Background: The quality of stroke care may diminish on weekends. Aims: We aimed to compare the quality of care and outcomes for patients with stroke/transient ischemic attack discharged on weekdays compared with those discharged on weekends. Methods: Data from the Australian Stroke Clinical Registry from January 2010 to December 2015 (n = 45 hospitals) were analyzed. Differences in processes of care by the timing of discharge are described. Multilevel regression and survival analyses (up to 180 days postevent) were undertaken. Results: Among 30,649 registrants, 2621 (8.6%) were discharged on weekends (55% male; median age 74 years). Compared to those discharged on weekdays, patients discharged on weekends were more often patients with a transient ischemic attack (weekend 35% vs. 19%; p < 0.001) but were less often treated in a stroke unit (69% vs. 81%; p < 0.001), prescribed antihypertensive medication at discharge (65% vs. 71%; p < 0.001) or received a care plan if discharged to the community (47% vs. 53%; p < 0.001). After accounting for patient characteristics and clustering by hospital, patients discharged on weekends had a 1 day shorter length of stay (coefficient = -1.31, 95% confidence interval [CI] = -1.52, -1.10), were less often discharged to inpatient rehabilitation (aOR = 0.39, 95% CI = 0.34, 0.44) and had a greater hazard of death within 180 days (hazard ratio = 1.22, 95% CI = 1.04, 1.42) than those discharged on weekdays. Conclusions: Patients with stroke/transient ischemic attack discharged on weekends were more likely to receive suboptimal care and have higher long-term mortality. High quality of stroke care should be consistent irrespective of the timing of hospital discharge.

IMPORTANCE Extracranial carotid and vertebral artery dissection is an important cause of stroke, particularly in younger individuals. In some but not all observational studies, it has been associated with a high risk of recurrent stroke. Both antiplatelet agents (APs) and anticoagulants (ACs) are used to reduce stroke risk, but whether 1 treatment strategy is more effective is unknown. OBJECTIVE To determine whether AP or AC therapy is more effective in preventing stroke in cervical dissection and the risk of recurrent stroke in a randomized clinical trial setting. A secondary outcome was to determine the effect on arterial imaging outcomes. DESIGN, SETTING, AND PARTICIPANTS Randomized, prospective, open-label international multicenter parallel design study with central blinded review of both clinical and imaging end points. Recruitment was conducted in 39 stroke and neurology secondary care centers in the United Kingdom and 7 centers in Australia between February 24, 2006, and June 17, 2013. One-year follow-up and analysis was conducted in 2018. Two hundred fifty participants with extracranial carotid and vertebral dissection with symptom onset within the last 7 days were recruited. Follow-up data at 1 year were available for all participants. INTERVENTIONS Randomization to AP or AC (heparin followed by warfarin) for 3 months, after which the choice of AP and AC agents was decided by the local clinician. MAIN OUTCOMES AND MEASURES The primary end point was ipsilateral stroke and death. A planned per protocol (PP) analysis was performed in patients meeting the inclusion criteria following central review of imaging to confirm the diagnosis of dissection. A secondary end point was angiographic recanalization in those with imaging confirmed dissection. RESULTS Two hundred fifty patients were randomized (118 carotid and 132 vertebral), 126 to AP and 124 to AC. Mean (SD) age was 49 (12) years. Mean (SD) time to randomization was 3.65 (1.91) days. The recurrent stroke rate at 1 year was 6 of 250 (2.4%) on ITT analysis and 5 of 197 (2.5%) on PP analysis. There were no significant differences between treatment groups for any outcome. Of the 181 patients with confirmed dissection and complete imaging at baseline and 3 months, there was no difference in the presence of residual narrowing or occlusion between those receiving AP (n=56 of 92) vs those receiving AC (n=53 of 89) (P=.97). CONCLUSIONS AND RELEVANCE During 12 months of follow-up, the number of recurrent strokes was low. There was no difference between treatment groups in outcome events or the rate of recanalization.

