Evaluating Stroke Code Activation Pathway in Emergency Departments study.

OBJECTIVES: To describe the clinical characteristics and outcomes of Code Stroke activations in an ED and determine predictors of a final diagnosis of stroke or transient ischemic attack (TIA) diagnosis. METHODS: This was a retrospective analysis of Code Stroke activations through an ED over 2 years at a quaternary stroke referral centre. Stroke Registry data was used to identify cases with clinical information abstracted from electronic medical records. The primary outcome was a final diagnosis of acute stroke or TIA and the secondary outcome was access to reperfusion therapies (thrombolysis and or endovascular clot retrieval). RESULTS: The study analysed data from 1354 Code Stroke patients in ED. Of all Code Strokes, 51% had a stroke or TIA diagnosis on discharge. Patient characteristics independently associated with increased risk of stroke were increasing age, pre-arrival notification by ambulance, elevated BP or presence of weakness or speech impairment as the initial presenting symptoms. Dizziness/vertigo/vestibular neuritis were the most common alternative diagnoses. One hundred and thirty-five patients (10%) underwent reperfusion therapy. Pre-arrival notification by ambulance was associated with higher proportion of eventual stroke/TIA diagnosis (68% vs 46%, P < 0.001) and significantly lower door to CT and door to needle times for patients undergoing thrombolysis. CONCLUSIONS: In a cohort of patients requiring Code Stroke activation in an ED, increased age, systolic blood pressure and weakness and speech impairment increased the risk of stroke. Prehospital notification was associated with lower door to needle times for patients undergoing thrombolysis.

Hospital Presentations in Long-Term Survivors of Stroke: Causes and Associated Factors in a Linked Data Study.

BACKGROUND AND PURPOSE: A comprehensive understanding of the long-term impact of stroke assists in health care planning. We aimed to determine changes in rates, causes, and associated factors for hospital presentations among long-term survivors of stroke. METHODS: Person-level data from the AuSCR (Australian Stroke Clinical Registry) during 2009 to 2013 were linked with state-based health department emergency department and hospital admission data. The study cohort included adults with first-ever stroke who survived the first 6 months after discharge from hospital. Annualized rates of hospital presentations (nonadmitted emergency department or admission)/person/year were calculated for 1 to 12 months prior, and 7 to 12 months (inclusive) after hospitalization. Multilevel, negative binomial regression was used to identify associated factors after adjustment for prestroke hospital presentations and stratification for perceived impairment status. Perceived impairments to health were defined according to the subscales and visual analog health status scores on the 5-Dimension European Quality of Life Scale. RESULTS: There were 7183 adults with acute stroke, 7-month survivors (median age 72 years; 56% male; 81% ischemic, and 42% with impairment at 90-180 days) from 39 hospitals included in this landmark analysis. Annualized presentations/person increased from 0.88 (95% CI, 0.86-0.91) to 1.25 (95% CI, 1.22-1.29) between the prestroke and poststroke periods, with greater rate increases in those with than without perceived impairment (55% versus 26%). Higher presentation rates were most strongly associated with older age (≥85 versus 65 years, incidence rate ratio, 1.52 [95% CI, 1.27-1.82]) and greater comorbidity score (incidence rate ratio, 1.06 [95% CI, 1.02-1.10]), whereas reduced rates were associated with greater social advantage (incidence rate ratio, 0.71 [95% CI, 0.60-0.84]). Poststroke hospital presentations (7-12 months) were most frequently related to recurrent cardiovascular and cerebrovascular events and sequelae of stroke. CONCLUSIONS: A large increase in annualized hospital presentation rates after stroke indicates the potential for improved community management and support for this vulnerable patient group.

Supporting anticoagulant treatment decision making to optimise stroke prevention in complex patients with atrial fibrillation: a cluster randomised trial.

