Objective To investigate variations in quality of acute stroke care and outcomes by day and time of admission in London hyperacute stroke units compared with the rest of England.
Design Prospective cohort study using anonymised patient-level data from the Sentinel Stroke National Audit Programme.
Setting Acute stroke services in London hyperacute stroke units and the rest of England.
Participants 68 239 patients with a primary diagnosis of stroke admitted between January and December 2014.
Interventions Hub-and-spoke model for care of suspected acute stroke patients in London with performance standards designed to deliver uniform access to high-quality hyperacute stroke unit care across the week.
Main outcome measures 16 indicators of quality of acute stroke care, mortality at 3 days after admission to the hospital, disability at the end of the inpatient spell, length of stay.
Results There was no variation in quality of care by day and time of admission to the hospital across the week in terms of stroke nursing assessment, brain scanning and thrombolysis in London hyperacute stroke units, nor was there variation in 3-day mortality or disability at hospital discharge (all p values>0.05). Other quality of care measures significantly varied by day and time of admission across the week in London (all p values<0.01). In the rest of England there was variation in all measures by day and time of admission across the week (all p values<0.01), except for mortality at 3 days (p value>0.05).
Conclusions The London hyperacute stroke unit model achieved performance standards for ‘front door’ stroke care across the week. The same benefits were not achieved by other models of care in the rest of England. There was no weekend effect for mortality in London or the rest of the England. Other aspects of care were not constant across the week in London hyperacute stroke units, indicating some performance standards were perceived to be more important than others.
- health economics
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Contributors MM, SM, NJF, RS, MMB and AIGR designed the study. MM and SM carried out the statistical analysis of data and SM drafted the manuscript. MM, SM, NJF, RS, MMB, AIGR and GB made substantial contributions to the interpretation of the findings. MM, SM, NJF, RS, MMB, AIGR, JE, AR and AB-L contributed to the drafting of the article or critical revision for important intellectual content, gave final approval of the version to be published and agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the article are appropriately investigated and resolved.
Funding This paper presents independent research commissioned by the National Institute for Health Research (NIHR) Health Services and Delivery Research Programme, funded by the Department of Health and Social Care (study reference 12/128/41 : Mixed methods analysis of the London Hyperacute Stroke System: identifying lessons on 24/7 working (METRO-24/7)). Robert Simister is supported by the National Institute for Health Research University College London Hospitals Biomedical Research Centre. Stephen Morris and Naomi J Fulop were supported by the NIHR Collaboration for Leadership in Applied Health Research and Care (CLAHRC) North Thames at Bart’s Health NHS Trust and NJF is an NIHR Senior Investigator. Mariya Melnychuk was supported by the Madrid Community Talent Attraction Fellowship (2017-T2/SOC-5379). Martin M Brown’s Chair in Stroke Medicine is supported by the Reta Lila Weston Trust for Medical Research. This work was undertaken at University College London, which received a proportion of funding from the UK Department of Health and Social Care’s National Institute for Health Research Biomedical Research Centres funding scheme. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.
Data sharing statement For this study we obtained anonymised patient-level data from the Sentinel Stroke National Clinical Audit Programme (SSNAP). No raw data is available for publication.
Patient consent for publication Not required.
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