Professor Jonathan Mant discusses the changes to the updated NICE quality standard on stroke in adults, and the importance of rehabilitation following stroke
Stroke occurs around 150,000 times per year in the UK.1 Death rates from stroke have fallen in recent years, but stroke still accounts for 7% of all deaths in the UK.1 While this fall in death rates is partly due to a fall in incidence, it is also due to improved survival following stroke.1 There are over 1.2 million stroke survivors living in the UK, and this number is likely to increase despite the fall in incidence, because of both improved survival and an ageing population (stroke is much more common in older people).1,2 Over one-half of all stroke survivors are left with a disability.1 In addition to the physical and cognitive sequelae of stroke, which include memory problems, concentration problems, and fatigue, many people with stroke also report emotional and social problems.3
NICE Quality Standard (QS) 2 on Stroke in adults5 was originally published in 2010 and focused largely on NICE Clinical Guideline (CG) 68, Stroke and transient ischaemic attack in over 16s: diagnosis and initial management.4 In June 2013 NICE published CG162 on Stroke rehabilitation in adults.2 In April 2016, an update to NICE QS2 was released reflecting the recommendations made in CG162.5
NICE quality standard on stroke in adults
The seven statements that comprise NICE Quality Standard 2 on Stroke in adults are listed in Table 1 (see below) and are discussed in detail below.5 The statements comprise one on acute care, three on rehabilitation, one on return to work, and two on longer-term follow up.
|1||Adults presenting at an accident and emergency (A&E) department with suspected stroke are admitted to a specialist acute stroke unit within 4 hours of arrival. [2010, updated 2016]|
|2||Adults having stroke rehabilitation in hospital or in the community are offered at least 45 minutes of each relevant therapy for a minimum of 5 days a week. [2010, updated 2016]|
|3||Adults who have had a stroke have access to a clinical psychologist with expertise in stroke rehabilitation who is part of the core multidisciplinary stroke rehabilitation team. [new 2016]|
|4||Adults who have had a stroke are offered early supported discharge if the core multidisciplinary stroke team assess that it is suitable for them. [new 2016]|
|5||Adults who have had a stroke are offered active management to return to work if they wish to do so. [new 2016]|
|6||Adults who have had a stroke have their rehabilitation goals reviewed at regular intervals. [2010, updated 2016]|
|7||Adults who have had a stroke have a structured health and social care review at 6 months and 1 year after the stroke, and then annually. [new 2016]|
|NICE. Stroke in adults. Quality Standard 2. NICE, 2016. Available at: www.nice.org.uk/qs2
Reproduced with permission
Prompt admission to specialist acute stroke units—statement 1
The continuing priority placed on early admission to a specialist acute stroke unit reflects the importance of early assessment and intervention. There is strong evidence that intravenous thrombolysis reduces the risk of long-term disability following acute stroke, and that the magnitude of benefit decreases the longer treatment is delayed.6 The indications for thrombolysis are broadening, as recent meta-analysis has demonstrated the effectiveness of the therapy in sub-groups (e.g. people aged over 80 years; people with either very severe or milder strokes) where previously there was clinical uncertainty.6
The scope for early intervention in acute stroke has been widened with evidence of the effectiveness of endovascular thrombectomy for people with acute ischaemic stroke caused by occlusion of arteries of the proximal anterior circulation.7 The impact of this intervention in eligible patients is dramatic: the number needed to treat to achieve an additional patient achieving functional independence is five, and the number needed to treat to lead to an improvement in functional outcome is only 2.6.7 This further strengthens the case for early admission to an acute stroke unit, where eligibility for such interventions can be assessed in a timely fashion, but raises questions about the structuring of future acute stroke care to maximise benefit from this therapy, which was not addressed in NICE QS2.
Statement 2, on the amount of rehabilitation therapy that is offered, appeared in the original NICE QS2 in 2010, and was endorsed by the guideline development group (GDG) for NICE CG162 on Stroke rehabilitation in adults, which noted evidence associating more intensive rehabilitation with better outcomes.8 An economic analysis carried out for the NICE CG162 GDG concluded that switching from the amount of therapy currently provided to the amount recommended in QS2—an increase of about 60 additional sessions per patient—was likely to be cost effective.8
Statement 3 is a new quality statement introduced in 2016. Emotional problems are common after stroke; a survey carried out for the Stroke Association found that 38% of stroke survivors reported emotional problems.9 The NICE CG162 GDG carried out some formal consensus work using a modified Delphi approach in areas where evidence was lacking, and reported a high level of agreement (74%) that a psychologist should be part of the core multidisciplinary stroke rehabilitation team.
Statement 4 is another new statement for 2016. A Cochrane review of 14 trials found that early supported discharge leads to a 20% reduction in the odds of being dead or dependent at the end of follow up, and on average to a 7-day reduction in length of hospital stay (13 trials).10 A National Audit Office analysis concluded that early supported discharge was cost effective.11 The Cochrane reviewed trials were carried out in selected people with stroke—typically those with moderate disability—and the quality statement acknowledges that early supported discharge should only be offered to people for whom it is suitable.