BACKGROUND: Anticoagulation for preventing stroke in atrial fibrillation is under-utilised despite evidence supporting its use, resulting in avoidable death and disability. We aimed to evaluate an intervention to improve the uptake of anticoagulation. METHODS: We carried out a national, cluster randomised controlled trial in the Australian primary health care setting. General practitioners received an educational session, delivered via telephone by a medical peer and provided information about their patients selected either because they were not receiving anticoagulation or for whom anticoagulation was considered challenging. General practitioners were randomised to receive feedback from a medical specialist about the cases (expert decisional support) either before or after completing a post-test audit. The primary outcome was the proportion of patients reported as receiving oral anticoagulation. A secondary outcome assessed antithrombotic treatment as appropriate against guideline recommendations. RESULTS: One hundred and seventy-nine general practitioners participated in the trial, contributing information about 590 cases. At post-test, 152 general practitioners (84.9%) completed data collection on 497 cases (84.2%). A 4.6% (Adjusted Relative Risk = 1.11, 95% CI = 0.86-1.43) difference in the post-test utilization of anticoagulation between groups was not statistically significant (p = 0.42). Sixty-one percent of patients in both groups received appropriate antithrombotic management according to evidence-based guidelines at post-test (Adjusted Relative Risk = 1.0; 95% CI = 0.85 to 1.19) (p = 0.97). CONCLUSIONS: Specialist feed-back in addition to an educational session did not increase the uptake of anticoagulation in patients with AF. TRIAL REGISTRATION: ANZCTRN12611000076976 Retrospectively registered.

Population-based stroke surveillance using big data: state-wide epidemiological trends in admissions and mortality in New South Wales, Australia.

OBJECTIVES: Epidemiological trends for major causes of death and disability, such as stroke, may be monitored using administrative data to guide public health initiatives and service delivery. METHODS: We calculated admissions rates for ischaemic stroke, intracerebral haemorrhage and subarachnoid haemorrhage between 1 January 2005 and December 31st, 2013 and rates of 30-day mortality and 365-day mortality in 30-day survivors to 31 December 2014 for patients aged 15 years or older from New South Wales, Australia. Annual Average Percentage Change in rates was estimated using negative binomial regression. RESULTS: Of 81,703 eligible admissions, 64,047 (78.4%) were ischaemic strokes and 13,302 (16.3%) and 4,778 (5.8%) were intracerebral and subarachnoid haemorrhages, respectively. Intracerebral haemorrhage admissions significantly declined by an average of 2.2% annually (95% Confidence Interval = -3.5% to -0.9%) (p < 0.001). Thirty-day mortality rates significantly declined for ischaemic stroke (Average Percentage Change -2.9%, 95% Confidence Interval = -5.2% to -1.0%) (p = 0.004) and subarachnoid haemorrhage (Average Percentage Change = -2.6%, 95% Confidence Interval = -4.8% to -0.2%) (p = 0.04). Mortality at 365-days amongst 30-day survivors of ischaemic stroke and intracerebral haemorrhage was stable over time and increased in subarachnoid haemorrhage (Annual Percentage Change 6.2%, 95% Confidence Interval = -0.1% to 12.8%), although not significantly (p = 0.05). DISCUSSION: Improved prevention may have underpinned declining intracerebral haemorrhage rates while survival gains suggest that innovations in care are being successfully translated. Mortality in patients surviving the acute period is unchanged and may be increasing for subarachnoid haemorrhage warranting investment in post-discharge care and secondary prevention.

Measuring stroke outcomes for 74 501 patients using linked administrative data: System-wide estimates and validation of 'home-time' as a surrogate measure of functional status.

AIMS: Administrative data offer cost-effective, whole-of-population stroke surveillance yet the lack of validated measures of functional status is a shortcoming. The number of days spent living at home after stroke ('home-time') is a patient-centred outcome that can be objectively ascertained from administrative data. Population-based validation against both severity and outcome measures and for all subtypes is lacking. We aimed to report representative 'home-time' estimates and validate 'home-time' as a surrogate measure of functional status after stroke. METHODS: Stroke hospitalisations from a state-wide census in New South Wales, Australia, from January 1, 2005 to March 31, 2014 were linked to prehospital data, poststroke admissions and deaths. We correlated 90-day 'home-time' with Glasgow Coma Scale (GCS) scores, measured upon a patient's initial contact with paramedics and Functional Independence Measure (FIM) scores, measured upon entry to rehabilitation after the acute hospital stroke admission. Negative binomial regressions identified predictors of 'home-time'. RESULTS: Patients with stroke (N = 74 501) spent a median of 53 days living at home 90 days after the event. Median 'home-time' was 60 days after ischaemic stroke, 49 days after subarachnoid haemorrhage and 0 days after intracerebral haemorrhage. GCS and FIM scores significantly correlated with 'home-time' (P < .001). Women spent significantly less time at home compared with men after stroke, although being married increased 'home-time' after ischaemic stroke and subarachnoid haemorrhage. CONCLUSIONS: These findings underscore the immediate and adverse impact of stroke. 'Home-time' measured using administrative data is a robust, replicable and valid patient-centred outcome enabling inexpensive population-based surveillance and system-wide quality assessment.

