Low Priority 'Brain Attack' Patients Missing Out On Life-Saving Surgery

Main Category: Stroke
Also Included In: Neurology / Neuroscience
Article Date: 08 Jun 2009 - 5:00 PDT

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Patients with symptoms of stroke or transient ischemic attack (TIA or brain attack) are missing out on potentially life saving treatment because they are routinely considered by the NHS as low priority cases. Instead of being fast-tracked into hospital for surgery the vast majority of patients are spending weeks and sometimes months on poorly managed referral pathways with the risk of going on to have more severe strokes.

A joint audit commissioned by the Healthcare Quality Improvement Partnership (HQIP) and carried out by the Royal College of Physicians and the Vascular Society, published on the BMJ website, shows that these patients experience unacceptable delays; from the onset of symptoms, to diagnosis and GP referral to investigation to surgery. The report also highlights significant variations in quality of care provision across the UK and a complete lack of cohesive referral pathways in most hospital Trusts.

Firm evidence exists that shows timely surgery of the neck arteries (Carotid Endarterectomy or CEA) for those experiencing symptoms of TIA, can prevent a major stroke, but the vast majority of patients are receiving treatment far too late too make a difference.

The most comprehensive study of CEA of its kind looking at 56% of operations carried out between 2005-7 shows that over 90% of patients failed to meet the standard set by the Department of Health's National Stroke Strategy of 48 hours from symptoms to the operating theatre, and 80% failed to meet the two week standard set by NICE. Over 30% of patients waited over 12 weeks for an operation. At this point benefits are minimal and the opportunity to prevent early stroke is gone.

Every year in the UK, approximately 120,000 people have a stroke and 20-30% dies within a month. Stroke is also the single largest cause of significant adult disability, with nearly a million people living with the after-effects of stroke, a third of them having long-term disability. Stroke costs the economy £7 billion yearly and £2.8bn in direct hospital care. Outcomes have been poor compared with other European countries and the UK carries out the lowest number of CEAs per head of population in the developed world, ten times fewer than in Australia and the USA. 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.

All clinicians would like to see CEA regarded as an operation which should be performed as rapidly as possible and would like to see appropriate vascular surgical services funded and reorganised to achieve this. This will require more qualified vascular surgeons, better organisation of rotas with weekend operating and an increase in funding on a par with cancer services in order to provide better and safer care.

Consultant vascular surgeon, Mr Tim Lees said: "Symptoms of stroke need to be taken more seriously. If a person has a heart attack the standard procedure is to get them into an ambulance and to hospital as quickly as possible, whereas if you have a brain attack (TIA or stroke) it may take weeks for you to be referred to a relevant specialist. This is simply not good enough. These patients need to be fast tracked through the emergency system and treated at the same level of priority as patients with other life threatening illnesses. If a patient is exhibiting symptoms of stroke they should be investigated and treated as quickly as possible."

Tony Rudd, Associate Director, Royal College of Physicians' Clinical Effectiveness and Evaluation Unit, and Chair of the Intercollegiate Stroke Working Party said: "Urgent treatment is needed for many people after a TIA to prevent the development of a major stroke. This study shows that services are not yet organised well enough to deliver the standards of care set out in the National Stroke Strategy and the NICE Acute Stroke and TIA guidelines and as a result there will be people having unnecessary strokes."

Jonothan Earnshaw, Honorary Secretary of the Vascular Society of Great Britain and Ireland said: "In the last couple of years vascular specialists in the UK and Ireland have recognised the need to treat patients with carotid disease more urgently. In many larger hospitals surgeons already work together to provide this service, but this is much more difficult for surgeons working in smaller district hospitals. Whereas some of the solution to this problem lies in redesign of existing pathways, a comprehensive service for urgent carotid surgery is unlikely to occur without centralisation of vascular services, or the creation of formal networks of specialists working together. The Vascular Society calls for funding to help achieve reorganisation of vascular services."

Robin Burgess, Chief Executive of the Healthcare Quality Improvement Partnership (HQIP) said: "The CEA Audit highlights the need to address the shortfalls in care. As with many HQIP commissioned national clinical audits, there is evidence that implementation of the practice changes identified could saves lives. There is urgent need for clinicians to review practice as a result of audit, and for commissioners to check that audit recommendations are being put into place."

Source
Royal College of Physicians