year, 36% of the patients who presented with stroke within four hours were not taken to a comprehensive stroke centre or primary stroke centre.

They say: “A significantly higher proportion of patients in London received care that was compliant with the care processes compared with in Greater Manchester and the rest of England (which were broadly similar). This suggests that the centralised model of care in London was more closely adhered to and achieved greater compliance with care processes.

“The upshot is that differences in mortality can be explained by the lower level of adherence in Greater Manchester or by differences between the two systems in terms of the access to hyperacute care for patients presenting after four hours of developing symptoms of stroke. This suggests that the type of system redesign and the extent of its implementation can affect patient outcomes and needs to be taken into account by those who are reorganising services.”

To assess the effectiveness of both centralisations, the researchers looked at data from 258,915 stroke admissions across England from 2008-2012, including 17,650 in Greater Manchester and 33,698 in London. They compared stroke survival from both areas before and after reconfiguration with the average for the rest of England, which has been improving since the publication of the National Stroke Strategy for the English NHS in December 2007.

Professor Naomi Fulop, of the UCL Department of Applied Health Research and senior report author, said: “Our study shows that radical centralisation of acute stroke care in cities saves lives and reduces time spent in hospital

“It may seem counter-intuitive for an ambulance to drive a critical patient straight past the nearest hospital, but it saves lives. While an individual may feel that losing their local hospital’s stroke unit is bad for them, going to a specialised centre further away actually increases their chance of surviving a stroke.

“Now that our paper has clearly shown the benefits of centralisation in London, other urban areas should seriously consider adopting a similar model.”

The research was commissioned by the National Institute for Health Research (NIHR) Health Services and Delivery Research Programme, funded by the Department of Health and performed by researchers from UCL, The University of Manchester, King’s College London and the Guy's and St Thomas' NHS Foundation Trust.

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