The impact of disease severity adjustment on hospital standardised mortality ratios: Results from a service-wide analysis of ischaemic stroke admissions using linked pre-hospital, admissions and mortality data.

BACKGROUND: Administrative data are used to examine variation in thirty-day mortality across health services in several jurisdictions. Hospital performance measurement may be error-prone as information about disease severity is not typically available in routinely collected data to incorporate into case-mix adjusted analyses. Using ischaemic stroke as a case study, we tested the extent to which accounting for disease severity impacts on hospital performance assessment. METHODS: We linked all recorded ischaemic stroke admissions between July, 2011 and June, 2014 to death registrations and a measure of stroke severity obtained at first point of patient contact with health services, across New South Wales, Australia's largest health service jurisdiction. Thirty-day hospital standardised mortality ratios were adjusted for either comorbidities, as is typically done, or for both comorbidities and stroke severity. The impact of stroke severity adjustment on mortality ratios was determined using 95% and 99% control limits applied to funnel plots and by calculating the change in rank order of hospital risk adjusted mortality rates. RESULTS: The performance of the stroke severity adjusted model was superior to incorporating comorbidity burden alone (c-statistic = 0.82 versus 0.75; N = 17,700 patients, 176 hospitals). Concordance in outlier classification was 89% and 97% when applying 95% or 99% control limits to funnel plots, respectively. The sensitivity rates of outlier detection using comorbidity adjustment compared with gold-standard severity and comorbidity adjustment was 74% and 83% with 95% and 99% control limits, respectively. Corresponding positive predictive values were 74% and 91%. Hospital rank order of risk adjusted mortality rates shifted between 0 to 22 places with severity adjustment (Median = 4.0, Inter-quartile Range = 2-7). CONCLUSIONS: Rankings of mortality rates varied widely depending on whether stroke severity was taken into account. Funnel plots yielded largely concordant results irrespective of severity adjustment and may be sufficiently accurate as a screening tool for assessing hospital performance.

Maximising data value and avoiding data waste: a validation study in stroke research.

OBJECTIVES: To determine the feasibility of linking data from the Australian Stroke Clinical Registry (AuSCR), the National Death Index (NDI), and state-managed databases for hospital admissions and emergency presentations; to evaluate data completeness and concordance between datasets for common variables. DESIGN, SETTING, PARTICIPANTS: Cohort design; probabilistic/deterministic data linkage of merged records for patients treated in hospital for stroke or transient ischaemic attack from New South Wales, Queensland, Victoria, and Western Australia. MAIN OUTCOME MEASURES: Descriptive statistics for data matching success; concordance of demographic variables common to linked databases; sensitivity and specificity of AuSCR in-hospital death data for predicting NDI registrations. RESULTS: Data for 16 214 patients registered in the AuSCR during 2009-2013 were linked with one or more state datasets: 15 482 matches (95%) with hospital admissions data, and 12 902 matches (80%) with emergency department presentations data were made. Concordance of AuSCR and hospital admissions data exceeded 99% for sex, age, in-hospital death (each κ = 0.99), and Indigenous status (κ = 0.83). Of 1498 registrants identified in the AuSCR as dying in hospital, 1440 (96%) were also recorded by the NDI as dying in hospital. In-hospital death in AuSCR data had 98.7% sensitivity and 99.6% specificity for predicting in-hospital death in the NDI. CONCLUSION: We report the first linkage of data from an Australian national clinical quality disease registry with routinely collected data from several national and state government health datasets. Data linkage enriches the clinical registry dataset and provides additional information beyond that for the acute care setting and quality of life at follow-up, allowing clinical outcomes for people with stroke (mortality and hospital contacts) to be more comprehensively assessed.

