CHAPTER 1
Setting the Scene

Caroline Watkins1 and Dominique Cadilhac2,3

1 University of Central Lancashire, Preston, UK

2 School of Clinical Sciences, Monash University, Clayton, VIC, Australia

3 Stroke Division, Florey Institute of Neuroscience and Mental Health, Parkville, VIC, Australia

KEY POINTS

• Transforming stroke services is of paramount importance in the quest to save lives and reduce dependency.
• Translating research evidence into clinical practice is challenging but many examples show that this is both achievable and worthwhile.
• Continued development of stroke nursing through expansion of the stroke nursing knowledge base and demonstration of competence and skill is pivotal to the future of the specialism.
• Continued development of stroke nursing is essential for development of stroke services, locally, nationally, and internationally.

1.1 Introduction

Internationally, stroke - and its impact on people's lives - is finally gaining the recognition it deserves, not only as an acute event and a chronic disease, but also as a preventable condition. The profile of stroke has more recently increased because a greater number of effective treatments, including those for prevention, have become available, and mechanisms for implementation have been established. However, in order to make these treatments available for everyone who might benefit, it is imperative that the public knows about, and has a heightened awareness of, stroke risk factors and stroke symptoms.

Public awareness campaigns are planned to raise the profile of modifiable stroke risk factors: smoking, hypertension, and atrial fibrillation, amongst others. Public campaigns for recognising the signs of stroke have been graphically driving home the message that if a stroke is suspected, the emergency medical services should be contacted. Emergency services must respond rapidly and get patients to centres providing specialist acute-stage treatments, ongoing rehabilitation, and long-term support. Throughout this care pathway, best-available treatment can only be provided if staff have stroke-specific knowledge and skills commensurate with their roles, and if all agencies involved work collaboratively, providing a seamless journey for the person affected by stroke. Nurses are the largest section of the workforce, and are involved throughout the entire stroke care pathway. Consequently, nurses have the greatest opportunity to play a primary role in providing leadership and ensuring the delivery of evidence-based stroke care.

The focus of this chapter is to describe the importance of stroke nursing in the context of wider systems. The extent of the problem of stroke is illustrated, and the reason stroke has become a burning issue for healthcare and research is explored. Policy imperatives are discussed, as well as the present and future of stroke-specific infrastructure. Importantly, the need to support stroke service developments and put in place mechanisms to produce evidence for practice is outlined, and how evidence can be implemented into practice is clarified. Fundamental to delivery of this huge agenda is the development of a stroke-specialist workforce. Staff delivering care along the stroke pathway need the right knowledge, skills, and experience in stroke, and should achieve recognition for it. Suitable recognition for specialising in stroke care should ensure that the most able staff pursue rewarding careers in stroke care. This then should establish a virtuous circle, whereby able staff stay in the speciality and contribute further to advancing the field, including delivery of sustainable quality improvements into the future. Staff can then also participate in ongoing audits of care, reflection on performance, and instigation of further improvements, and thus constantly drive up the quality of care.

1.2 Stroke Epidemiology

Stroke is a major cause of mortality and morbidity in adults. Globally, it is the second leading cause of disease burden after ischaemic heart disease given the combined effects of premature death and long-term disability [1]. In addition, over 90% of this stroke burden is attributed to modifiable risk factors, with about 74% being associated with behavioural factors such as smoking, poor diet, and physical inactivity [2]. Therefore, much could be done to reduce the incidence and prevalence of stroke. Crude incidence varies greatly amongst countries, according to both the different risk factor profiles and the timing of different studies. The reported age-adjusted incidence rates range from 54 per 100 000 population per year in Lagos, Nigeria (2007-2008) to 146 per 100 000 per year in Iwate, Japan (based on World Health Organization World standard population) [3]. Stroke incidence rates are generally greater in men that in women, and women will generally experience their stroke event at an older age. Greater mortality in women is mostly explained by age, but also by stroke severity, atrial fibrillation, and pre-stroke functional limitations [4]. Case-fatality rates within 28-30 days also range widely amongst countries, from about 10% in Dijon, France to 37% in rural Trivandrum, India [3].

Many countries are experiencing increases in life expectancy. Since age is the strongest factor contributing to stroke incidence, there are concerns that the numbers will rise and this will impact on the ability of the health systems to manage stroke effectively. Currently, trends are unclear, and further research is needed to understand what the future holds. Whilst stroke incidence may not increase, and may even decrease [5], it is clear that more people are surviving stroke and living with the sequelae [6]. Surviving with moderate to severe disability can have profound effects in all domains of life [7], and poor quality of life has been associated with greater unmet needs over the longer term. Whilst we want acute stroke interventions to improve survival rates, we also want them to ensure independent survival.

Importantly, we also need prevention interventions to be a priority, given that the overall global burden of stroke is substantial. Summary measures of population health capture both morbidity and mortality and are used to describe the burden of disease. These summary measures include Health Adjusted Life Expectancy (), Disability Adjusted Life Years (s), and Quality Adjusted Life Years (s). The HALE value represents the number of expected years of life equivalent to years lived in full health adjusted for time spent in poor health, based on current rates of ill health (e.g. chronic disease) and mortality in a community. The DALY is a health gap measure and captures the years of life lost () due to premature mortality and the years of life lived with disability (), for example as a consequence of experiencing stroke. QALYs are based on a similar conceptual framework (life expectancy plus quality of life), but assumptions and methods differ. In recent work to determine the health gap experienced by stroke survivors compared to the normal population, it was determined that the QALYs lost per first-ever stroke were about 5.09 for ischaemic stroke and 6.17 for intracerebral haemorrhage [8]. In other words, if a stroke was prevented, this represents the health gain that could be achieved on average per person.

1.3 Cost Burden

The costs of stroke are substantial, due to the complexity and chronic nature of this condition. The greatest costs incurred in the first year are associated with hospital care and rehabilitation [9]. Comparing results of cost-of-illness studies between countries is complicated due to the different methodological approaches, such as the types of costs included and the time horizon [10]. Since the costs of stroke peak within the first year and decline over time, it is important to quantify long-term resource use in order to gain a greater understanding of the potential lifetime impact on society. Furthermore, the direct costs of informal care and indirect costs of productivity losses (inability to work or perform important home duties) after stroke are often omitted, despite these costs being substantial. Using 10 years of follow-up data, the authors of the North East Melbourne Stroke Incidence study (Australia) estimated the average lifetime costs at US$68,769 for ischaemic stroke and US$54,956 for intracerebral haemorrhage in 2010 [11]. In other recent work undertaken in a more remote geographic Australian location, the lifetime costs of stroke were substantially larger (US$207,218), and the greatest costs were associated with patients who had an Indigenous background, renal disease, heart disease, or hypertension [12].

In contrast, 5-year costs per stroke in the United Kingdom have been reported as £29,405 in 2001-2002, if informal care was included [13]. In the United States, the average costs within 1 year of hospitalisation per stroke averaged US$47,790 in 2008 [14], and the lifetime health costs were estimated to be US$140,000 per patient with ischaemic stroke in 2010 [15, 16]. To contain the growing total costs of stroke and associated health expenditure, it is essential that cost-effective prevention and treatment...