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After the onset of stroke symptoms, much disability and death can be prevented by ensuring immediate access to effective specialist assessment and treatment. Our work on improving pathways of care in acute stroke has included research on raising public awareness of stroke, so that people seek emergency medical advice promptly, and research and development on emergency medical services' skills and practice. The findings of this research have led to impacts on clinical care and health services practice via inclusion in national and international clinical guidelines and training, improvements in the recognition of stroke, and reduced pre-hospital delays and time to emergency department diagnosis. Such improvements are known to reduce death and disability from stroke.
Research in Oxford by Rothwell and colleagues since 2000 has radically changed how minor strokes and transient ischaemic attacks (TIAs) are managed. First, the risk of a major stroke in days after a minor stroke/TIA was found to be much higher than thought. In consequence, these `warning' events were rebranded as a medical emergency in clinical guidelines. Second, Rothwell showed that a delay in treating individuals at high risk of major stroke substantially reduced the benefits. Third, the Rothwell group developed a simple risk score (`ABCD system') to triage high-risk individuals, showing that more urgent treatment reduced the 90-day risk of major stroke by 80%. This strategy has been implemented in the National Stroke Strategy and NICE and international guidelines. In the UK it is estimated to prevent 10,000 strokes per year, and to save the NHS £200 million in acute care costs alone.
Worldwide, around 5 million stroke-related deaths occur annually, while another 5 million people are left with chronic disabilities following strokes. University of Glasgow research demonstrated that admission to a specialist stroke unit significantly improves patients' chances of survival and recovery. This discovery transformed the culture of stroke service delivery in the UK. These studies drove the development of new advice in national and international clinical practice guidelines and promoted the implementation of NHS healthcare targets and audit activities to standardise and evaluate the quality of stroke care. In the UK, the early death rate after stroke has fallen from over 45% to under 30% in the past 20 years; at least one-fifth of that decline is attributed to the introduction of stroke units.
Forster, House and Young have played a leading role in establishing the importance of long-term psychological and social distress after stroke, shifting the clinical emphasis (and evidence base) in stroke care from a limited focus on physical recovery to acceptance of the importance of psychological and social factors. Evidence we have generated has informed the stroke care pathway in national and international clinical guidelines that influence stroke service delivery, by providing guidance to clinical teams on psychological treatments after stroke and information provision. In tandem we have developed the methodology of stroke rehabilitation research, involving clinical staff in delivery of multi-site studies and thereby enhancing evidenced-based stroke care.
Stroke is a major health burden to patients, carers and the NHS, with UK costs estimated at £15.5bn annually. Clot-busting agents (thrombolytics) can substantially improve the consequences of ischaemic stroke, but only if administered rapidly. Newcastle research that recognised the importance of rapid referral to a stroke unit allowed reconfiguration of ambulance services for direct transport of victims to a specialised centre. Newcastle work also validated a test developed for paramedics to recognise the signs of stroke, which was developed as the nationwide Face-Arms-Speech-Time (Act FAST) campaign. Use of thrombolytics has increased eightfold between 2005 and 2012, and there has been a considerable increase in public awareness of FAST.
Stroke affects 15 million people globally and is a leading cause of death and adult physical disability. King's College London (KCL) research has provided the evidence that underpins many of the present day policies, guidelines and clinical practice for stroke care, not only in the UK but also in other countries. KCL research has demonstrated that stroke units are effective and reduce mortality and dependence by 22%. The implementation of these findings in England has increased the number of patients managed on a stroke unit from 18% to 62% between 2000-2012, preventing 550 deaths, enabling 1,700 more patients to make a full recovery and saving £82 million per year.
Stroke is the third most common cause of death and single most important cause of adult disability in the UK, affecting over 150,000 individuals per annum and costing the economy approximately £8 billion annually in health, social and indirect care costs.
High blood pressure (BP) is the most common modifiable risk factor to prevent stroke, but the use of BP-lowering therapy in the acute phase of stroke is controversial. Clinical trials co-ordinated at the University of Leicester have confirmed the safety of continuation of pre-existing BP-lowering therapy in acute stroke and the de novo treatment of high blood pressure in acute intracerebral haemorrhage. This has resulted in changes to the most recent US (2013) and UK (2012) guidelines, which will significantly impact on clinical management of this common clinical problem in acute stroke.
Research by the University of Nottingham's Division of Rehabilitation and Ageing has informed the effective implementation of evidence-based Early Supported Discharge (ESD) and community services for stroke survivors. The findings of an international consensus on the implementation of ESD have played a significant role in shaping local, regional, national and international service specifications. Qualitative and implementation studies have helped to shape better working practices between acute and community stroke services, including joint decision-making on who should be eligible for ESD and ensuring that services derive the full benefits of robust and relevant data capture.
Impact: Health and welfare; saving lives by determining that aspirin is an effective treatment for acute stroke and that heparin anticoagulation is ineffective.
Significance: In the UK, treating all acute stroke patients with aspirin and avoiding heparin means 1800 people avoid death or disability each year; aspirin is also highly cost-effective.
Beneficiaries: Stroke patients, the NHS, the economy.
Attribution: Sandercock, UoE, designed, led and reported the International Stroke Trial, and was on the steering committee of the Chinese Acute Stroke Trial.
Reach: Up to 15M stroke patients annually affected by guideline changes worldwide, encompassing Europe, North America and Australasia; educational events by the World Stroke Academy promote aspirin use.
Impact: Health and welfare; Wardlaw's work on diagnostic imaging in stroke prevention and treatment has effected changes to clinical guidelines worldwide, prevented thousands of strokes and decreased disability.
Significance: In the UK, changes in stroke treatment consequent upon effective imaging result in 6000 more quality-adjusted life-years and save ~£300M per year. Improved stroke prevention averts 1760 strokes and saves the NHS £30M per year.
Beneficiaries: Stroke patients, the NHS and healthcare providers in other countries
Attribution: The research took place entirely at UoE.
Reach: UK, Europe, N. America, Australasia.