Decreasing Risk of Fatal Subarachnoid Hemorrhage and Other Epidemiological Trends in the Era of Coiling Implementation in Australia.

BACKGROUND AND PURPOSE: Subarachnoid hemorrhage (SAH) is associated with a high risk of mortality and disability in survivors. We examined the epidemiology and burden of SAH in our population during a time services were re-organized to facilitate access to evidence-based endovascular coiling and neurosurgical care. METHODS: SAH hospitalizations from 2001 to 2009, in New South Wales, Australia, were linked to death registrations to June 30, 2010. We assessed the variability of admission rates, fatal SAH rates and case fatality over time and according to patient demographic characteristics. RESULTS: There were 4,945 eligible patients admitted to hospital with SAH. The risk of fatal SAH significantly decreased by 2.7% on average per year (95% CI = 0.3-4.9%). Case fatality at 2, 30, 90, and 365 days significantly declined over time. The average annual percentage reduction in mortality ranged from 4.4% for 30-day mortality (95% CI -6.1 to -2.7) (P < 0.001) to 4.7% for mortality within 2 days (-7.1 to -2.2) (P < 0.001) (Table 3). Three percent of patients received coiling at the start of the study period, increasing to 28% at the end (P-value for trend <0.001). Females were significantly more likely to be hospitalized for a SAH compared to males [incident rate ratio (IRR) = 1.33, 95% CI = 1.23-1.44] (P < 0.001) and to die from SAH (IRR = 1.40, 95% CI = 1.24-1.59) (P < 0.001). People born in South-East Asia and the Oceania region had a significantly increased risk of SAH, while the risk of fatal SAH was greater in South-East and North-East Asian born residents. People residing in areas of least disadvantage had the lowest risk of hospitalization (IRR = 0.83, 95% CI = 0.74-0.92) and also the lowest risk of fatal SAH (0.81, 95% CI = 0.66-1.00) (P < 0.001 and P = 0.003, respectively). For every 100 SAH admissions, 20 and 15 might be avoided in males and females, respectively, if the risk of SAH in our population equated to that of the most socio-economically advantaged. CONCLUSION: Our study reports reductions in mortality risk in SAH corresponding to identifiable changes in health service delivery and evolving treatments such as coiling. Addressing inequities in SAH risk and mortality may require the targeting of prevalent and modifiable risk factors to improve population outcomes.

Differentiating Incident from Recurrent Stroke Using Administrative Data: The Impact of Varying Lengths of Look-Back Periods on the Risk of Misclassification.

BACKGROUND/AIMS: Administrative data are widely used to monitor epidemiological trends in stroke and outcomes; yet there is scant empirical guidance on how to best differentiate incident from recurrent stroke. METHODS: We identified all hospital admissions in New South Wales, Australia, with a principal stroke diagnosis from July 1, 2013 to June 30, 2014, linked to 12 years of previous admissions. We calculated the proportion of cases identified with a prior stroke to determine the number of years of look-back required to minimise misclassification of incident and recurrent strokes. RESULTS: Using the maximum available look-back period of 12 years, 1,171 out of 8,364 eligible stroke cases (14.0%) had a stroke history. A 1-year look-back period identified only 25.1% of these patients and 1 in 10 stroke cases were misclassified as incident. With a 10-year clearance period, less than 1 in 100 stroke cases were misclassified as incident. The risk of misclassification was lower in patients younger than 65 years and in those with haemorrhagic stroke. CONCLUSION: Hospital administrative data sets linked to prior admissions can be used to distinguish recurrent from incident stroke. The risk of misclassifying recurrent stroke cases as incident events is negligible with a look-back period of 10 years.

Addressing the challenges of cross-jurisdictional data linkage between a national clinical quality registry and government-held health data.

OBJECTIVE: To describe the challenges of obtaining state and nationally held data for linkage to a non-government national clinical registry. METHODS: We reviewed processes negotiated to achieve linkage between the Australian Stroke Clinical Registry (AuSCR), the National Death Index, and state held hospital data. Minutes from working group meetings, national workshop meetings, and documented communications with health department staff were reviewed and summarised. RESULTS: Time from first application to receipt of data was more than two years for most state data-sets. Several challenges were unique to linkages involving identifiable data from a non-government clinical registry. Concerns about consent, the re-identification of data, duality of data custodian roles and data ownership were raised. Requirements involved the development of data flow methods, separating roles and multiple governance and ethics approvals. Approval to link death data presented the fewest barriers. CONCLUSION: To our knowledge, this is the first time in Australia that person-level data from a clinical quality registry has been linked to hospital and mortality data across multiple Australian jurisdictions. Implications for Public Health: The administrative load of obtaining linked data makes projects such as this burdensome but not impossible. An improved national centralised strategy for data linkage in Australia is urgently needed.

