Regional differences in acute stroke care and patient outcomes

Stroke continues to place a large burden on society, ranking as the third leading cause of death in Australia, and accounting for around 7% of all deaths in the year 2017. The burden of stroke has considerably reduced over time, however, which has been partially attributed to advances made in the field of acute stroke care. Regrettably, such advances (e.g. the advent of acute stroke units, thrombolysis) have not been uniformly distributed throughout our society. Indeed, there is some evidence to suggest that rural areas have comparatively poor access to such interventions. It remains unclear, however, as to what the extent of these care disparities are, and what impact they may be having on patient outcomes. The purpose of this body of work was to characterise and contrast the care provided to, and outcomes of, people with stroke across geographical settings (e.g. with varying degrees of rurality). Doing so will indicate whether patients' hospital care and outcomes contribute to wider geographical disparities in health. Recommendations produced by this thesis will also assist clinicians and policymakers to improve the delivery of stroke services in both urban and rural settings. In order to address these objectives, a systematic review was conducted as a way of characterising the existing body of literature. Several databases, including CINAHL, PubMed and Scopus were systematically searched for published and unpublished literature until 9th December 2017. Studies were included if they compared the acute care provided to, or outcomes of, patients hospitalised for stroke in urban versus rural settings. A total of 28 studies were included in the review (16 on care, 12 on outcomes). This review showed that with few exceptions, studies addressing the provision of care suggested that rural patients have less access to most aspects of acute stroke care. At the same time, studies reporting urban-rural differences in patient outcomes were inconsistent in their findings. Capitalising on a number of gaps identified in the systematic review, a study was conducted to describe the regional differences in acute stroke care and outcomes within the Australian state of Tasmania. This entailed a retrospective case note audit of 395 acute stroke cases from all four of Tasmania's major public hospitals. Sixteen care processes were recorded, which covered time-critical treatment, allied health interventions, and secondary prevention. Outcome measures were assessed using 30-day mortality and discharge destination, both of which were analysed for differences between urban and rural hospitals using logistic regression models. Results of the audit indicated that no patients in rural hospitals were administered thrombolysis, and that these hospitals also did not have acute stroke units. With few exceptions, patients' access to the remaining care indicators was comparable between regions. After adjusting for confounders, there were no significant differences between regions in terms of 30-day mortality (OR = 0.99, 95% C.I. 0.46-2.18) or discharge destination (OR = 1.24, 95% C.I. 0.81-1.91). Overall, the findings from this study indicated that with the exception of acute stroke unit care and thrombolysis, stroke care within Tasmania's urban and rural hospitals was broadly similar. No significant differences were found between regions in terms of patient outcomes. Upon completion of the medical record audit, the primary researcher had a set of quantitative findings, but little understanding of how the experiences of clinicians delivering care differed between regions. In order to address this, a sequential-explanatory approach was used to understand the local barriers and facilitators to providing care in urban and rural settings. A total of two focus groups and five individual interviews were conducted with Tasmanian clinicians from the subject hospitals (one urban, two rural) used in the initial study. An inductive process of thematic analysis was then used to identify themes and subthemes across the data set. Four major themes were isolated from analysis of the data: systemic issues, clinician factors, additional support, and patient factors. Overall, the findings suggested that acute stroke care within the study's urban hospital was structured and comprehensive, aided by the hospital's acute stroke unit and specialist nursing support. In contrast, care provided in the study's rural hospitals was somewhat less sophisticated, and often constrained by an absence of infrastructure or poor access to existing resources. The main limitation of the initial Tasmanian-specific medical record audit was its relatively small sample from only four hospitals. In order to address this limitation, the primary researcher collaborated with the Australian Stroke Clinical Registry (AuSCR) on a study using data from this registry. This study utilised data submitted by 50 hospitals (25 urban, 25 rural) during the period January 2010 to December 2015. Data in relation to four care processes were analysed, and patient outcomes were assessed using mortality at intervals of 7, 30, 90 and 180 days. Data in relation to participants' health-related quality of life (HRQoL) was also collected at follow up using the EuroQoL-5 dimension-3 level (EQ-5D3L) instrument, while an overall measure of perceived health was obtained using the visual analog scale (VAS). Of the 28,115 patients, 8,159 (29%) were admitted to hospitals located within rural areas. Compared to those admitted to urban hospitals, patients in rural hospitals less often received thrombolysis if an ischaemic stroke (urban 12.7% vs rural 7.5%, p<0.001), and fewer were discharged with a care plan (urban 61.3% vs 44.7%, p<0.001). No significant differences were found in terms of survival or overall self-reported quality of life. In conclusion, rural access to recommended components of acute stroke care was comparatively poorer; however, as was the case in the initial study, this did not appear to impact health outcomes at approximately 6 months. This thesis demonstrates that when compared to hospitals located in urban areas, those in rural areas typically provided a basic form of acute stroke care, with reduced access to stroke unit care and thrombolysis. An increased use of telestroke, coupled with a more efficient use of existing resources would greatly help to improve the state of stroke care in rural areas. No regional differences in patient outcomes were reported in either of the quantitative studies. This finding was consistent with previous research; however, it may have been influenced by methodological limitations, particularly relating to statistical power to detect differences in outcomes. Similarities in patient outcomes between regions should not be taken as that both regions have access to a commensurate level of care, when in fact, the level of care differs markedly between regions. The urban-rural disparity in stroke care must be addressed now, while it is primarily an issue of thrombolysis and stroke unit care, as the disparity can only be expected to grow with the advent of new therapies.