BackgroundPneumonia frequently complicates stroke and has a major impact on outcome. We derived and internally validated a simple clinical risk score for predicting stroke‐associated pneumonia (SAP), and compared the performance with an existing score (A2DS2).Methods and ResultsWe extracted data for patients with ischemic stroke or intracerebral hemorrhage from the Sentinel Stroke National Audit Programme multicenter UK registry. The data were randomly allocated into derivation (n=11 551) and validation (n=11 648) samples. A multivariable logistic regression model was fitted to the derivation data to predict SAP in the first 7 days of admission. The characteristics of the score were evaluated using receiver operating characteristics (discrimination) and by plotting predicted versus observed SAP frequency in deciles of risk (calibration). Prevalence of SAP was 6.7% overall. The final 22‐point score (ISAN: prestroke Independence [modified Rankin scale], Sex, Age, National Institutes of Health Stroke Scale) exhibited good discrimination in the ischemic stroke derivation (C‐statistic 0.79; 95% CI 0.77 to 0.81) and validation (C‐statistic 0.78; 95% CI 0.76 to 0.80) samples. It was well calibrated in ischemic stroke and was further classified into meaningful risk groups (low 0 to 5, medium 6 to 10, high 11 to 14, and very high ≥15) associated with SAP frequencies of 1.6%, 4.9%, 12.6%, and 26.4%, respectively, in the validation sample. Discrimination for both scores was similar, although they performed less well in the intracerebral hemorrhage patients with an apparent ceiling effect.ConclusionsThe ISAN score is a simple tool for predicting SAP in clinical practice. External validation is required in ischemic and hemorrhagic stroke cohorts.

Study objectives: to determine whether access to high-quality stroke care is affected by the age or gender of the patient or by weekend admission. Design: data were collected as part of the National Sentinel Audit of stroke in 2004, both on the organisation of in-patient stroke care and the process of care to hospitals managing stroke patients. Setting: two hundred and forty-six hospitals from England, Wales and Northern Ireland took part in the 2004 National Stroke Audit, a response rate of 100%. These sites audited the care of 8,718 patients. Audit Tool: Royal College of Physicians Intercollegiate Working Party Stroke Audit Tool. Results: overall standards of care for cases of stroke in England, Wales and Northern Ireland are low. Older patients are less likely to be treated in a stroke unit than younger patients (risk ratio comparing 85+ years with those <65 years 0.82 (95% CI 0.75-0.90). Seventy-one per cent of patients under 65 years were scanned within 24 h compared to 51% aged over 85 years. Older patients were also less likely than younger ones to receive secondary prevention and some aspects of rehabilitation, especially around higher functioning. Standards were consistently better for patients of all ages managed in stroke units compared to general wards. At weekends, patients were less likely to be admitted directly to a stroke unit (risk ratio 0.77 95% CI 0.69-0.86) and brain imaging was performed less often for older (85+ years) patients (weekday 56%, weekend 40%). There was little evidence of differences in standards of care between males and females. Conclusion: there is clear evidence of an age effect on the delivery of stroke care in England, Wales, and Northern Ireland, with older patients being less likely to receive care in line with current clinical guidelines. Quality of acute care is also less good for patients admitted at weekends. No systematic evidence for sexism was identified.

Objective:To identify why the National Clinical Guideline recommendation of 45 minutes of each appropriate therapy daily is not met in many English stroke units.Design:Mixed-methods case-study evaluation, including modified process mapping, non-participant observations of service organisation and therapy delivery, documentary analysis and semi-structured interviews.Setting:Eight stroke units in four English regions.Subjects:Seventy-seven patients with stroke, 53 carers and 197 stroke unit staff were observed; 49 patients, 50 carers and 131 staff participants were interviewed.Results:Over 1000 hours of non-participant observations and 433 patient-specific therapy observations were undertaken. The most significant factor influencing amount and frequency of therapy provided was the time therapists routinely spent, individually and collectively, in information exchange. Patient factors, including fatigue and tolerance influenced therapists’ decisions about frequency and intensity, typically resulting in adaptation of therapy rather than no provision. Limited use of individual patient therapy timetables was evident. Therapist staffing levels were associated with differences in therapy provision but were not the main determinant of intensity and frequency. Few therapists demonstrated understanding of the evidence underpinning recommendations for increased therapy frequency and intensity. Units delivering more therapy had undertaken patient-focused reorganisation of therapists’ working practices, enabling them to provide therapy consistent with guideline recommendations.Conclusion:Time spent in information exchange impacted on therapy provision in stroke units. Reorganisation of therapists’ work improved alignment with guidelines.

SummaryBackgroundWe aimed to estimate socioeconomic disparities in the incidence of hospitalisation for first-ever stroke, quality of care, and post-stroke survival for the adult population of England.MethodsIn this cohort study, we obtained data collected by a nationwide register on patients aged 18 years or older hospitalised for first-ever acute ischaemic stroke or primary intracerebral haemorrhage in England from July 1, 2013, to March 31, 2016. We classified socioeconomic status at the level of Lower Super Output Areas using the Index of Multiple Deprivation, a neighbourhood measure of deprivation. Multivariable models were fitted to estimate the incidence of hospitalisation for first stroke (negative binomial), quality of care using 12 quality metrics (multilevel logistic), and all-cause 1 year case fatality (Cox proportional hazards).FindingsOf the 43·8 million adults in England, 145 324 were admitted to hospital with their first-ever stroke: 126 640 (87%) with ischaemic stroke, 17 233 (12%) with intracerebral haemorrhage, and 1451 (1%) with undetermined stroke type. We observed a socioeconomic gradient in the incidence of hospitalisation for ischaemic stroke (adjusted incidence rate ratio 2·0, 95% CI 1·7–2·3 for the most vs least deprived deciles) and intracerebral haemorrhage (1·6, 1·3–1·9). Patients from the lowest socioeconomic groups had first stroke a median of 7 years earlier than those from the highest (p<0·0001), and had a higher prevalence of pre-stroke disability and diabetes. Patients from lower socioeconomic groups were less likely to receive five of 12 care processes but were more likely to receive early supported discharge (adjusted odds ratio 1·14, 95% CI 1·07–1·22). Low socioeconomic status was associated with a 26% higher adjusted risk of 1-year mortality (adjusted hazard ratio 1·26, 95% CI 1·20–1·33, for highest vs lowest deprivation decile), but this gradient was largely attenuated after adjustment for the presence of pre-stroke diabetes, hypertension, and atrial fibrillation (1·11, 1·05–1·17).InterpretationWide socioeconomic disparities exist in the burden of ischaemic stroke and intracerebral haemorrhage in England, most notably in stroke hospitalisation risk and case fatality and, to a lesser extent, in the quality of health care. Reducing these disparities requires interventions to improve the quality of acute stroke care and address disparities in cardiovascular risk factors present before stroke.FundingNHS England and the Welsh Government.

Objective To estimate the relations between the organisation of stroke services, process measures of care quality, and 30 day mortality in patients admitted with acute ischaemic stroke.