Non-urban stroke patients in New Zealand face poorer outcomes, lack critical care

Patients treated for stroke at non-urban hospitals in New Zealand experience poorer outcomes and face reduced access to crucial stroke interventions across the entire care spectrum, according to a study published in Neurology.

“Departures from best practice stroke care in smaller, non-urban New Zealand hospitals have been accepted where a small population is dispersed over a wide geographic area,” Stephanie G. Thompson, MHealSc, of the department of medicine at the University of Otago in New Zealand, and colleagues wrote. “Within these settings, patients are often treated by clinicians without specific training in stroke care. It is unclear to what degree, if any, these compromises affect patient outcomes.”

Researchers sought to examine associations between hospital locations, stroke patient outcomes and access to the best practices of stroke care in the Southern Pacific dual-island nation.

The prospective, multicenter, observational study utilized information from all 28 New Zealand hospitals that treat acute stroke (18 non-urban), as well as affiliated rehabilitation and community services, to identify 2,379 eligible participants (mean age, 75 years; 51.2% men; 1,430 urban-dwelling) who had been admitted to hospital between May 1, and Oct. 31, 2018.

Researchers measured functional outcome based on the modified Rankin Scale (mRS); independence (mRS scores 0-2); quality of life (EQ5D-3L); stroke/vascular events; death at 3, 6 and 12 months; and proportion accessing thrombolysis, thrombectomy, stroke units, key investigations, secondary prevention and inpatient/community rehabilitation. They adjusted results for age, sex, ethnicity, stroke severity/type, comorbidities, baseline function and differences in baseline characteristics.

Thompson and colleagues reported that patients treated at non-urban hospitals were more likely to score in a higher mRS category (greater disability) at 3- (adjusted OR = 1.28; 95% CI, 1.07-1.53), 6- (aOR = 1.33; 95% CI, 1.07-1.65) and 12-months (aOR = 1.31; 95% CI, 1.06-1.62). Additionally, those patients were more likely to have died (aOR = 1.57; 95% CI, 1.17-2.12) or experienced recurrent stroke (aOR = 1.94; 95% CI, 1.14-3.29) and vascular events at 12 months (aOR = 1.65; 95% CI, 1.09-2.52).

Data further showed that fewer non-urban patients received recommended stroke interventions, which included endovascular thrombectomy (aOR = 0.25; 95% CI, 0.13-0.49), acute stroke unit care (aOR = 0.6; 95% CI, 0.49-0.73), antiplatelet prescriptions (aOR = 0.72; 95% CI, 0.58-0.88) or at least 60 minutes of physical therapy (aOR = 0.55; 95% CI, 0.4-0.77) and community rehabilitation (aOR = 0.69; 95% CI, 0.56-0.84).

“This research highlights specific areas for targeted improvement that will likely need to involve new models of care, in addition to focused resource investment and education,” Thompson and colleagues wrote.