Declining rates of fatal and nonfatal intracerebral hemorrhage: epidemiological trends in Australia.

BACKGROUND: A recent systematic review of epidemiological studies reported intracerebral hemorrhage (ICH) incidence and mortality as unchanged over time; however, comparisons between studies conducted in different health services obscure assessment of trends. We explored trends in ICH rates in a large, representative population in New South Wales, Australia's most populous state (≈7.3 million). METHODS AND RESULTS: Adult hospitalizations with a principal ICH diagnosis from 2001 to 2009 were linked to death registrations through to June 30, 2010. Trends for overall, fatal, and nonfatal ICH rates within 30 days and fatal rates for 30-day survivors at 365 days were calculated. There were 11 332 ICH patient admissions meeting eligibility criteria, yielding a crude hospitalization rate of 25.2 per 100 000 (age-standardized rate: 17.2). Age- and sex-adjusted overall rates significantly declined by an average of 1.6% per year (P=0.03). Fatal ICH declined by an average of 2.6% per year (P=0.004). For 30-day survivors, a nonsignificant decline of 2.3% per year in fatal ICH at 365 days was estimated (P=0.17). Male sex and birth in the Oceania region and Asia were associated with an increased ICH risk, although this depended on age. Approximately 12% of ICH admissions would be prevented if the socioeconomic circumstances of the population equated with those of the least disadvantaged. CONCLUSIONS: Overall and fatal ICH rates have fallen in this large Australian population. Improvements in cardiovascular prevention and acute care may explain declining rates. There was no evidence of an increase in devastated survivors because the longer term mortality of 30-day survivors has not increased over time.

Supporting Treatment decision making to Optimise the Prevention of STROKE in Atrial Fibrillation: the STOP STROKE in AF study. Protocol for a cluster randomised controlled trial.

BACKGROUND: Suboptimal uptake of anticoagulation for stroke prevention in atrial fibrillation has persisted for over 20 years, despite high-level evidence demonstrating its effectiveness in reducing the risk of fatal and disabling stroke. METHODS: The STOP STROKE in AF study is a national, cluster randomised controlled trial designed to improve the uptake of anticoagulation in primary care. General practitioners from around Australia enrolling in this 'distance education' program are mailed written educational materials, followed by an academic detailing session delivered via telephone by a medical peer, during which participants discuss patient de-identified cases. General practitioners are then randomised to receive written specialist feedback about the patient de-identified cases either before or after completing a three-month posttest audit. Specialist feedback is designed to provide participants with support and confidence to prescribe anticoagulation. The primary outcome is the proportion of patients with atrial fibrillation receiving oral anticoagulation at the time of the posttest audit. DISCUSSION: The STOP STROKE in AF study aims to evaluate a feasible intervention via distance education to prevent avoidable stroke due to atrial fibrillation. It provides a systematic test of augmenting academic detailing with expert feedback about patient management.

Incidence of metastatic breast cancer in an Australian population-based cohort of women with non-metastatic breast cancer at diagnosis.

OBJECTIVES: To estimate the incidence of metastatic breast cancer (MBC) in Australian women with an initial diagnosis of non-metastatic breast cancer. DESIGN, SETTING AND PARTICIPANTS: A population-based cohort study of all women with non-metastatic breast cancer registered on the New South Wales Central Cancer Register (CCR) in 2001 and 2002 who received care in a NSW hospital. MAIN OUTCOME MEASURES: 5-year cumulative incidence of MBC; prognostic factors for MBC. RESULTS: MBC was recorded within 5 years in 218 of 4137 women with localised node-negative disease (5-year cumulative incidence, 5.3%; 95% CI, 4.6%-6.0%); and 455 of 2507 women with regional disease (5-year cumulative incidence, 18.1%; 95% CI, 16.7%-19.7%). The hazard rate for developing MBC was highest in the second year after the initial diagnosis of breast cancer. Determinants of increased risk of MBC were regional disease at diagnosis, age less than 50 years and living in an area of lower socio-economic status. CONCLUSIONS: Our Australian population-based estimates are valuable when communicating average MBC risks to patients and planning clinical services and trials. Women with node-negative disease have a low risk of developing MBC, consistent with outcomes of adjuvant clinical trials. Regional disease at diagnosis remains an important prognostic factor.

