Quantifying regional variations in components of acute stroke unit (ASU) care in the international HeadPoST study

Journal article


Ouyang, Menglu, Zhang, Yao, Wang, Xia, Song, Lili, Billot, Laurent, Robinson, Thompson, Lavados, Pablo M., Arima, Hisatomi, Hackett, Maree L., Olavarría, Verónica V., Muñoz-Venturelli, Paula, Middleton, Sandy, Watkins, Caroline L., Pontes-Neto, Octavio M., Lee, Tsong-Hai, Brunser, Alejandro M. and Anderson, Craig S.. (2020) Quantifying regional variations in components of acute stroke unit (ASU) care in the international HeadPoST study. Journal of the Neurological Sciences. 419, p. 117187. https://doi.org/10.1016/j.jns.2020.117187
AuthorsOuyang, Menglu, Zhang, Yao, Wang, Xia, Song, Lili, Billot, Laurent, Robinson, Thompson, Lavados, Pablo M., Arima, Hisatomi, Hackett, Maree L., Olavarría, Verónica V., Muñoz-Venturelli, Paula, Middleton, Sandy, Watkins, Caroline L., Pontes-Neto, Octavio M., Lee, Tsong-Hai, Brunser, Alejandro M. and Anderson, Craig S.
Abstract

Objective
Access to acute stroke unit (ASU) care is known to vary worldwide. We aimed to quantify regional variations in the various components of ASU care.

Method
Secondary analysis of the Head Positioning in acute Stroke Trial (HeadPoST), an international, multicentre, cluster crossover trial of head-up versus head-down positioning in 11,093 acute stroke patients at 114 hospitals in 9 countries. Patients characteristics and 11 standard components of processes of care were described according to ASU admission within and across four economically-defined regional groups (Australia/UK, China [includes Taiwan], India/Sri Lanka, and South America [Brazil/Chile/Colombia]). Variations in process of ASU care estimates were obtained in hierarchical mixed models, with adjustment for study design and potential patient- and hospital-level confounders.

Results
Of 11,086 patients included in analyses, 59.7% (n = 6620) had an ASU admission. In China, India/Sri Lanka and South America, ASU patients were older, had greater neurological severity and more premorbid conditions than non-ASU patients. ASU patients were more likely to receive reperfusion therapy and multidisciplinary care within regions, but the components of care varied across regions. With Australia/UK as reference, patients in other regions had a lower probability of receiving reperfusion therapy, especially in India/Sri Lanka (adjusted odds ratio [aOR] 0.27, 95% confidence interval [CI] 0.12–0.63) and multidisciplinary care (mainly in formal dysphagia assessment, physiotherapy and occupational therapy).

Conclusion
There is significant variation in the components of stroke care across economically-defined regions of the world. Ongoing efforts are required to reduce disparities and optimise health outcomes, especially in resource poor areas.

Clinical trial registration
HeadPoST is registered at ClinicalTrials.gov (NCT02162017).

