While a lack of provision in stroke rehabilitation is failing to capitalise on the significant improvements to acute treatment over the last decade, the advent of Integrated Care Systems presents an opportunity to redress this imbalance, says Mike Farrar, former chief executive of the NHS Confederation
The stroke pathway has seen such significant improvements over the last decade with the introduction of hyperacute stroke units, improved brain-imaging, rapid thrombolysis and the game-changing thrombectomy.
However, are we devaluing these interventions by failing to recognise the opportunities which help people to return to productive lives after a stroke?
In an area of healthcare which used to be seen as a life-or-death situation, the chances of surviving a stroke are significantly better than before, with the UK mortality rate halving over 20 years. Yet, the long-term outlook for these patients remains poor with the five-year survival rates remaining low.
The Stroke Association estimates that 100,000 people have a stroke in the UK every year, with two thirds of survivors leaving hospital with a disability. We currently have 1.2million stroke survivors living in the UK, at an estimated cost to the health and care sector of £26billion a year. This cost is expected to triple by 2035.
The provision of rehabilitation is an essential element of the care pathway yet is often the least well supported and resourced. When we look at service developments and national standards, the area of the pathway lacking is always after care and rehabilitation.
This is not unique to the UK and our colleagues in the USA are experiencing similar issues. Once a patient has left an acute situation, where the latest interventions, medications and technological advancements have been provided, the same level of attention just isn’t there post-discharge.
One would argue that the early supported discharge packages show great gains for rehabilitation and support, but I think everyone would agree: this is where the intensity of care stops. Once a patient is discharged from health, we can often see a marked deterioration in their wellbeing with an undetermined longer-term impact.
There is an underlying mindset within the system that the priority lies with the acute care management and what happens after is less important.
As a system, we respond exceptionally well in crisis, and focus innovation and resource at this stage of patient’s journey. But there is very little strategy – and we continue on the funding treadmill in front of us by continually investing in acute interventions. But it is clear that the cost benefit doesn’t help if we don’t take a more strategic view of the whole care pathway.
The failure to provide effective rehabilitation immediately after the acute episode, can lead to reduced functioning mobility and normal life for the individual. The consequence of this failure is added cost for the health and care system, reduced economic productivity and can increase social care costs if it leads to patients losing their ability to live independently.
This can also lead to more frequent emergency trips to hospital for related symptoms such as falls or secondary strokes. But the data currently collected may identify re-admitted patient episodes as a new case rather than allowing the system to recognise and then count it as a re-admission. This often masks the failure of the rehabilitation and ongoing support offered which could have prevented further problems.
The link to co-morbidities is also missing with more people dying in the first six months after a stroke from cardiac events, rather than consequences of a stroke – which means we are overlooking opportunities to influence outcomes in other ways.
The cost of high-quality rehabilitation may pay itself back over time but immediate cost pressures in the system can often mean that rehabilitation is not funded as a priority, which in turn reduces patient outcomes.
So where do we go from here? The key to getting the balance is to argue the need for data and the evidence to build up the business case. We are seeing some professionals and clinicians leading the charge and looking for that evidence to balance the funding model.
The Mount Sinai health system in the USA recruited a randomly selected sample of people who were enrolled in a remote monitoring programme. Of the sample, 90 per cent had a crisis that the health system could have intervened on. Without the follow-up, these crises would never have been caught.
In Cardiff and Vale, they’re currently trialling a system that joins up the data to the patient – rather than the episode – to track the re-admissions and how that plays out. The data outcomes are providing interesting insights into chronic conditions and helping to modify their understanding of where they put their money.
We are also seeing a role for digital platforms to be used for virtual rehabilitation. There are many ways to do this and the growth of digital care technology in local authorities should be used to support and endorse these changes across the whole health and care system. As an example, Visionable’s platform allows any deterioration to be identified early and prevent serious problems occurring. As people wait longer for care, this early warning is crucial to avoid patient harm.
Furthermore, all these actions will help reduce re-admissions which will also make a major contribution to optimising the NHS and care capacity we need to deliver elective recovery.
I believe there is a real opportunity here for us to shift the way we approach rehabilitation pathways, and how we track impacts so we can begin to count effectively. And this dialogue should really appeal to the new Integrated Care Systems and their Integrated Care Boards as we embark on our new NHS structures in 2022.