Objective To determine whether early and more frequent mobilization after stroke affects health-related quality of life. Methods A Very Early Rehabilitation Trial (AVERT) was an international, multicenter (56 sites), phase 3 randomized controlled trial, spanning 2006–2015. People were included if they were aged ≥18 years, presented within 24 hours of a first or recurrent stroke (ischemic or hemorrhagic), and satisfied preordained physiologic criteria. Participants were randomized to usual care alone or very early and more frequent mobilization in addition to usual care. Quality of life at 12 months was a prespecified secondary outcome, evaluated using the Assessment of Quality of Life 4D (AQoL-4D). This utility-weighted scale has scores ranging from −0.04 (worse than death) to 1 (perfect health). Participants who died were assigned an AQoL-4D score of 0. Results No significant difference in quality of life at 12 months between intervention (median 0.47, interquartile range [IQR] 0.07–0.81) and usual care (median 0.49, IQR 0.08–0.81) groups was identified (p = 0.86), nor were there any group differences across the 4 AQoL-4D domains. The same lack of group difference in quality of life was observed at 3 months. When cohort data were analyzed (both groups together), quality of life was strongly associated with acute length of stay, independence in activities of daily living, cognitive function, depressive symptoms, and anxiety symptoms (all p < 0.001). Quality of life in AVERT participants was substantially lower than population norms, and the gap increased with age. Conclusions Earlier and more frequent mobilization after stroke did not influence quality of life. Clinical trial registration anzctr.org.au; ACTRN12606000185561 Classification of evidence This study provides Class II evidence that for people with stroke, earlier and more frequent mobilization did not influence quality of life over the subsequent year.

Introduction: There is some evidence that women receive evidence-based care less often than men, but how this influences long-term mortality after stroke is unclear. We explored this issue using data from a national stroke registry. Methods: Data are first-ever hospitalized strokes (2010-2014) in the Australian Stroke Clinical Registry from 39 hospitals linked to the national death registrations. Multilevel Poisson regression was used to estimate the women:men mortality rate ratio (MRR), with adjustment for sociodemographics, stroke severity, and processes of care (stroke unit care, intravenous thrombolysis, antihypertensive agent[s], and discharge care plan). Results: Among 14,118 events (46% females), women were 7 years older and had greater baseline severity compared to men (29% vs. 37%; p < 0.001), but there were no differences in the four processes of care available across hospitals. In the whole cohort, 1-year mortality was greater in women than men (MRRunadjusted 1.44, 95% confidence interval [CI] 1.34-1.54). However, there were no differences after adjusting for age and stroke severity (MRRadjusted 1.03, 95% CI 0.95-1.10). In analyses of additional processes from Queensland hospitals (n = 5224), women were less often administered aspirin <= 48 hours (61% vs. men 69%, p < 0.015). In Queensland hospitals, there were no statistically significant sex differences in 1-year mortality after adjusting for age, stroke severity, and early administration of aspirin. Conclusion: Greater mortality in women can be explained by differences in age and stroke severity. This highlights the importance of better management of risk factors in the elderly and, potentially, the need for greater access to early aspirin for women with stroke.

Background: The Victorian Stroke Telemedicine (VST) program is the largest stroke telemedicine service operating in Australia. Patients and clinicians at 16 regional hospitals in Victoria are provi...

Background: Following DAWN and DEFUSE 3, optimal imaging selection of large vessel ischemic stroke patients for thrombectomy >6h is important. We hypothesized that perfusion mismatch used in EXTEND-IA and DEFUSE 3 would identify more patients eligible for thrombectomy than clinical-core mismatch used in DAWN. Methods: Prospectively collected data were analyzed for acute ischemic stroke patients aged>18 with pre-treatment whole brain CT perfusion from 2012-2017 at a comprehensive stroke center. CTP was omitted >6h in patients with extensive CT hypodensity. We compared the proportion of patients with anterior circulation large vessel occlusion (ICA, M1 and tandem occlusions) who fulfilled criteria for DAWN (clinical-core mismatch: age<80 & NIHSS≥20 with <51mL core, age<80 & NIHSS10-19 with <31mL core, age>80 & NIHSS>10 with<21mL core), DEFUSE3 (mismatch ratio>1.8, mismatch>15mL, core<70mL, age<91, NIHSS>5) and EXTEND-IA (mismatch ratio>1.2, mismatch>10mL, core<70mL, no age or NIHSS limits). Pre-morbid function, alteplase eligibility and tandem occlusion trial exclusions were not applied to emulate clinical practice. Independent functional outcome was defined as 90 day mRS 0-2. Results: Of 982 ischemic stroke patients evaluated with pre-treatment CTP, 291 had large vessel occlusion. Within 6h of stroke onset, 175/231 (76%) patients met EXTEND-IA criteria compared to 153/231 (60%) DEFUSE3 and 96/231 (42%) DAWN, p<0.0001 for all comparisons. Beyond 6h after onset, 39/58 (67%) met EXTEND-IA mismatch criteria compared to 33/58 (57%) DEFUSE 3 criteria and 26/58 (45%) DAWN criteria, p<0.0001 for all comparisons. Overall 4 patients with clinical-core mismatch did not meet perfusion mismatch criteria. Patients eligible for DEFUSE3 but not DAWN achieved independence in 48% vs 40% in those eligible for both studies, OR 2.1 95%CI 0.9-5.0, p=0.09 in logistic regression adjusted for age and NIHSS. Similar findings applied to patients eligible for EXTEND-IA but not DAWN. Conclusions: Perfusion mismatch selection would lead to substantially more patients receiving thrombectomy than clinical-core mismatch. These patients were generally older with milder NIHSS, but had similar probability of independent outcomes.

