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Background: Variation from evidence-based care contributes to increased deaths and disability after stroke. Aim(s): To determine whether iterative quality improvement interventions (individually and collectively) change clinical practice and improve stroke care. Method(s): Before-and-after design comparing 20 self-selected Queensland hospitals across four time-points: T0 [baseline:03/2004-06/2012]; T1 [financial incentives for stroke unit care: 07/2012-02/2014]; T2 [externally facilitated quality improvement program (Stroke Link) incorporating clinical performance feedback; +/- action plan; ongoing support:03/ 2014-10/2014], T3 [post-measurement:11/2014-12/2015] compared to temporal trends in 23 other Australian hospitals contributing data to the Australian Stroke Clinical Registry. Outcome(s): Primary: net change in composite score (proportion of processes achieved of 8 pre-defined processes) [T0 vs T3]. Secondary: change in individual processes; composite score change comparing hospitals that did vs did not develop action plans in T2. Multivariable analyses adjusted for patient clustering by hospital. Result(s): Patient characteristics were similar across time-points (45-47% female, median age 73-75 years) in 23,800 Queensland patients (11,894 [T0]; 4781 [T3]); and n=20,484 from comparator hospitals (5,903 [T0]; 5,188 [T3]). Primary Outcome: 18% absolute improvement in composite score (coeff 0.18 95% CI 0.15, 0.21) compared to no change in comparator hospitals (95%CI -0.03, 0.03). Overall, 6/8 individual processes improved e.g. stroke unit admission odds ratio [OR] 1.57, intravenous thrombolysis if ischaemic stroke OR 1.41; mobilised during admission OR 2.19. Hospitals developing action plans had greater improvements in composite score (coeff 0.23 95%CI 0.09, 0.37). Conclusion(s): In Queensland hospitals positive changes in clinician practice were achieved from quality improvement interventions implemented during the Stroke123 study. Application in other settings

Background: Variation from evidence-based care contributes to increased deaths and disability after stroke. Aim(s): To determine whether iterative quality improvement interventions (individually and collectively) change clinical practice and improve stroke care. Method(s): Before-and-after design comparing 20 self-selected Queensland hospitals across four time-points: T0 [baseline:03/2004-06/2012]; T1 [financial incentives for stroke unit care: 07/2012-02/2014]; T2 [externally facilitated quality improvement program (Stroke Link) incorporating clinical performance feedback; +/- action plan; ongoing support:03/ 2014-10/2014], T3 [post-measurement:11/2014-12/2015] compared to temporal trends in 23 other Australian hospitals contributing data to the Australian Stroke Clinical Registry. Outcome(s): Primary: net change in composite score (proportion of processes achieved of 8 pre-defined processes) [T0 vs T3]. Secondary: change in individual processes; composite score change comparing hospitals that did vs did not develop action plans in T2. Multivariable analyses adjusted for patient clustering by hospital. Result(s): Patient characteristics were similar across time-points (45-47% female, median age 73-75 years) in 23,800 Queensland patients (11,894 [T0]; 4781 [T3]); and n=20,484 from comparator hospitals (5,903 [T0]; 5,188 [T3]). Primary Outcome: 18% absolute improvement in composite score (coeff 0.18 95% CI 0.15, 0.21) compared to no change in comparator hospitals (95%CI -0.03, 0.03). Overall, 6/8 individual processes improved e.g. stroke unit admission odds ratio [OR] 1.57, intravenous thrombolysis if ischaemic stroke OR 1.41; mobilised during admission OR 2.19. Hospitals developing action plans had greater improvements in composite score (coeff 0.23 95%CI 0.09, 0.37). Conclusion(s): In Queensland hospitals positive changes in clinician practice were achieved from quality improvement interventions implemented during the Stroke123 study. Application in other settings

Background and Aims: Little is known about the frequency of contacts with hospitals prior to an intracerebral haemorrhage (ICH) and if there were missed opportunities for stroke prevention. We determined the number of emergency presentations or admissions to hospital within three months prior to an ICH and describe if risk factors were the reason for contacts. Method(s): Australian Stroke Clinical Registry (AuSCR) data obtained in Queensland (2009-13; where there is the greatest coverage) were linked to Emergency Department (ED) and hospital admissions datasets. The first stroke registered in the AuSCR was the index event. A three month 'look-back' period was evaluated. Comorbidities were derived using ICD-10 coding. Descriptive statistics performed. Result(s): Among 5,616 registrants, 705 (13%) had an ICH (51% male, 50% aged 75+years, 80% first-ever events). Within three months prior to their ICH, 86 (12%) registrants had 136 ED presentations (median time to last presentation before ICH: 17 days) and 153 (22%) experienced 211 hospital admissions (median time to admission before ICH: 34 days). Very few patients had a risk factor recorded as the primary diagnosis in ED presentations (1% hypertension, 3% atrial fibrillation, 0.1% diabetes). A larger proportion of patients had a pre-ICH hospital admission discharge diagnostic code for stroke risk factors: 18% hypertension, 9% atrial fibrillation, 10% diabetes. Conclusion(s): About one in five patients with ICH have contact with hospitals three months prior to this major event. Some who were admitted to hospital, had important stroke risk factors, especially hypertension, that should be addressed to mitigate subsequent ICH.