Through system-wide commissioning, there is the opportunity to balance the investment and provide transformation – and to use one provider to deliver a whole pathway, including more robust rehabilitation services.
By enhancing the data capture in real time and making sure the money follows the patient, we could really see a marked difference – not only in our public purse, but in the quality of people’s lives.
This could be the start of an ambitious new programme and I would encourage clinical and professional leaders to get on board.
‘Screen for loneliness in stroke survivors’
Calls come after a first-of-its-kind study reveals at least one in three people are living with clinical levels of loneliness post-stroke
At least one in three stroke survivors are living with clinical levels of loneliness, a new study has found, prompting calls for clinicians to routinely screen for such a situation and devise a bespoke solution for each patient.
The research, the first large-scale study of its kind, revealed that stroke survivors are at least 70 per cent more likely than the general population to experience loneliness.
Prevalence rates of loneliness among survivors ranged from 30 to 44 per cent, with levels of anxiety and depression – both of which are recognised as psychological consequences of stroke and are routinely screened for in clinical assessment – at 25 per cent and 30 per cent respectively.
The study, from the University of Bangor, revealed that many who are not objectively socially isolated may experience high levels of loneliness. This suggests that it’s the individual’s subjective experience of their social situation that is important, rather than the quantity of social contact.
Calls have now been made for greater recognition of loneliness as a consequence of stroke, and for action to be taken to give appropriate support to each person affected.
“Clinicians need to start thinking about the whole profile of the person cognitively, taking into account their pre-stroke personality and who they are, rather than ‘one size fits all’ approach of peer support or social groups, which is unlikely to always be the answer,” says Dr Christopher Byrne, who led the study and whose work received the 2021 British Neuropsychological Society Humphreys & Riddoch Prize.
“The findings suggest that one in three people who come into the clinical room are suffering from loneliness and that’s really quite heartbreaking. We need to screen for loneliness and think about how to make interventions on an individual basis.”
The research team, including Dr Richard Ramsey from Macquarie University, Sydney, Australia, analysed ONS data from 21,874 people in Wales between 2016 and 2018, of whom 244 had a history of stroke – a percentage broadly replicated among the wider UK population.
The findings that up to 44 per cent of those with a history of stroke reporting they are lonely marks a three-fold increase on studies looking at loneliness among the general population, and double the level seen in general primary care outpatients.
The fact loneliness exceeded instances of depression and anxiety is a significant finding, says Dr Byrne, who also works in the North Wales Brain Injury Service.
“I started to recognise that loneliness was a very common problem for people with ABI. While clinicians routinely assess for anxiety and depression, no-one asks whether someone is feeling lonely,” he says.
“This was a common occurrence in the clinical room, but the support just isn’t there. This is why I wanted to do this research. In the NHS, we get people along to social groups and peer support, but I think the research helps to show the need for more tailored intervention.
“The fact that we found people can be lonely even in an environment with a lot of social contact, which is very different to social isolation, and presents the challenge of how can we help in these situations?
“This helps to show that interventions should target greater quality rather than quantity, and they need to be determined individually taking into account the holistic picture of the patient.”
Dr Rudi Coetzer, clinical director at The Disabilities Trust and honorary professor at Bangor University, supervised Dr Byrne’s research.
”This novel research utilising big data helps to make more visible the profound loneliness many persons with stroke experience and reminds us of the importance of considering in greater depth the emotional lives of those we care for after brain injury,” he said.
Anger and upset ‘can trigger stroke’
Physical exertion can also be significant in the immediate run-up to a stroke, the INTERSTROKE study has found
Anger, upset and physical exertion can all be factors in triggering stroke, a global study has found.
The INTERSTROKE research, which looks into causes of stroke, revealed one in 11 survivors had experienced a period of anger or upset in the hour leading up to it.
Furthermore, one in 20 patients had engaged in heavy physical exertion.
INTERSTROKE, the largest research project of its kind, analysed 13,462 cases of acute stroke, involving patients with a range of ethnic backgrounds in 32 countries around the world.