Objectives: Hospital data used to assess regional variability in disease management and outcomes, including mortality, lack information on disease severity. We describe variance between hospitals in 30-day risk-adjusted mortality rates (RAMRs) for stroke, comparing models that include or exclude stroke severity as a covariate.Design: Cohort design linking Australian Stroke Clinical Registry data with national death registrations. Multivariable models using recommended statistical methods for calculating 30-day RAMRs for hospitals, adjusted for demographic factors, ability to walk on admission, stroke type, and stroke recurrence.Setting: Australian hospitals providing at least 200 episodes of acute stroke care, 2009-2014.Main outcome measures: Hospital RAMRs estimated by different models. Changes in hospital rank order and funnel plots were used to explore variation in hospital-specific 30-day RAMRs; that is, RAMRs more than three standard deviations from the mean.Results: In the 28 hospitals reporting at least 200 episodes of care, there were 16 218 episodes (15 951 patients; median age, 77 years; women, 46%; ischaemic strokes, 79%). RAMRs from models not including stroke severity as a variable ranged between 8% and 20%; RAMRs from models with the best fit, which included ability to walk and stroke recurrence as variables, ranged between 9% and 21%. The rank order of hospitals changed according to the covariates included in the models, particularly for those hospitals with the highest RAMRs. Funnel plots identified significant deviation from the mean overall RAMR for two hospitals, including one with borderline excess mortality.Conclusions: Hospital stroke mortality rates and hospital performance ranking may vary widely according to the covariates included in the statistical analysis.

Scaling of projects from inception to establishment within the healthcare system is rarely formally reported. The Victorian Stroke Telemedicine (VST) programme provided a very useful opportunity to describe how rural hospitals in Victoria were able to access a network of Melbourne-based neurologists via telemedicine. The VST programme was initially piloted at one site in 2010 and has gradually expanded as a state-wide regional service operating with 16 hospitals in 2017. The aim of this paper is to summarise the factors that facilitated the state-wide transition of the VST programme. A naturalistic case-study was used and data were obtained from programme documents, e.g. minutes of governance committees, including the steering committee, the management committee and six working groups; operational and evaluation documentation, interviews and research field-notes taken by project staff. Thematic analysis was undertaken, with results presented in narrative form to provide a summary of the lived experience of developing and scaling the VST programme. The main success factors were attaining funding from various sources, identifying a clinical need and evidence-based solution, engaging stakeholders and facilitating co-design, including embedding the programme within policy, iterative evaluation including performing financial sustainability modelling, and conducting dissemination activities of the interim results, including promotion of early successes.

Background and Purpose— Interhospital transfer is a critical component in the treatment of acute anterior circulation large vessel occlusive stroke transferred for mechanical thrombectomy. Real-world data for benchmarking and theoretical modeling are limited. We sought to characterize transfer workflow from primary stroke center (PSC) to comprehensive stroke center after the publication of positive thrombectomy trials. Methods— Consecutive patients transferred from 3 high-volume PSCs to a single comprehensive stroke center between January 2015 and August 2016 were included in a retrospective study. Factors associated with key time metrics were analyzed with emphasis on PSC intrahospital workflow. Results— Sixty-seven patients were identified. Median age was 74 years (interquartile range [IQR], 63.5–78) and National Institutes of Health Stroke Scale 17 (IQR, 12–21). Median transfer time measured by PSC-door-to-comprehensive stroke center-door was 128 minutes (IQR, 107–164), of which 82.8% was spent at PSCs (door-in-door-out [DIDO]; 106 minutes; IQR, 86–143). The lengthiest component of DIDO was computed-tomography-to-retrieval-request (median 59.5 minutes; IQR, 44–83). The 37.3% had DIDO exceeding 120 minutes. DIDO times differed significantly between PSCs ( P =0.01). In multivariate analyses, rerecruiting the initial ambulance crew for transfer ( P <0.01) and presentation during working hours ( P =0.04) were associated with shorter DIDO times. Conclusions— In a metropolitan hub-and-spoke network, PSC-door-to-comprehensive stroke center-door and DIDO times are long even in high-volume PSCs. Improving PSC workflow represents a major opportunity to expedite mechanical thrombectomy and improve patient outcomes.