Keywordsstroke units; care; international; clinical trial; outcome; acute stroke
Year2020
JournalJournal of the Neurological Sciences
Journal citation419, p. 117187
PublisherElsevier BV
ISSN0022-510X
Digital Object Identifier (DOI)https://doi.org/10.1016/j.jns.2020.117187
Scopus EID2-s2.0-85092699001
Open accessPublished as ‘gold’ (paid) open access
Research or scholarlyResearch
Page range1-6
FunderNational Health and Medical Research Council
Publisher's version
License
File Access Level
Open
Output statusPublished
Publication dates
Online14 Oct 2020
Publication process dates
Accepted10 Oct 2020
Deposited10 Jun 2021
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Sutton, C, Watkins, Caroline, Cook, N, Leathley, M, McAdam, J and Dey, P. (2013) Postal and face-to-face administration of stroke outcome measures : Can mixed modes be used? Stroke: a journal of cerebral circulation. https://doi.org/10.1161/STROKEAHA.112.671743
Training emergency services' dispatchers to recognise stroke: An interrupted time-series analysis
Watkins, Caroline, Leathley, Michael, Jones, Susanne, Ford, Gary, Quinn, Tom and Sutton, Chris. (2013) Training emergency services' dispatchers to recognise stroke: An interrupted time-series analysis. BMC Health Services Research. 13(318), pp. 1 - 9. https://doi.org/10.1186/1472-6963-13-318
'is he awake?' : Dialogues between callers and call handlers about consciousness during emergency calls for suspected acute stroke
Gibson, J, Bullock, M, Ford, G, Jones, Susanne, Leathley, M, McAdam, J, Quinn, T and Watkins, Caroline. (2013) 'is he awake?' : Dialogues between callers and call handlers about consciousness during emergency calls for suspected acute stroke. Emergency Medicine Journal. https://doi.org/10.1136/emermed-2012-201195
The identification of acute stroke : An analysis of emergency calls
Jones, Susanne, Carter, B, Ford, G, Gibson, J, Leathley, M, McAdam, J, O'Donnell, Maryanne, Punekar, S, Quinn, T and Watkins, Caroline. (2013) The identification of acute stroke : An analysis of emergency calls. International Journal of Stroke. https://doi.org/10.1111/j.1747-4949.2011.00749.x
The challenges of implementing a telestroke network: A systematic review and case study
French, Beverley, Day, Elaine, Watkins, Caroline, McLoughlin, Alison, Fitzgerald, Jane, Leathley, Michael, Davies, Paul, Emsley, Hedley, Ford, Gary and Jenkinson, Damian. (2013) The challenges of implementing a telestroke network: A systematic review and case study. BMC Medical Information and Decision Making. 13(125), pp. 1 - 9. https://doi.org/10.1186/1472-6947-13-125
The use of formal and informal knowledge sources in patients' treatment decisions in secondary stroke prevention : Qualitative study
Gibson, J and Watkins, Caroline. (2013) The use of formal and informal knowledge sources in patients' treatment decisions in secondary stroke prevention : Qualitative study. Health Expectations. https://doi.org/10.1111/j.1369-7625.2011.00724.x
Illustrating problems faced by stroke researchers : A review of cluster-randomized controlled trials
Sutton, C, Watkins, Caroline and Dey, P. (2013) Illustrating problems faced by stroke researchers : A review of cluster-randomized controlled trials. International Journal of Stroke. https://doi.org/10.1111/j.1747-4949.2012.00915.x
Using telemedicine for acute stroke assessment
Gibson, J, Fitzgerald, Jenny, Gibson, A, McAdam, J, Lightbody, L, McLoughlin, A, Watkins, Caroline and Day, E. (2013) Using telemedicine for acute stroke assessment. Nursing Times.
Clinical effectiveness, cost-effectiveness and service users' perceptions of early, well-resourced communication therapy following a stroke : A randomised controlled trial (the ACT NoW study)
Bowen, A, Hesketh, A, Patchick, E, Young, A, Davies, Lauren, Vail, A, Long, A, Watkins, Caroline, Wilkinson, Michael David and Pearl, G. (2012) Clinical effectiveness, cost-effectiveness and service users' perceptions of early, well-resourced communication therapy following a stroke : A randomised controlled trial (the ACT NoW study). Health Technology Assessment. 16(26), pp. 1 - 159. https://doi.org/10.3310/hta16260
People's experiences of the impact of transient ischaemic attack and its consequences : Qualitative study
Gibson, J and Watkins, Caroline. (2012) People's experiences of the impact of transient ischaemic attack and its consequences : Qualitative study. Journal of Advanced Nursing. 68(8), pp. 1707 - 1715. https://doi.org/10.1111/j.1365-2648.2011.05849.x
Stroke management : Updated recommendations for treatment along the care continuum
Wright, Leah, Hill, Kelvin M., Bernhardt, Julie, Lindley, Richard, Ada, Louise, Bajorek, Beata V., Barber, P. Alan, Beer, Christopher, Golledge, Jonathon, Gustafsson, L., Hersh, D., Kenardy, J., Perry, L., Middleton, S., Brauer, S. G. and Nelson, M. R.. (2012) Stroke management : Updated recommendations for treatment along the care continuum. Internal Medicine Journal. 42(5), pp. 562 - 569. https://doi.org/10.1111/j.1445-5994.2012.02774.x
