Health policy and outcomes 2006.
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Cost of Illness↗
Biomedical subjects
Anthony G Rudd
Publications and source records attributed to Anthony G Rudd.
Estimation of the risk of stroke in black populations in Barbados and South London.
BACKGROUND AND PURPOSE: The incidence of stroke in black populations is a public health issue, but how risk varies between black communities is unclear. METHODS: Population-based registers in South London (SLSR) and Barbados (Barbados Register of Strokes [BROS]). Stroke incidence estimated by age group, gender and stroke subtype from January 1995 to December 2002 (SLSR), and October 2001 to September 2003 (BROS). Incidence rate ratios [IRR] estimated adjusting for age and sex. RESULTS: Two hundred and seventy-one cases registered in SLSR and 628 cases in BROS. Average age of stroke was 66.1 years (SD 13.7) in SLSR and 71.5 years (SD 14.9) in BROS (P<0.001). The incidence rate/1000 population in SLSR was 1.61 (European adjusted; 95% CI, 1.41 to 1.81) and 1.08 (world adjusted; 95% CI, 0.95 to 1.21). For Barbados incidence rates were 1.29 (European adjusted; 95% CI, 1.19 to1.39) and 0.85 (world adjusted; 95% CI, 0.78 to 0.92). Overall IRR for SLSR: BROS adjusted for age and sex was 1.26 (95% CI, 1.09 to 1.46). Statistically significant subtype differences included total anterior cerebral infarction (IRR, 1.82; 95% CI, 1.23 to 2.69), posterior cerebral infarction (IRR, 2.12; 95% CI, 1.28 to 3.53), primary intracerebral hemorrhage (IRR, 1.56; 95% CI, 1.03 to 2.35) and subarachnoid hemorrhage (IRR, 5.04; 95% CI, 2.54 to 9.97). CONCLUSIONS: The risk of stroke in black Caribbeans is higher in South London than Barbados, and particularly so for specific stroke subtypes. The risk in Barbados approaches that in the white population in South London and strokes occur at an older age. Whether environmental factors mediate these differences in migrant populations requires further study.
Adult↗
Poststroke survival for black-Caribbean populations in barbados and South london.
BACKGROUND AND PURPOSE: There are variations in mortality rates for stroke in black communities, but the factors associated with survival remain unclear. METHODS: The authors studied population-based stroke registers with follow up in South London (270 participants, 1995 to 2002) and Barbados (578 participants, 2001 to 2003). Differences in sociodemographic factors, stroke risk factors and their management, case severity, and acute management between London and Barbados were studied. Survival analysis used Kaplan-Meier curves, log-rank test, and Cox proportional hazards model with stratification. RESULTS: There were 1411 person-years of follow-up. Patients in Barbados had poorer survival (log-rank test P=0.037), particularly those with a prestroke Barthel index scores between 15 and 20 (1-year survival, 56.4% versus 74.3%; P<0.001). This disadvantage remained significant (hazard ratio [HR], 1.99; 95% CI, 1.23 to 3.21, P=0.005) after adjustment for age and year of stroke and stratification for stroke subtype and socioeconomic status (SES). After stratification by SES, clinical stroke subtype, and Glasgow Coma Score, and adjustment for other potential confounders, additional factors reducing survival were untreated atrial fibrillation (AF; HR, 8.54; 95% CI, 2.14 to 34.08, P=0.002), incontinence after stroke (HR, 2.64; 95% CI, 1.79 to 3.89), and dysphagia (HR, 2.25; 95% CI, 1.57 to 3.24). Patients not admitted to the hospital had improved survival (HR, 0.35; 95% CI, 0.21 to 0.58). Interaction terms between location and Barthel score, location and AF, and location and transient ischemic attack were included in the final model to reflect the greater difference in survival with a high Barthel score of 15 or more, absence of untreated AF, and having untreated transient ischemic attack. CONCLUSIONS: Black-Caribbean people with stroke living in Barbados have worse survival than similar patients in South London, particularly if they have good mobility before the stroke. Further exploration and refinement of measurement of confounding factors such as SES and poststroke management along with exploring the cultural/environmental differences between the communities is required to understand these stark differences.