BACKGROUND:In 2010, rapid access to stroke thrombolysis centres was limited in some regional areas in the Australian state of Victoria. These results, and planning for endovascular clot retrieval (ECR), have led to the implementation of strategies by the Victorian Stroke Clinical Network, the Victorian Stroke Telemedicine Program and local health services to improve state-wide access.AIMS:To examine whether access to stroke reperfusion services (thrombolysis and ECR) in regional Victoria have subsequently improved.METHODS:The locations of suspected stroke patients attended by ambulance in 2015 were mapped, and drive times to the nearest reperfusion services were calculated. We then calculated the proportion of cases with transport times within: (i) 60 min to thrombolysis centres; and (ii) 180 min to two ECR centres designated to receive regional patients. Statistical comparisons to existing 2010 data were made.RESULTS:In 2015, Ambulance Victoria attended 16 418 cases of suspected stroke (2.9% of all emergency calls), of whom 4597 (28%) were located in regional Victoria. Compared to 2010, a greater proportion of regional suspected stroke patients in 2015 were located within 60 min of a thrombolysis centre by road (77-95%, P < 0.001). A 3-h road travel time to the two ECR centres is currently possible for 88% of regional patients.CONCLUSION:A strategic and region-specific approach has resulted in improved access by road transport to reperfusion therapies for stroke patients across Victoria.

Background: Given the potential differences in etiology and impact, the treatment and outcome of younger patients (aged 18–64 years) require examination separately to older adults (aged ≥65 years) who experience acute stroke. Methods: Data from the Australian Stroke Clinical Registry (2010–2015) including demographic and clinical characteristics, provision of evidence-based therapies and health-related quality of life (HRQoL) post-stroke was used. Descriptive statistics and multilevel regression models were used for group comparisons. Results: Compared to older patients (age ≥65 years) among 26,220 registrants, 6,526 (25%) younger patients (age 18–64 years) were more often male (63 vs. 51%; p < 0.001), born in Australia (70 vs. 63%; p < 0.001), more often discharged home from acute care (56 vs. 38%; p < 0.001), and less likely to receive antihypertensive medication (61 vs. 73%; p < 0.001). Younger patients had a 74% greater odds of having lower HRQoL compared to an equivalent aged-matched general population (adjusted OR 1.74, 95% CI 1.56–1.93, p < 0.001). Conclusions: Younger stroke patients exhibited distinct differences from their older counterparts with respect to demographic and clinical characteristics, prescription of antihypertensive medications and residual health status.

BACKGROUND AND PURPOSE:Interhospital transfer is a critical component in the treatment of acute anterior circulation large vessel occlusive stroke transferred for mechanical thrombectomy. Real-world data for benchmarking and theoretical modeling are limited. We sought to characterize transfer workflow from primary stroke center (PSC) to comprehensive stroke center after the publication of positive thrombectomy trials.METHODS:Consecutive patients transferred from 3 high-volume PSCs to a single comprehensive stroke center between January 2015 and August 2016 were included in a retrospective study. Factors associated with key time metrics were analyzed with emphasis on PSC intrahospital workflow.RESULTS:Sixty-seven patients were identified. Median age was 74 years (interquartile range [IQR], 63.5-78) and National Institutes of Health Stroke Scale 17 (IQR, 12-21). Median transfer time measured by PSC-door-to-comprehensive stroke center-door was 128 minutes (IQR, 107-164), of which 82.8% was spent at PSCs (door-in-door-out [DIDO]; 106 minutes; IQR, 86-143). The lengthiest component of DIDO was computed-tomography-to-retrieval-request (median 59.5 minutes; IQR, 44-83). The 37.3% had DIDO exceeding 120 minutes. DIDO times differed significantly between PSCs (P=0.01). In multivariate analyses, rerecruiting the initial ambulance crew for transfer (P<0.01) and presentation during working hours (P=0.04) were associated with shorter DIDO times.CONCLUSIONS:In a metropolitan hub-and-spoke network, PSC-door-to-comprehensive stroke center-door and DIDO times are long even in high-volume PSCs. Improving PSC workflow represents a major opportunity to expedite mechanical thrombectomy and improve patient outcomes.