Background: Literature on the 'weekend' effect on stroke care has variable conclusions. Our aim was to compare quality of care and outcomes for patients (with stroke/TIA) discharged on weekdays compared with those discharged on weekends. Method(s): Data from the Australian Stroke Clinical Registry (AuSCR) between January 2010 and December 2013 (n = 40 hospitals) were analysed. Differences in pro-cesses of care by timing of discharge were described. Multilevel regression and survival analyses (up to 180 days post event) were undertaken. Result(s): Among 14,693 eligible registrants, 1,270 (8.7%) were discharged on weekends (54% male; median age 74 years). Compared to those discharged on weekdays, patients discharged on weekends were more likely to have had a TIA (weekend 31% vs 19%; p< 0.001), could walk on admission (51% vs 41%; p<0.001) and less often received stroke unit care (68% vs 79%; p < 0.001). Patients discharged on weekends were discharged to home more often (65% vs 50%; p = 0.001), but were less often pre-scribed antihypertensive medication at discharge (63% vs 70%; p < 0.001) or received a care plan if discharged to the community (42% vs 48%; p = 0.001). After accounting for patient characteristics and clustering by hospital, patients discharged on weekends had a one day shorter length-of-stay (coefficient - 1.41, 95% CI: - 1.8 to - 1.03) and were more likely to die within 180 days (HR: 1.30, 95%CI: 1.07 to 1.60) than those discharged on weekdays. Conclusion(s): Patients with stroke or TIA discharged on weekends were more likely to receive sub-optimal discharge care and have a worse outcome. Understanding the factors related to poor outcomes is important.

Background and Aims: Little is known about the frequency of contacts with hospitals prior to an intracerebral haemorrhage (ICH) and if there were missed opportunities for stroke prevention. We determined the number of emergency presentations or admissions to hospital within three months prior to an ICH and describe if risk factors were the reason for contacts. Method(s): Australian Stroke Clinical Registry (AuSCR) data obtained in Queensland (2009-13; where there is the greatest coverage) were linked to Emergency Department (ED) and hospital admissions datasets. The first stroke registered in the AuSCR was the index event. A three month 'look-back' period was evaluated. Comorbidities were derived using ICD-10 coding. Descriptive statistics performed. Result(s): Among 5,616 registrants, 705 (13%) had an ICH (51% male, 50% aged 75+years, 80% first-ever events). Within three months prior to their ICH, 86 (12%) registrants had 136 ED presentations (median time to last presentation before ICH: 17 days) and 153 (22%) experienced 211 hospital admissions (median time to admission before ICH: 34 days). Very few patients had a risk factor recorded as the primary diagnosis in ED presentations (1% hypertension, 3% atrial fibrillation, 0.1% diabetes). A larger proportion of patients had a pre-ICH hospital admission discharge diagnostic code for stroke risk factors: 18% hypertension, 9% atrial fibrillation, 10% diabetes. Conclusion(s): About one in five patients with ICH have contact with hospitals three months prior to this major event. Some who were admitted to hospital, had important stroke risk factors, especially hypertension, that should be addressed to mitigate subsequent ICH.

Background: Literature on the 'weekend' effect on stroke care has variable conclusions. Our aim was to compare quality of care and outcomes for patients (with stroke/TIA) discharged on weekdays compared with those discharged on weekends. Method(s): Data from the Australian Stroke Clinical Registry (AuSCR) between January 2010 and December 2013 (n = 40 hospitals) were analysed. Differences in pro-cesses of care by timing of discharge were described. Multilevel regression and survival analyses (up to 180 days post event) were undertaken. Result(s): Among 14,693 eligible registrants, 1,270 (8.7%) were discharged on weekends (54% male; median age 74 years). Compared to those discharged on weekdays, patients discharged on weekends were more likely to have had a TIA (weekend 31% vs 19%; p< 0.001), could walk on admission (51% vs 41%; p<0.001) and less often received stroke unit care (68% vs 79%; p < 0.001). Patients discharged on weekends were discharged to home more often (65% vs 50%; p = 0.001), but were less often pre-scribed antihypertensive medication at discharge (63% vs 70%; p < 0.001) or received a care plan if discharged to the community (42% vs 48%; p = 0.001). After accounting for patient characteristics and clustering by hospital, patients discharged on weekends had a one day shorter length-of-stay (coefficient - 1.41, 95% CI: - 1.8 to - 1.03) and were more likely to die within 180 days (HR: 1.30, 95%CI: 1.07 to 1.60) than those discharged on weekdays. Conclusion(s): Patients with stroke or TIA discharged on weekends were more likely to receive sub-optimal discharge care and have a worse outcome. Understanding the factors related to poor outcomes is important.

OBJECTIVE: To compare two self-report questionnaires for identifying possible depression in women with metastatic breast cancer. METHOD: We conducted structured psychiatric interviews and administered the Beck Depression Inventory Short Form (BDI-SF) and Hospital Anxiety and Depression Scale (HADS) to 227 women with stage IV breast cancer. The accuracy for identifying DSM-IV-defined major and minor depression was examined. Sensitivity, specificity, positive (PPV) and negative (NPV) predictive values were calculated and receiver operating characteristic curves plotted. RESULTS: Seventy-four (32.6%) patients satisfied DSM-IV criteria for a depressive disorder. With a cut-off of 4, the BDI-SF had a sensitivity of 0.84, specificity of 0.63, and PPV of 0.52. A cut-off of 11 on the HADS-Depression scale (HADS-D) resulted in sensitivity, specificity, and PPV of 0.16, 0.97, and 0.75, respectively. For major depression alone, the BDI-SF with a cut-off of 5 had excellent sensitivity but poor PPV; the HADS, with a cut-off of 7, had weak sensitivity and PPV. CONCLUSIONS: Overall, the two scales perform similarly in identifying major depression, while the BDI-SF is the more useful in screening for DSM-IV major or minor depression categories in this clinical group.