Return to work—statement 5
Statement 5 reflects the aspirations of the UK Stroke Strategy,12 and recommendations from NICE CG162, and emphasises that active management should include:2
- identifying the demands of the person's job and potential impairments on their work performance
- tailoring an intervention to the individual in the work setting
- liaison with employers.
A recent analysis of an online forum found that a significant barrier was lack of understanding of the 'invisible impairments' such as fatigue and cognitive impairments, in both the workplace and among healthcare professionals.13
Regular review of goals and needs—statements 6 and 7
Statement 6 on the regular review of rehabilitation goals was made in the original version of QS2 in 2010. It was endorsed by the GDG for NICE CG162, which declined to set a time interval for when the review should be carried out, acknowledging that it should depend on patient needs, and how much time had passed since the stroke.
Statement 7, on regular review of health and social care needs, although a new statement, reflects a recommendation in the 2007 National Stroke Strategy.12 The NICE CG162 GDG failed to achieve consensus on how frequent reviews should be, but noted that many respondents felt that the approach endorsed in the National Stroke Strategy was sensible.8,12 It is essentially a pragmatic recognition of the evidence that people with stroke do have long-term problems and needs, and they perceive that many of these are not met by current services.9
Implementing NICE Quality Standard 2
Implementing the quality statements from NICE QS2 will be challenging. Insights into current attainment of some of these statements is provided by analysis of the Sentinel Stroke National Audit Programme (see Table 2, below).14
|1||Speed of admission to specialist acute stroke unit||March 2016||58.3|
|2||Receipt of minimum amount of therapy in hospital (occupational therapy)||March 2014
|3||Receipt of minimum amount of therapy in hospital (physiotherapy)||March 2014
|4||Receipt of minimum amount of therapy in hospital (speech and language therapy)||March 2014
|5||Treated by early supported discharge team||March 2014
|6||Rehabilitation goals agreed within 5 days||March 2014
|7||Health and social care review 6 months after stroke||March 2016||29.9|
|Note: see Table 1 (above) for full text of quality statements|
|NICE. Stroke in adults. Quality Standard 2. NICE, 2016. Available at: www.nice.org.uk/qs2
Reproduced with permission
Of patients with suspected stroke presenting at Accident & Emergency (A&E), 58% are currently admitted to a specialist acute stroke unit within 4 hours of arrival (statement 1). Strategies to potentially improve this include ensuring that ambulances pre-alert A&E to the arrival of a suspected stroke patient and maximising uptake of the Face Arm Speech Test (FAST) screen by ambulance and A&E staff.15,16
The audit data suggest that the majority of patients are receiving at least 45 minutes of physiotherapy and occupational therapy 5 days a week while in hospital (statement 2), and that the proportion is improving year by year.14 However, the audit data does not include community rehabilitation, where achievement of this standard is likely to be more challenging.
There are no data for statement 3, though the GDG for QS2 noted that, at present, a clinical psychologist is not always a member of the core stroke rehabilitation team.8
Less than one-third of stroke patients currently receive care from an early discharge support team, but the proportion has improved over the last 3 years (statement 4).14 It is not clear what the ideal proportion should be, but a major barrier is that currently only two-thirds of hospitals have access to early supported discharge services.1
No data are available with regard to supporting people to return to work after stroke (statement 5). This is something that potentially applies to the one-quarter of people under 65 years old who have had a stroke,1 but is likely to be a difficult quality statement to implement as it may require specialist input that may not be available.
Statement 6 and 7
A high proportion (nearly 90%) of patients have rehabilitation goals set within 5 days of admission, but data on whether these goals are regularly reviewed (statement 6) are not available.14 The challenge is how this will happen once patients have been discharged from hospital. This is a particular issue, as many stroke patients report feeling abandoned post discharge.17 Their feedback underlines the importance of statement 7 and regular review after stroke, yet only 30% of stroke patients currently have a review at 6 months.14 This in part reflects a lack of clarity over who should perform these reviews, what they should entail, and how they fit in with existing reviews, such as those for the Quality and Outcomes Framework, which focus on blood pressure control, uptake of antiplatelet agents, and uptake of flu vaccination.18
It is community-based implementation of NICE QS2 that is likely to be problematic. This reflects a range of potential problems, including: underinvestment in community-based rehabilitation compared with hospital-based rehabilitation; lack of effective communication between specialist services and primary care; and lack of clarity over the role of primary care. It also reflects a range of unanswered questions:
- what is the best way to carry out the longer-term structured reviews?
- how should stroke-specific issues be addressed in the context of multiple comorbidity?
- what is the best way to engage primary care in the longer-term management of stroke?
- what should be managed by a generalist and what should be managed by a specialist in the long term?
Stroke is a condition with long-term physical and psychosocial sequelae. The updated NICE QS2 places a welcome emphasis on rehabilitation and longer-term care after stroke, but achievement of this quality standard will be challenging. In the context of multiple morbidity and limited specialist services, implementation of the standard will require engagement from primary care, but models of care that integrate primary care with specialist services are yet to be developed.