Doing the simple things well
Middleton, Sandy. (2012) Doing the simple things well. Royal College of Nursing Australia. 19(2), pp. 65-66. https://doi.org/10.1016/j.colegn.2012.04.001
Hi4D-ADSiP 3-D dynamic facial articulation database
Matuszewski, B, Quan, W, Shark, L, McLoughlin, A, Lightbody, C, Emsley, H and Watkins, Caroline. (2012) Hi4D-ADSiP 3-D dynamic facial articulation database. Image and Vision Computing. 30(10), pp. 713 - 727. https://doi.org/10.1016/j.imavis.2012.02.002
Effectiveness of enhanced communication therapy in the first four months after stroke for aphasia and dysarthria : A randomised controlled trial
Bowen, Audrey, Hesketh, Anne, Patchick, Emma, Young, Alys, Davies, Linda, Vail, Andy, Long, Andrew, Watkins, Caroline, Wilkinson, Michael David, Pearl, Gill, Ralph, Matthew A. Lambon and Tyrrell, Pippa. (2012) Effectiveness of enhanced communication therapy in the first four months after stroke for aphasia and dysarthria : A randomised controlled trial. British Medical Journal. 345(e4407), pp. 1 - 15. https://doi.org/10.1136/bmj.e4407
Callers' experiences of making emergency calls at the onset of acute stroke : A qualitative study
Jones, Stephanie, Dickinson, H, Ford, G, Gibson, J, Leathley, M, McAdam, J, McLoughlin, A, Quinn, T and Watkins, Caroline. (2012) Callers' experiences of making emergency calls at the onset of acute stroke : A qualitative study. Emergency Medicine Journal. 29(6), pp. 502 - 505. https://doi.org/10.1136/emj.2010.108563
Improving quality of life by increasing outings after stroke : Study protocol for the Out-and-About trial
McClusky, Annie, Ada, Louise, Middleton, Sandy, Kelly, Patrick J., Goodall, Stephen, Grimshaw, Jeremy M., Logan, Pip, Longworth, Mark and Karageorge, A.. (2012) Improving quality of life by increasing outings after stroke : Study protocol for the Out-and-About trial. International Journal of Stroke. 8(1), pp. 54-58. https://doi.org/10.1111/j.1747-4949.2012.00966.x
Authors' reply to Enderby, Meteyard, and Thornton
Bowen, Audrey, Hesketh, Anne, Patchick, Emma, Young, Alys, Davies, Linda, Vail, Andy, Long, Andrew F., Watkins, Caroline, Wilkinson, Mo, Pearl, Gill, Ralph, Matthew A. and Tyrrell, Pippa. (2012) Authors' reply to Enderby, Meteyard, and Thornton. BMJ: British Medical Journal. 345(7874), pp. 1 - 2. https://doi.org/10.1136/bmj.e6023
Mapping vocational rehabilitation services for people with long term neurological conditions: Summary report
Playford, E, Radford, K, Burton, C, Gibson, A, Sweetland, J and Watkins, Caroline. (2011) Mapping vocational rehabilitation services for people with long term neurological conditions: Summary report United Kingdom: Department of Health.
The UK forum for stroke training and the stroke-specific education framework
Watkins, Caroline, Barron, Tracey, Davis, David, Hatton, Steve, Jenkinson, D, Jones, Stephanie, Price, Chris, South, Adrian, Quinn, T and Leathley, M. (2011) The UK forum for stroke training and the stroke-specific education framework. Journal of Paramedic Practice. 3(9), pp. 481 - 482. https://doi.org/10.12968/jpar.2011.3.9.481
Study protocol :iCONS: identifying continence options after stroke: A randomised trial
Thomas, Lois, Watkins, Caroline, French, B, Sutton, C, Forshaw, D, Cheater, F, Roe, B, Leathley, M, Burton, C, McColl, E and Booth, J. (2011) Study protocol :iCONS: identifying continence options after stroke: A randomised trial. Trials. 12, pp. 1 - 10. https://doi.org/10.1186/1745-6215-12-131
The 12-month effects of early motivational interviewing after acute stroke :A randomized controlled trial
Watkins, Caroline, Wathan, J, Leathley, M, Auton, M, Deans, Carol, Dickinson, H, Jack, Cathy, Sutton, C, Van Den Broek, M and Lightbody, C. (2011) The 12-month effects of early motivational interviewing after acute stroke :A randomized controlled trial. Stroke: a journal of cerebral circulation. 42(7), pp. 1956 - 1961. https://doi.org/10.1161/STROKEAHA.110.602227
Combined conservative interventions for urge, stress or mixed incontinence in adults (protocol)
French, Beverley, Thomas, Lois H., Sutton, Christopher J., Booth, J., Brittain, Katie, Burton, Christopher R., Cheater, Francine, Roe, Brenda, Hay-Smith, E. Jean C., McAdam, J. J. and Watkins, Caroline. (2010) Combined conservative interventions for urge, stress or mixed incontinence in adults (protocol). Cochrane Database of Systematic Reviews. https://doi.org/10.1002/14651858.CD008910
Changing stroke mortality trends in middle-aged people : An age-period-cohort analysis of routine mortality data in persons aged 40 to 69 in England
Sutton, C, Marsden, J, Watkins, Caroline, Leathley, M and Dey, P. (2010) Changing stroke mortality trends in middle-aged people : An age-period-cohort analysis of routine mortality data in persons aged 40 to 69 in England. Journal of Epidemiology and Community Health. 64(6), pp. 523 - 529. https://doi.org/10.1136/jech.2008.086785
