Stroke patients miss out on vital care

Last year, a report by the National Audit Office (NAO) concluded that the Department of Health’s strategy for stroke care has increased the priority and awareness of the condition and started to improve patients’ care and outcomes. It estimated that a stroke patient’s chances of dying within ten years have been reduced from 71% to 67% since 2006. Nevertheless, the NAO found that improvements are not universal, and progress in follow-up care continues to lag behind acute care services. Further data have now come to light, with the publication of additional audits, which highlight the need for improvement in a number of key areas of stroke care. Patients with symptoms of stroke or transient ischemic attack (TIA or “mini stroke”) are missing out on life-saving treatment because they fail to recognise the symptoms – according to the UK Audit of Vascular Surgical Services and Carotid Endarterectomy.1 Moreover, when the symptoms of TIA are recognised, patients are routinely treated as low priority cases in the NHS. The audit, commissioned by the Healthcare Quality Improvement Partnership (HQIP) as part of the National Clinical Audit and Patient Outcomes Programme, has prompted surgeons to call for an urgent review of vascular services. Ensuring that these high risk patients are fast-tracked into hospital (in the same way as potential heart attack patients) would avoid hundreds of avoidable deaths, each year.

Evidence shows that patients with classic symptoms of TIA – i.e. facial or arm weakness, speech problems and blurred vision – are at risk of having a severe stroke if they do not receive surgery of the neck arteries (carotid endarterectomy or CEA) as soon as possible, ideally within 48 hours, but no longer than 14 days. However, a lack of public awareness of the symptoms of TIA, combined with poor professional understanding of treatment and referral options, mean that instead of being treated as emergency cases at the first sign of symptoms, thousands of patients are waiting weeks, or sometimes months, for an operation that may be of no benefit by the time they receive it. In practical terms, if patients undergo surgery within two weeks, experts predict that around 200 strokes could be prevented for every 1,000 operations. The National Institute for Health and Clinical Excellence (NICE) sets a timeframe of two weeks from symptoms to surgery, while the Government’s National Stroke Strategy (NSS) target is 48 hours. The audit shows that only 3% of patients made the NSS guideline and approximately a third of patients made the NICE guideline of 14 days. Currently, the average wait from symptom to surgery is 28 days and referral to surgery is 19 days. Most delays in meeting the two week target relate to presentation and referral, with 18% of patients failing to present to a GP or hospital and 40% not being referred on from primary care. However, 18% of patients missed the deadline due to the limited availability of staff or operating time and 9% due to a lack of imaging equipment, prompting surgeons to call for an immediate review of the organisation of vascular services.

The audit report also looks at the wider issue of vascular surgical services and highlights significant regional variations in the quality of vascular care provision for CEA and four other conditions, including Abdominal Aortic Aneurysm surgery (AAA) and leg amputation. Vascular surgeons recommended that, to ensure patients are receiving the highest quality care, centralisation of some services will be necessary. Low volume centre hospitals will also need to create vascular networks, merging with other centres in order to ensure that the full range of vascular services, specialist staff, clinics and facilities are available 24 hours a day, 7 days a week. UK surgeons currently carry out the lowest number of CEAs per head of population in the developed world, ten times fewer than in Australia and the US. Of the estimated 10,000 patients per year who might benefit from carotid endarterectomy only 4,500 operations are performed annually in the UK. Stroke is a preventable and treatable disease and with better recognition of people at highest risk, early surgical intervention can significantly reduce the incidence and severity of stroke.