No difference demonstrated between faxed or mailed prenotification in promoting questionnaire response among family physicians: a randomized controlled trial.

OBJECTIVE: Achieving high survey participation rates among physicians is challenging. We aimed to assess the effectiveness of response-aiding strategies in a postal survey of 1,000 randomly selected Australian family physicians (FPs). STUDY DESIGN AND SETTING: A two × two randomized controlled trial was undertaken to assess the effectiveness of a mailed vs. faxed prenotification letter and a mailed questionnaire sealed with a label marked attention to doctor vs. a control label. At the time of our final reminder, we randomized remaining nonresponders to receive a more or less personalized mail-out. RESULTS: Response did not significantly differ among eligible FPs receiving a prenotification letter via mail or fax. However, 25.6% of eligible FPs whose questionnaires were sealed with a label marked attention to the doctor responded before reminders were administered and compared with 18.6% of FPs whose questionnaires were sealed with a control label (P=0.008). Differences were not statistically significant thereafter. There was no significant difference in response between FPs who received a more vs. less personalized approach at the time of the final reminder (P=0.16). CONCLUSION: Mail marked attention to doctor may usefully increase early response. Prenotification letters delivered via fax are equally effective to those administered by mail and may be cheaper.

Relative survival after transient ischaemic attack: results from the Program of Research Informing Stroke Management (PRISM) study.

BACKGROUND AND PURPOSE: There is a lack of modern-day data quantifying the effect of transient ischemic attack (TIA) on survival, and recent data do not take into account expected survival. METHODS: Data for 22 157 adults hospitalized with a TIA from July 1, 2000, to June 30, 2007, in New South Wales, Australia, were linked with registered deaths to June 30, 2009. We estimated survival relative to the age- and sex-matched general population up to 9-years after hospitalization for TIA comparing relative risk of excess death between selected subgroups. RESULTS: At 1 year, 91.5% of hospitalized patients with TIA survived compared with 95.0% expected survival in the general population. After 5 years, observed survival was 13.2% lower than expected in relative terms. By 9 years, observed survival was 20% lower than expected. Females had higher relative survival than males (relative risk, 0.79; 95% CI, 0.69-0.90; P<0.001). Increasing age was associated with an increasing risk of excess death compared with the age-matched population. Prior hospitalization for stroke (relative risk, 2.63; 95% CI, 1.98-3.49) but not TIA (relative risk, 1.42; 95% CI, 0.86-2.35) significantly increased the risk of excess death. Of all risk factors assessed, congestive heart failure, atrial fibrillation, and prior hospitalization for stroke most strongly impacted survival. CONCLUSIONS: This study is the first to quantify the long-term effect of hospitalized TIA on relative survival according to age, sex, and medical history. TIA reduces survival by 4% in the first year and by 20% within 9 years. TIA has a minimal effect on mortality in patients <50 years but heralds significant reduction in life expectancy in those >65 years.

Outcomes for patients with ischaemic stroke and atrial fibrillation: the PRISM study (A Program of Research Informing Stroke Management).