Aged↗
Socioeconomic status and stroke.
This paper reviews the current evidence for the association between socioeconomic status and stroke incidence, survival, mortality, and other outcomes. The evidence is strongest for mortality and incidence of stroke, with high rates of stroke in low socioeconomic groups being a consistent finding. Low socioeconomic groups also have lower survival and greater stroke severity than high socioeconomic groups, although there is less evidence for this association. The mechanisms through which socioeconomic status affects stroke risk and outcomes are unclear but some studies report that differences in risk-factor prevalence could account for some of the variation. We discuss the implications of these findings and make recommendations for future research. Studies using prospective population-based methods with improved control for confounding factors are needed to confirm or refute these associations. Understanding the causal associations between socioeconomic status and stroke will allow interventions to be appropriately targeted and assessed.
Confounding Factors, Epidemiologic↗
Survival differences after stroke in a multiethnic population: follow-up study with the South London stroke register.
OBJECTIVES: To identify ethnic differences in survival after stroke and examine the factors that influence survival. DESIGN: Population based stroke register with follow-up. SETTINGS: South London stroke register. PARTICIPANTS: 2321 patients with first stroke registered between January 1995 and December 2002. MAIN OUTCOME MEASURES: Sociodemographic factors, risk factors for stroke and their management, severity of stroke, and acute service provision factors. Survival analysis with Kaplan-Meier curves, log rank test, and Cox's proportional hazard model with stratification. RESULTS: In univariable analyses of survival, outcome was better for black people than white people (median 33.7 v 20.0 months). After stratification by socioeconomic status, type of stroke, and Glasgow coma score, and adjustment for other potential confounders, being black was generally associated with better survival, taking into account the interaction between ethnicity and age, and ethnicity and prior Barthel score. Of the risk factors for stroke considered, current smoking (hazard ratio 1.21, 95% confidence interval 1.01 to 1.45, P = 0.044), untreated atrial fibrillation (1.36, 1.08 to 1.72, P = 0.009), untreated diabetes (1.53, 1.05 to 2.22, P = 0.027), and treated diabetes (1.61, 1.27 to 2.03, P < 0.001) were associated with reduced survival. CONCLUSION: In general, black patients in a south London population with first ever stroke are more likely to survive than white patients, the exceptions being in those aged < 65 and those with a prior Barthel score < 15. Some pre-stroke risk factors that have the potential to be modified, including the appropriate treatment of existing health problems, have a strong impact on survival.
Black People↗
Health policy and outcomes research 2004.
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Health Policy↗
Secondary prevention for stroke in the United Kingdom: results from the National Sentinel Audit of Stroke.
STUDY OBJECTIVES: To measure the quality of secondary prevention of stroke provided to patients in England, Wales and Northern Ireland. DESIGN: Retrospective case note analysis. SETTING: 235 hospitals (95% of all such hospitals), providing care for acute stroke patients in England, Wales and Northern Ireland and primary health care for follow-up data. PATIENTS: 8,200 patients admitted with stroke between 1(st) April and 30(th) June 2001. Data on up to 40 consecutive cases submitted by each hospital. AUDIT TOOL: Royal College of Physicians Intercollegiate Stroke Working Party Stroke Audit. RESULTS: 24% of patients with previous cerebrovascular disease were not on anti-thrombotic medication at the time of admission. Nine percent of appropriate patients were not taking anti-thrombotic medication at discharge. Patients left with moderate to very severe disability (Barthel scores 14 or less) compared with those independent with mild disability (Barthel score 15-20) were more likely not to have anti-thrombotic treatment (18% versus 8%). Fifty-four percent of patients with known hyperlipidaemia and 21% of those with previous ischaemic heart disease were on lipid lowering therapy on admission. Sixty-four percent of patients had lipids measured during their hospital stay and of those with high total cholesterol or LDL the rate of non-treatment was 36%. Older patients (75+ years) were less likely to be treated (54%) than those <65 years (71%). Seventy-nine percent of known patients with hypertension were on treatment at admission, with 78% being treated by discharge from hospital. At 6 months after stroke a systolic blood pressure of 140 mmHg or less, and a diastolic of 85 mmHg or less, was achieved in 41% of known pre-stroke hypertensives on treatment, 31% of previously untreated hyper-tensives but on treatment at follow-up and 40% of patients not previously labelled as hypertensive. CONCLUSIONS: Major deficiencies in delivery of secondary prevention after stroke have been demonstrated. Services need reorganisation to prevent unnecessary mortality and morbidity in this group of patients.
