Health and Social Care Committee

Inquiry into Stroke Risk Reduction

 

SRR 13 – British Association of Stroke Physicians

 

 

basp@basp.ac.uk

 

Professor Pradeep B Khanna MBE FRCP

 

 

 

 

The National Assembly for Wales

Health and Social Care Committee Inquiry into

Stroke Risk Reduction

 

Submission by the British Association of Stroke Physicians – September 2011

 

 

About us

 

The objective of BASP (The British Association of Stroke Physicians) is to promote the advancement of Stroke Medicine within the United Kingdom.

 

BASP does this by several means including:

 

 

 

 

 

 

Current BASP membership stands at nearly 500 full (consultant grade) and associate (training grade) members from all nations of the UK involved in delivering care and treatment to people with stroke and those at risk of stroke.

 

 

INTRODUCTION

 

BASP is aware that development of stroke services in Wales has been given high priority by the Health Minister.  There has been significant improvement demonstrated over the last 18-24 months in acute stroke care in Wales achieved with only modest additional financial resources.  We understand that a Welsh Stroke Delivery Plan, including Stroke Prevention, is being drafted for the period 2011-2015.

 

What is the current provision of stroke risk reduction services and how effective are the Welsh Government’s policies in addressing any weaknesses in these services?

 

Currently, in Wales, there is no comprehensive stroke risk reduction provision and primary and secondary prevention is undertaken via the General Medical Services (GMS) contract, supported by the Quality and Outcomes Framework (QOF) provided by General Practitioners.  The delivery framework for 2011/12 (published by NHS Wales under their Tier 1 priorities) has highlighted the importance of acute stroke care along with outcome focussed measures for transient cerebral ischaemic attacks (TIA) and early rehabilitation.  However, no specific targets have been identified for stroke prevention: a missed opportunity.  There is still a lack of public awareness and no large scale promotion programmes have been undertaken in Wales.  There is an opportunity to join up services between Primary and Secondary care so as to offer a comprehensive stroke risk reduction service although most areas are offering TIA Outpatient Clinics – still only 5 days/week rather than 7 days/week with no comprehensive plan and lack of resources.  The National Sentinel Organisational Audit UK 2010 revealed that, of the 15 acute hospitals in Wales, only 3 sites (20%) delivered services for the same day assessment and treatment of high risk TIA patients, which is recommended by expert groups and the English Department of Health’s National Stroke Strategy.  Furthermore, the 2010 Audit revealed paucity of consultant stroke physicians and trainees in Wales compared to England.  Similarly, there is lack of clear policy on management of atrial fibrillation.

 

Furthermore, Wales, with its geographical challenges, needs plans which offer interventions and services consistently across both rural and urban areas.  Also, low socio-economic and high unemployment rates leads to inequality and poor life-styles leading to obesity, poor diet, smoking and poor attendances to health services or engagement with preventative health.  New ways of reaching remote communities, perhaps through the increased use of telemedicine, need to be explored.  In particular, there is a need to focus on more preventative and remedial measures to tackle:

 

a. Smoking

b. Hypertension

c. TIA services

d. Pro-active screening and management of atrial fibrillation to prevent strokes

 

As a method of collaborative service improvement that has proved particularly effective in England, Joint Cardiac-Stroke Networks in Wales should be established – each led by a clinical director with a remit of reducing the burden of stroke and heart disease through improving both prevention and treatment, with a ring-fenced budget.

 

 

 

What are your views on the implementation of the Welsh Government’s Stroke Risk Reduction Action Plan and whether action to raise public awareness of the risk factors for stroke has succeeded?

 

The Stroke Risk Reduction Action Plan in Wales focuses on primary prevention and builds upon the work which is already being delivered under the Cardiac NSF and the National Service Framework for Older People in Wales.  In doing so, the Action Plan is not comprehensive and has not stated any action on early detection and treatment of transient cerebral ischaemic episodes or atrial fibrillation.  There is no clear evidence that the public awareness of risk factors for stroke has increased and the implementation is, indeed, very patchy.  Furthermore, even though there is a plan, no resources have been identified.  It is our view that the Action Plan is limited to primary prevention and not specific enough, nor comprehensive enough, for transient cerebral ischaemic episodes and stroke prevention.  More joined-up work is required to reduce risk factors and prevent strokes by:

 

a.         Addressing social and economic factors and healthy life-style, including pro-

            active public awareness programmes;

b.         Specifically identifying and managing vascular risk factors particularly hypertension, hyperlipidaemia and atrial fibrillation;

c.         Seven-day TIA Outpatient Clinics, linked to appropriate neuro-imaging and carotid             endarterectomy services.