BACKGROUND: In the past decade the prevalence of atrial fibrillation (AF) has been increasing in ageing populations while stroke prevention and management have advanced. To inform clinician practice, health service planning and further research, it is timely to reassess the burden of AF-related ischaemic stroke. METHODS: We identified patients aged 18+ years with a primary or stay diagnosis of ischaemic stroke (ICD-10-AM I63.x), from July 1, 2000 to June 30, 2006, using an administrative health dataset of all hospitalisations in New South Wales (population ∼7 million). Fact of death was determined to December 2007. RESULTS: Of the 26,960 index cases of ischaemic stroke, 25.4% had AF recorded during admission. Median age for AF and non-AF patients was 80.4 and 75.2 years, respectively (p < 0.001). Mortality was significantly higher in patients with AF at 30 days (19.4 vs. 11.5%), 90 days (27.7 vs. 15.8%) and 365 days (38.5 vs. 22.6%) (p values <0.0001). Adjusting for age and co-morbidities reduced these differences, with 90-day mortality of 20.9% in AF patients versus 14.7% in non-AF patients (p value <0.0001). The effect of AF on outcomes appears stronger in younger stroke patients relative to patients without AF (p value(interaction) <0.0001). At 30 days, the relative risk of mortality due to AF was 3.16 (95% CI 1.92-5.25) amongst those younger than 50, 1.71 (95% CI 1.32-2.22) in patients aged 50-64 years, 1.39 (95% CI 1.16-1.66) in patients aged 65-74 years, 1.29 (95% CI 1.17-1.43) in those aged 75-84 years, and 1.23 (95% CI 1.13-1.33) in those aged 85+ years. AF patients, surviving admission, spent a median of 19.2 days (95% CI 18.4-20.1) in hospital compared with 14.5 days (95% CI 13.9-15.1) for patients without AF (p < 0.001), with differences in length of stay greatest in younger patients (p value(interaction) <0.0001). 90-Day stroke survivors with AF spent an average of 21.5 days (95% CI 20.6-22.4) in hospital versus 16.6 days (95% CI 15.9-17.2) in those without AF. AF patients accessed more in-hospital rehabilitation (36.6%; 95% CI 35.0-38.2) than patients without AF (31.8%; 95% CI 31.0-32.7) (p value <0.0001), and differences in the proportion of AF versus non-AF patients accessing rehabilitation was greatest in younger patients (p value(interaction) <0.0006). CONCLUSIONS: Ischaemic stroke patients with AF have substantially worse outcomes than patients without AF, which can be partly explained by older age and greater co-morbidities. We have quantified the large effect of AF in younger patients and our results strongly argue for new antithrombotic research in young AF patients.

Local opinion leaders: effects on professional practice and health care outcomes.

BACKGROUND: Clinical practice is not always evidence-based and, therefore, may not optimise patient outcomes. Opinion leaders disseminating and implementing 'best evidence' is one method that holds promise as a strategy to bridge evidence-practice gaps. OBJECTIVES: To assess the effectiveness of the use of local opinion leaders in improving professional practice and patient outcomes. SEARCH STRATEGY: We searched Cochrane EPOC Group Trials Register, the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, HMIC, Science Citation Index, Social Science Citation Index, ISI Conference Proceedings and World Cat Dissertations up to 5 May 2009. In addition, we searched reference lists of included articles. SELECTION CRITERIA: Studies eligible for inclusion were randomised controlled trials investigating the effectiveness of using opinion leaders to disseminate evidence-based practice and reporting objective measures of professional performance and/or health outcomes. DATA COLLECTION AND ANALYSIS: Two review authors independently extracted data from each study and assessed its risk of bias. For each trial, we calculated the median risk difference (RD) for compliance with desired practice, adjusting for baseline where data were available. We reported the median adjusted RD for each of the main comparisons. MAIN RESULTS: We included 18 studies involving more than 296 hospitals and 318 PCPs. Fifteen studies (18 comparisons) contributed to the calculations of the median adjusted RD for the main comparisons. The effects of interventions varied across the 63 outcomes from 15% decrease in compliance to 72% increase in compliance with desired practice. The median adjusted RD for the main comparisons were: i) Opinion leaders compared to no intervention, +0.09; ii) Opinion leaders alone compared to a single intervention, +0.14; iii) Opinion leaders with one or more additional intervention(s) compared to the one or more additional intervention(s), +0.10; iv) Opinion leaders as part of multiple interventions compared to no intervention, +0.10. Overall, across all 18 studies the median adjusted RD was +0.12 representing a 12% absolute increase in compliance in the intervention group. AUTHORS' CONCLUSIONS: Opinion leaders alone or in combination with other interventions may successfully promote evidence-based practice, but effectiveness varies both within and between studies. These results are based on heterogeneous studies differing in terms of type of intervention, setting, and outcomes measured. In most of the studies the role of the opinion leader was not clearly described, and it is therefore not possible to say what the best way is to optimise the effectiveness of opinion leaders.