Aged↗
Health policy and outcome research in stroke.
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Canada↗
Ethnic differences in markers of thrombophilia: implications for the investigation of ischemic stroke in multiethnic populations: the South London Ethnicity and Stroke Study.
BACKGROUND AND PURPOSE: The role of hypercoagulable states in the pathogenesis of ischemic stroke in black subjects is not known, and data on normal reference ranges in black populations are lacking. This study estimated ethnic-specific reference ranges in a community population to determine the prevalence of thrombophilic states in a multiethnic stroke population. METHODS: Free protein S, protein C, antithrombin III, activated protein C resistance, IgG anticardiolipin antibodies, and lupus anticoagulant were determined in 130 consecutive ischemic stroke cases < or =65 years of age (50 black Caribbeans, 30 black Africans, 50 whites) and 130 community controls. RESULTS: Black African controls had significantly lower protein S (P<0.001) and protein C (P=0.049) and a trend toward lower antithrombin III (P=0.056) levels compared with white controls. Black Caribbean and African controls had higher diluted Russell's viper venom time ratios compared with whites (P=0.001, P<0.001). Using ethnic-specific reference ranges, 8 controls (6.3%) and 11 cases (8.5%) had thrombophilia abnormalities (odds ratio [OR], 1.39; 95% confidence interval [CI], 0.54 to 3.57; P=0.50). ORs were 0.96 (95% CI, 0.18 to 4.99; P=0.96) for whites, 1.57 (95% CI, 0.41 to 5.94; P=0.51) for black Caribbeans, and 2.07 (95% CI, 0.18 to 24.2; P=0.95) for black Africans. CONCLUSIONS: Failure to account for ethnic differences in the normal reference ranges for thrombophilia markers may lead to inappropriate diagnosis and investigation of hypercoagulable states in black individuals. Protein S and protein C deficiencies and lupus anticoagulant may contribute to stroke risk in a minority of black cases, but they are unlikely to be major contributors to the excess stroke risk seen in young individuals of African and African-Caribbean descent.
Africa↗
Cause of stroke recurrence is multifactorial: patterns, risk factors, and outcomes of stroke recurrence in the South London Stroke Register.
BACKGROUND AND PURPOSE: This article examines stroke recurrence and whether the subtype of the initial stroke influences the risk and subtypes of further strokes. The proportion of recurrences attributable to conventional risk factors is quantified. METHODS: From January 1995 to August 2000, all first-in-a-lifetime strokes (n=1626) were identified and prospectively followed up in a defined multiethnic inner city population of 234 533. Twelve overlapping referral sources and face-to-face follow-up at 3 months and 1 and 3 years were used to attain complete registration of stroke recurrence. Index and recurrent stroke were classified according to the Oxford Community Stroke Project classification. RESULTS: In 2744 person-years of follow-up, 153 recurrences were observed. At 5 years, the cumulative risk of first stroke recurrence was 16.6% (95% CI, 13.5 to 20.4), and the combined risk of death or stroke recurrence was 65.3% (95% CI, 61.9 to 68.6). Ethnicity and subtype of index stroke were not associated with stroke recurrence. A change in subtype between index and recurrent stroke occurred in 45.5% (95% CI, 35.8 to 55.2) of cases and was most frequent among index lacunar strokes and primary intracerebral hemorrhages. In multivariable analyses, diabetes mellitus and atrial fibrillation were associated with both stroke recurrence and recurrence-free survival. In the stroke population, 9.1% (95% CI, -2.0 to 20.2) of recurrences were attributable to diabetes and 4.9% (95% CI, -7.3 to 17.2) to atrial fibrillation during the first year after the index stroke. CONCLUSIONS: The cause of stroke recurrence is multifactorial, and the subtypes of index and recurrent strokes are often not identical. Most recurrences remain unexplained by conventional risk factors.