 

Lowering the risk

 

Intervention

Relative reduction of stroke

Absolute risk of stroke without treatment over first 2 years

Absolute stroke risk reduction over 2 years

Numbers needed to treat over 2 years to prevent one stroke

Aspirin in sinus rhythm

20

15

 

3

33

Systolic blood pressure lower by 9 mmHg

25

15

4

25

Cholesterol lower by 1.2 mmol/L

25

15

4

25

Carotid endarterectomy for >70% stenosis

40

25

15

7

Warfarin in atrial fibrillation

67

24

16

6

 

References:-

Lancet 1997; 349:1641-49; BMJ 2002; 324:71-86; Lancet 2006; 367 (9523): 1665-73; Hypertens 2006; 24:1413-17; Lancet 2000; 356: 1955-64; Stroke 2004; 35: 1024; BMJ 2001; 322: 321-26; Stroke 2004; 35: 2902-06; New England Journal of Medicine 2005; 352: 1293-1304; New England Journal of Medicine 1991; 325: 445-53; Lancet 2003; 361: 107-16

 

 

What are the particular problems in the implementation and delivery of stroke risk reduction actions?

 

As previously stated, the Stroke Risk Reduction Action Plan in Wales is not comprehensive and there is a lack of coordination and ownership of stroke prevention between Primary and Secondary Care.  Public awareness is still lacking.  The current arrangements for the QOF in primary care do not support the pro-active screening and anticoagulant treatment of people with atrial fibrillation, although the relevant QOF indicators are currently under review with the National Institute for Health and Clinical Excellence (NICE).  TIAs are still not recognised as an emergency and this ignorance and ‘culture’ needs to be tackled.  The most important problem is lack of resources which is hindering the development of a 7-day TIA service, which requires same-day access to carotid artery and brain imaging, and close emergency liaison with vascular surgical centres.

 

 

What evidence exists in favour of an atrial fibrillation screening programme being launched in Wales?

 

Atrial fibrillation (AF) is the commonest cause for sustained heart rhythm disturbance and a major predisposing risk factor for stroke.  The NSF for Wales recognises that AF is associated with a 5-fold increase in risk and severity of stroke and is a major risk factor, especially in older people.  One in every five strokes is attributable to AF and, with an ageing population, the incidence and the prevalence of AF is increasing.  What is more, strokes resulting from AF also tend to be more severe.  The majority of those who do survive are severely disabled such that they are dependent upon another person or persons for at least some of their ordinary daily tasks such as washing, dressing, bathing, feeding and using the lavatory.  The combination of a severe stroke with age over 75 years confers a very high probability of death or severe disability, with a predictive value for such a poor outcome of 96%.

 

It is proposed that AF should be identified as a priority for the NHS in Wales and awareness campaigns in high-risk groups should be undertaken.  Early identification, detection and management are the key to reduce the morbidity and mortality associated with AF and stroke.  For this purpose, pro-active screening programmes should be identified with establishment of a Specialist Clinical Team who would also act as an ‘Atrial Fibrillation champion’ in the Health Board.  Opportunistic screening by the pharmacists and Primary Care teams should be encouraged and incentivised through the QOF, especially in patients with other risk factors such as diabetes, hypertension or heart failure and also among those patients who receive the annual ‘flu vaccination in the GP surgery.  Dedicated clinics in GP practices and specialist secondary care services should also be established.  There is strong evidence that primary and secondary prevention in AF is highly cost-effective, and particularly more so in the elderly because of their high level of background stroke risk.

 

 

 

Key messages

 

The British Association of Stroke Physicians advocates that the Welsh Assembly Government should, as part of a comprehensive programme for the reduction of stroke risk for the population of Wales:

 

a)     Develop and promote a NHS Wales Stroke Prevention Action Plan;

b)    Establish collaborative Welsh Cardiac and Stroke Networks covering 1-2 million population, with highly visible clinical leadership;

c)     Raise awareness of stroke prevention among the public and primary healthcare professionals;

d)    Increase the detection and treatment of hypertension and AF by means of pro-active and opportunistic screening among high risk groups in primary care;

e)     Establish Rapid Access 7-day TIA clinics;

f)      Lobby NICE for a change in their QOF indicator for AF, and promote the wider use of the GRASP-AF tool in surgeries to drive up the proportion of people with AF who receive effective anticoagulation;

g)     Develop specialist secondary care services to support the management of AF in the local population;

h)    Ensure sufficient resources for TIA and stroke services

 

 

References:-

 

a)        Guidance on Risk Assessment & Stroke Prevention for atrial fibrillation (GRASP – AF)

b)        Lancet 1993 Nov 20; 342: 1255-62

c)        Cochrane Database of Systematic Reviews; 2004 Oct 18