- Further advances in understanding of the role of thrombolysis and the demonstration of the effectiveness of thrombectomy for some people with stroke underline the continuing importance of prompt admission of someone with suspected stroke to an acute stroke unit
- Early supported discharge reduces length of stay in hospital, improves outcome, and is cost-effective
- Elements of these quality standards cannot be met in some parts of the country because the relevant service is not being provided—for example having a clinical psychologist as part of the core multidisciplinary stroke team, or offering early supported discharge
- Many stroke survivors report a feeling of 'abandonment' after discharge from hospital. Services are not currently configured to address this need
- From a primary care perspective, key issues that need addressing include:
- need for better communication with specialist services
- how to address stroke issues in the context of multiple comorbidity
- how best to carry out the structured reviews after stroke
- clarification over what post-stroke problems should be met by generalist primary care services and what the role of specialist services are in the long term.
GP commissioning messages
written by Dr David Jenner, GP, Cullompton, Devon
- Commissioners should review their local stroke services against NICE QS2 and aim to meet the quality statements through their STPs
- Commissioners and local providers may need to agree significant reconfiguration of services to meet quality statement 1 on thromboprophylaxis:
- this may mean some centralisation of specialist acute stroke services so they are not provided in all current hospitals
- Early supported discharge is beneficial and cost-effective for cohorts of stroke patients and will help to reduce demand for hospital beds and thus should be effectively commissioned
- Rehabilitation post stroke is a vital part of stroke care and should be actively commissioned; it should include psychological support
- The health and social care review after stroke at 6 months and then annually could be:
- undertaken in the community via specialist stroke nurses, or
- commissioned by GP teams through a locally commissioned enhanced service.
QS=quality standard; STPs=sustainability and transformation plans
- Stroke Association. State of the nation: stroke statistics. January 2016. London: Stroke Association, 2016. Available at: www.stroke.org.uk/resources/state-nation-stroke-statistics (accessed 9 August 2016).
- NICE. Stroke rehabilitation in adults. NICE Clinical Guideline 162. NICE, 2013. Available at: www.nice.org.uk/cg162
- Murray J, Young J, Forster A. Review of longer term problems after a disabling stroke. Rev Clin Gerontol 2007; 17 (4): 277–292.
- NICE. Stroke and transient ischaemic attack in over 16s: diagnosis and initial management. NICE Clinical Guideline 68. NICE, 2008. Available at: www.nice.org.uk/cg68
- NICE. Stroke in adults. NICE Quality Standard 2. NICE, 2010 (last updated April 2016). Available at: www.nice.org.uk/qs2
- Stroke Thrombolysis Trialists’ Collaborative Group. Effect of treatment delay, age, and stroke severity on the effects of intravenous thrombolysis with alteplase for acute ischaemic stroke: a meta-analysis of individual patient data from randomised trials. Lancet 2014; 384 (9958): 1929–1935.
- HERMES Collaboration. Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials. Lancet 2016; 387 (10029): 1723–1731.
- National Clinical Guideline Centre. Stroke rehabilitation: long term rehabilitation after stroke. NICE Clinical Guideline 162—methods, evidence and recommendations. NICE, 2013. Available at: www.nice.org.uk/guidance/cg162/evidence
- McKevitt C, Fudge N, Redfern J et al. Self-reported long-term needs after stroke. Stroke 2011; 42 (5): 1398–1403.
- Fearon P, Langhorne P, Early Supported Discharge Trialists. Services for reducing duration of hospital care for acute stroke patients. Cochrane Database Syst Rev 2012; 9: CD000443.pub3.
- National Audit Office. Progress in improving stroke care: report by the Comptroller and Auditor General. London: NAO 2010. Available at: www.nao.org.uk/wp-content/uploads/2010/02/0910291.pdf
- Department of Health. National stroke strategy. London: DH 2007. Available at: clahrc-gm.nihr.ac.uk/wp-content/uploads/DoH-National-Stroke-Strategy-2007.pdf
- Balasooriya-Smeekens C, Bateman A, Mant J, De Simoni A. Barriers and facilitators to staying in work after stroke: insight from an online forum. BMJ Open 2016; 6 (4): doi:10.1136/bmjopen-2015-009974
- NICE. Stroke in adults. NICE Quality Standard 2—uptake data for this guidance. Available at: www.nice.org.uk/guidance/qs2/uptake
- Sheppard J, Mellor R, Greenfield S et al. The association between pre-hospital care and in-hospital treatment decisions in acute stroke: A cohort study. Emerg Med J 2013; doi: 10.1136/emermed-2013-203026
- Penaloza-Ramos M, Sheppard J, Jowett S et al. Cost effectiveness of optimising acute stroke services for thrombolysis. Stroke 2014; 45 (2): 553–562.
- Stroke Association. Feeling overwhelmed: the emotional impact of stroke. Life after stroke campaign report. Stroke Association, 2013. Available at: www.stroke.org.uk/sites/default/files/feeling_overwhelmed_final_web.pdf
- British Medical Association, NHS Employers, NHS England. 2016/17 General Medical Services (GMS) contract Quality and Outcomes Framework (QOF): guidance for GMS contract 2016/17. BMA, NHS Employers: 2016. Available at: bit.ly/1UQz6ne