Aged↗
New-onset fecal incontinence after stroke: prevalence, natural history, risk factors, and impact.
BACKGROUND AND PURPOSE: Fecal incontinence (FI) is a common complication after stroke, yet epidemiological research into this distressing condition is limited. The purpose of this study was to describe the prevalence, natural history, associations, and impact of new-onset FI after stroke. METHODS: Stroke patients in the community-based South London Stroke Register (January 1995 to 2000) without preexisting FI were characterized regarding bowel continence at 7 to 10 days, 3 months, and 1 and 3 years after stroke. FI was defined as any degree of bowel leakage. RESULTS: Prevalence of poststroke FI was 30% (7 to 10 days), 11% (3 months), 11% (1 year), and 15% (3 years). One third of patients with FI at 3 months were continent by 1 year; conversely, 63% incontinent at 1 year had been continent at 3 months. Characteristics of 91 patients with FI and 755 without FI at 3 months were compared using multiple logistic regression. Acute stroke associations of neglect (adjusted odds ratio [OR], 1.9; 95% CI, 1.0 to 3.5) and initial urinary incontinence (OR, 6.2; 95% CI, 3.2 to 11.9) were no longer significant after adjustment for clinical factors at 3 months. Final independent associations were anticholinergic drug use (OR, 3.1; 95% CI, 1.1 to 10.2) and needing help with toilet use (OR, 3.5; 95% CI, 1.4 to 17.3). FI at 3 months increased the risk of long-term placement (28% vs 6%) and death within 1 year (20% vs 8%). CONCLUSIONS: New-onset FI in stroke survivors is common but may be transient. Modifiable risk factors for FI 3 months after stroke are constipating drug use and difficulty with toilet access, raising implications for developing treatment and prevention strategies.
Aged↗
Natural history of cognitive impairment after stroke and factors associated with its recovery.
OBJECTIVES: To describe the natural history of cognitive impairment following stroke over three years; determine factors associated with recovery of post-stroke cognitive impairment and examine the effect of this recovery on stroke outcomes. DESIGN: Observational study. SETTING: Population-based register of first-ever strokes. MEASURES: Mini-Mental State Examination (MMSE) for cognition (cognitive impairment: MMSE<24), Barthel and Frenchay activity indices for disability. METHODS: To describe its natural history, cognition was assessed at three months, 1, 2 and 3 years after stroke in 163 subjects registered in 1995. Recovery of cognitive impairment was examined using a larger cohort registered between 1995 and 1998 (n = 476) and 193 subjects cognitively impaired at three months were reassessed a year post stroke; 34 who had recovered cognitively (MMSE 24-30) were compared with 102 with persistent cognitive impairment in terms of demography, risk factors, initial impairments and stroke subtype. RESULTS: At three months, 1, 2 and 3 years post stroke, the prevalence rates of cognitive impairment were 39%, 35%, 30% and 32% respectively. Multivariable analyses showed that recovery was associated with smoking (OR 3.7; 95% CI 1.2-11.8), compromised by visuospatial neglect (OR 0.27; 95% CI 0.08-0.89), and had a near-significant association with right hemispheric lesion (OR 2.87; 95% CI 0.94-8.78). Cognitive recovery was associated with less institutionalization (p = 0.032) and being less disabled, on Barthel (p = 0.001) and Frenchay Activity Indices (p = 0.028). CONCLUSIONS: Cognitive impairment remains highly prevalent up to three years after first stroke. Recovery from cognitive impairment is associated with smoking and possibly right hemisphere strokes, but compromised by visuospatial neglect. These associations require further clarification.
Aged↗
Cognitive impairment after stroke: clinical determinants and its associations with long-term stroke outcomes.
