Objectives The policy of centralising hyperacute stroke units (HASUs) in England aims to provide stroke care in units that are both large enough to sustain expertise (>600 admissions/year) and dispersed enough to rapidly deliver time-critical treatments (<30 min maximum travel time). Currently, just over half (56%) of patients with stroke access care in such a unit. We sought to model national configurations of HASUs that would optimise both institutional size and geographical access to stroke care, to maximise the population benefit from the centralisation of stroke care.
Design Modelling of the effect of the national reconfiguration of stroke services. Optimal solutions were identified using a heuristic genetic algorithm.
Setting 127 acute stroke services in England, serving a population of 54 million people.
Participants 238 887 emergency admissions with acute stroke over a 3-year period (2013–2015).
Intervention Modelled reconfigurations of HASUs optimised for institutional size and geographical access.
Main outcome measure Travel distances and times to HASUs, proportion of patients attending a HASU with at least 600 admissions per year, and minimum and maximum HASU admissions.
Results Solutions were identified with 75–85 HASUs with annual stroke admissions in the range of 600–2000, which achieve up to 82% of patients attending a stroke unit within 30 min estimated travel time (with at least 95% and 98% of the patients being within 45 and 60 min travel time, respectively).
Conclusions The reconfiguration of hyperacute stroke services in England could lead to all patients being treated in a HASU with between 600 and 2000 admissions per year. However, the proportion of patients within 30 min of a HASU would fall from over 90% to 80%–82%.
- organisation of health services
- quality in health care
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Contributors MA is the lead author and guarantor, and proposed the key methodology to be used in the study. He also contributed to coding of the model. KP wrote much of the code used in the model and contributed to refining the basis of the modelling. She was involved in reviewing and editing the paper. EV developed the initial prototypes of the model employed, testing a number of heuristic approaches. She was involved in reviewing and editing the paper. TM framed the initial problem of balancing access to stroke care with developing a unit of sufficient size to maintain expertise, and recommended the modelling study contained herein. He critiqued the methods used in this study, and was involved in reviewing and editing the paper. KS oversaw all work. He was involved in framing the problem to be modelled. He critiqued the methods used in this study, and was involved in reviewing and editing the paper. MJ is the clinical stroke consultant for the work and paper. He was involved in framing the problem to be modelled. He advised on the clinical objectives of the study, was involved in authoring, reviewing and editing the paper.
Funding This study was funded by the National Institute of Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care for the South West Peninsula. The views and opinions expressed in this paper are those of the authors, and not necessarily those of the NHS, the National Institute for Health Research or the Department of Health. TM was funded by NIHR CLAHRC Wessex.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.
Data sharing statement Full data and code used for this study are available at https://github.com/MichaelAllen1966/stroke_unit_location. Included in the data and code are counts of acute stroke admissions in England by LSOA; estimated travel times from all LSOAs to al acute stroke units; hospital information (name, location); and full source code used to produce results reported here (which runs using open source software).
Author note The lead author (MA) confirms that the manuscript is a honest, accurate and transparent account of the study being reported, and that no important aspects of the study have been omitted.
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