Does repetitive task training improve functional activity after stroke? : A Cochrane systematic review and meta-analysis
French, Beverley, Thomas, Lois, Leathley, Michael, Sutton, Christopher, McAdam, Joanna, Forster, Anne, Langhorne, Peter, Price, Chris, Walker, Annette and Watkins, Caroline. (2010) Does repetitive task training improve functional activity after stroke? : A Cochrane systematic review and meta-analysis. Journal of Rehabilitation Medicine. 42(1), pp. 9 - 15. https://doi.org/10.2340/16501977-0473
Very early rehabilitation or intensive telemetry after stroke : A pilot randomised trial
Langhorne, P, Stott, D, Knight, A, Bernhardt, Julie, Barer, D and Watkins, Caroline. (2010) Very early rehabilitation or intensive telemetry after stroke : A pilot randomised trial. Cerebrovascular Diseases. 29(4), pp. 352 - 360. https://doi.org/10.1159/000278931
Does repetitive task training improve functional activity after stroke? : A Cochrane systematic review and meta-analysis
French, Beverley, Thomas, Lois, Leathley, Michael, Sutton, Christopher, McAdam, Joanna, Forster, Anne, Langhorne, Peter, Price, Chris, Walker, Annette and Watkins, Caroline. (2010) Does repetitive task training improve functional activity after stroke? : A Cochrane systematic review and meta-analysis. Journal of Rehabilitation Medicine. 42(1), pp. 9 - 15. https://doi.org/10.2340/16501977-0473
Stroke knowledge and awareness : An integrative review of the evidence
Jones, Susanne, Jenkinson, A, Leathley, M and Watkins, Caroline. (2010) Stroke knowledge and awareness : An integrative review of the evidence. Age and Ageing. 39(1), pp. 11 - 22. https://doi.org/10.1093/ageing/afp196;10.1093/ageing/afp196
Nursing patients with neurological problems
Watkins, Caroline Leigh. (2009) Nursing patients with neurological problems. In In G. Castledine and A. Close (Ed.). Oxford handbook of adult nursing pp. 435 - 484 Oxford University Press. https://doi.org/10.1093/med/9780199231355.003.0013
Repetitive task training for improving functional ability after stroke
French, Beverley, Thomas, Lois H., Leathley, Michael John, Sutton, Christopher J., McAdam, Joanna J., Forster, Anne, Langhorne, Peter J., Price, Christopher I.M., Walker, Andrew and Watkins, Caroline L.. (2009) Repetitive task training for improving functional ability after stroke. Stroke: a journal of cerebral circulation. 40(4), pp. 98 - 99. https://doi.org/10.1161/STROKEAHA.108.519553
Psychological intervention poststroke: ready for action?
Watkins, Caroline and French, Beverley. (2009) Psychological intervention poststroke: ready for action? Stroke. 40(9), pp. 2951 - 2952. https://doi.org/10.1161/STROKEAHA.109.562348
Treatment of stroke: Acting on the symptoms
Jones, Stephanie, Leathley, Michael J. and Watkins, Caroline Leigh. (2008) Treatment of stroke: Acting on the symptoms. Asian Hospital and Healthcare Management.
Treatment of urinary incontinence after stroke in adults (review)
Thomas, Lois H., Cross, S., French, B., Leathley, M. J., Sutton, C. J. and Watkins, Caroline Leigh. (2008) Treatment of urinary incontinence after stroke in adults (review). Cochrane Database of Systematic Reviews. https://doi.org/10.1002/14651858.CD004462.pub3
Engaging service users in the development of stroke services: An action research study
Jones, Stephanie P., Auton, Malcolm F., Burton, Christopher R. and Watkins, Caroline L.. (2008) Engaging service users in the development of stroke services: An action research study. Journal of Clinical Nursing. 17(10), pp. 1270 - 1279. https://doi.org/10.1111/j.1365-2702.2007.02259.x
Acute stroke management: An online course
Jones, Stephanie, McLoughlin, A. and Watkins, Caroline. (2008) Acute stroke management: An online course. Journal of Paramedic Practice: the clinical monthly for emergency care professionals. 3(6), pp. 322 - 326.
Can early onset bone loss be effectively managed in post-stroke patients? An integrative review of the evidence
Marsden, Jenny, Gibson, Lorna Mary, Lightbody, Catherine Elizabeth, Sharma, Anil Kumar, Siddiqi, Mashood and Watkins, Caroline. (2008) Can early onset bone loss be effectively managed in post-stroke patients? An integrative review of the evidence. Age and Ageing. 37(2), pp. 142 - 150. https://doi.org/10.1093/ageing/afm198
A systematic review of repetitive functional task practice with modelling of resource use, costs and effectiveness
French, Beverley, Leathley, Michael John, Sutton, Christopher J., McAdam, Joanna J., Thomas, Lois H., Forster, A., Langhorne, Peter J., Price, Christopher I.M., Walker, Annette and Watkins, Caroline. (2008) A systematic review of repetitive functional task practice with modelling of resource use, costs and effectiveness. Health Technology Assessment. 12(30), pp. 1 - 140. https://doi.org/10.3310/hta12300