“Our research found that anger or emotional upset was linked to an approximately 30 per cent increase in risk of stroke during one hour after an episode – with a greater increase if the patient did not have a history of depression,” said Professor Andrew Smyth, professor of clinical epidemiology at NUI Galway – which co-led the study – director of the HRB-Clinical Research Facility Galway and a consultant nephrologist at Galway University Hospitals.
“The odds were also greater for those with a lower level of education.
“We also found that heavy physical exertion was linked to an approximately 60 per cent increase in risk is of intracerebral haemorrhage during the one hour after the episode of heavy exertion.
“There was a greater increase for women and less risk for those with a normal BMI.
“The study also concluded that there was no increase with exposure to both triggers of anger and heavy physical exertion.”
The research analysed patterns in patients who suffered ischemic stroke – the most common type of stroke, which occurs when a blood clot blocks or narrows an artery leading to the brain – and also intracerebral haemorrhage, which is less common and involves bleeding within the brain tissue itself.
Co-author of the paper, Dr Michelle Canavan, consultant stroke physician at Galway University Hospitals, said: “Our message is for people to practice mental and physical wellness at all ages.
“But it is also important for some people to avoid heavy physical exertion, particularly if they are high-risk of cardiovascular, while also adopting a healthy lifestyle of regular exercise.”
The global INTERSTROKE study was co-led by Professor Martin O’Donnell, professor of neurovascular medicine at NUI Galway, and consultant stroke physician at Galway University Hospitals, in collaboration with Prof Salim Yusuf of the Population Health Research Institute of McMaster University and Hamilton Health Sciences, Canada.
“Some of the best ways to prevent stroke are to maintain a healthy lifestyle, treat high blood pressure and not to smoke, but our research also shows other events such as an episode of anger or upset or a period of heavy physical exertion independently increase the short-term risk,” Prof O’Donnell said.
“We would emphasise that a brief episode of heavy physical exertion is different to getting regular physical activity, which reduces the long-term risk of stroke.”
1 in 100 COVID patients develop brain conditions
A new study reveals the risk of stroke, haemorrhage or encephalitis as a result of the virus
Around one in 100 patients hospitalised with COVID-19 will develop brain conditions including stroke and haemorrhage as a result of the virus, the largest multi-site study to date has found.
The multi-institutional research investigated brain complications of COVID and found that complications of the central nervous system can occur in one in 100 people.
“Much has been written about the overall pulmonary problems related to COVID-19, but we do not often talk about the other organs that can be affected,” said study lead author Dr Scott H. Faro, professor of radiology and neurology and director of the division of neuroradiology/head and neck imaging at Thomas Jefferson University in Philadelphia.
“Our study shows that central nervous system complications represent a significant cause of morbidity and mortality in this devastating pandemic.”
The most common complication was ischemic stroke, with an incidence of 6.2 per cent, followed by intracranial haemorrhage (3.72 per cent) and encephalitis (0.47 per cent), an inflammation of the brain.
Dr Faro initiated the study after discovering that existing literature on central nervous system complications in hospitalised COVID-19 infected patients was based on a relatively small number of cases.
To derive a more complete picture, he and his colleagues analysed nearly 40,000 cases of hospitalised COVID-19 positive patients from seven US and four western European university hospitals.
The patients had been admitted between September 2019 and June 2020. Their average age was 66 years old, and there were twice as many men as women.
The most common cause of admission was confusion and altered mental status, followed by fever. Many of the patients had co-morbidities like hypertension, cardiac disease and diabetes.
There were 442 acute neuroimaging findings that were most likely associated with the viral infection. The overall incidence of central nervous system complications in this large patient group was 1.2 per cent.
“Of all the inpatients who had imaging such as MRI or a CT scan of brain, the exam was positive approximately ten per cent of the time,” Dr Faro said.
“The incidence of 1.2 per cent means that a little more than one in 100 patients admitted to the hospital with COVID-19 are going to have a brain problem of some sort.”
The researchers also discovered a small percentage of unusual findings, such as acute disseminating encephalomyelitis, an inflammation of the brain and spinal cord, and posterior reversible encephalopathy syndrome, a syndrome that mimics many of the symptoms of a stroke.
“It is important to know an accurate incidence of all the major central nervous system complications,” Dr Faro said.
“There should probably be a low threshold to order brain imaging for patients with COVID-19.”
The study is being presented at the annual meeting of the Radiological Society of North America (RSNA).
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