OBJECTIVES: To identify factors that were associated with cognitive impairment 3 months after stroke, and to examine the associations of cognitive impairment with stroke outcomes up to 4 years after stroke. DESIGN: Observational study. SETTING: Population-based stroke register. PARTICIPANTS: Six hundred forty-five subjects with first-ever stroke, identified from the register. MEASUREMENTS: Subjects were assessed for cognition using the Mini-Mental State Examination (MMSE) 3 months after stroke. Cognitively impaired subjects (MMSE <24, n = 248 (38%)) were compared with cognitively intact subjects (MMSE 24-30, n = 397) in terms of demographic details, stroke risk factors, laterality of stroke, and initial poststroke impairments. Outcome data collected at 1, 3, and 4 years poststroke included disability assessed by the Barthel Index (BI) and the Frenchay Activity Index, case fatality, and institutionalization. RESULTS: Two hundred forty-eight (38%) of 645 subjects were cognitively impaired 3 months after stroke. Using multivariate analyses, cognitive impairment was associated with age of 75 and older (odds ratio (OR) = 2.5, 95% confidence interval (CI) = 1.5-4.2), ethnicity (Caribbean/African (OR = 1.9, 95% CI = 1.2-3.2) and Asian (OR = 3.4, 95% CI = 1.1-10.2), lower socioeconomic class (OR = 2.1, 95% CI = 1.3-3.3), left hemispheric lesion (OR = 1.6, 95% CI = 1.01-2.4), visual field defect (OR = 2.0, 95% CI = 1.2-3.2), and urinary incontinence (OR = 4.8, 95% CI = 3.1-7.3). Using multivariate analyses, cognitive impairment was associated with death or disability (BI <15) at 4 years after stroke (OR = 2.2, 95% CI = 1.1-4.5). In univariate analyses, it was also associated with higher institutionalization 4 years after stroke (P =.001). CONCLUSIONS: Cognitive impairment is common 3 months after stroke and is independently associated with older age, ethnicity, lower social class, left hemispheric stroke, visual field defect, and urinary incontinence. It is associated with poor long-term outcomes, including survival and disability, up to 4 years after stroke. Because physical and cognitive impairments after stroke have independent prognostic implications, measures that evaluate both functions should be used in future studies of stroke outcome and in care of stroke patients.
Aged↗
Health care follow-up after stroke: opportunities for secondary prevention.
BACKGROUND: Stroke patients have a 15-fold increased risk of a recurrence, but management of risk factors following stroke has been found to be unsatisfactory. Little is known about health service follow-up of patients after stroke or, consequently, the opportunities for providing secondary prevention to patients. OBJECTIVE: The aim of the present study was to investigate the relationship between health service follow-up and management of risk factors after stroke. METHODS: The study used data from the population-based South London Stroke Register, collected prospectively between 1995 and 1998. Main measures included risk factor change and follow-up by hospital physicians, GPs and district nurses. Logistic regression was used to determine relationships between these measures. RESULTS: Seven hundred and seventeen stroke survivors were registered with first stroke between 1995 and 1998. Most patients were followed-up on at least one occasion by at least one service within the first 3 months after stroke: 51% saw a hospital specialist; 72% saw a GP; and 14% saw a community nurse. However, 14% of patients did not see a doctor at all. Disabled patients were less likely to see a doctor, only 17% of severely disabled patients seeing a hospital specialist [odds ratio (OR) 0.17; 95% confidence interval (CI) 0.07-0.41]. Doctor-led follow-up was related to treatment of physiological risk factors (e.g. 73% of hypertensive patients who had seen a GP were treated compared with 59% who had seen only a hospital specialist and 47% who had seen neither). Contact with health services was not associated with behavioural risk factor change. CONCLUSIONS: Opportunities for delivering secondary prevention existed through a range of services, but problems of continuity and effectiveness of care are evident. Further investigation is needed to determine how best to intervene to address these issues. In other words, whether interventions should concentrate on improving access and availability of current services, or whether the focus should be on making current strategies more effective.
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