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Stroke is the second leading cause of death and the third leading cause of disability worldwide and its burden is increasing rapidly in low-income and middle-income countries, many of which are unable to face the challenges it imposes. In this Health Policy paper on primary stroke prevention, we provide an overview of the current situation regarding primary prevention services, estimate the cost of stroke and stroke prevention, and identify deficiencies in existing guidelines and gaps in primary prevention. We also offer a set of pragmatic solutions for implementation of primary stroke prevention, with an emphasis on the role of governments and population-wide strategies, including task-shifting and sharing and health system re-engineering. Implementation of primary stroke prevention involves patients, health professionals, funders, policy makers, implementation partners, and the entire population along the life course.

Introduction: There is limited evidence on the costs and outcomes of patients with aphasia after stroke. The aim of this study was to estimate costs in patients with aphasia after stroke according to the aphasia therapies provided. Methods: A three-arm, prospective, randomized, parallel group, open-label, blinded endpoint assessment trial conducted in Australia and New Zealand. Usual ward-based care (Usual Care) was compared to additional usual ward-based therapy (Usual Care Plus) and a prescribed and structured aphasia therapy program in addition to Usual Care (the VERSE intervention). Information about healthcare utilization and productivity were collected to estimate costs in Australian dollars for 2017–18. Multivariable regression models with bootstrapping were used to estimate differences in costs and outcomes (clinically meaningful change in aphasia severity measured by the WAB-R-AQ). Results: Overall, 202/246 (82%) participants completed follow-up at 26 weeks. Median costs per person were $23,322 (Q1 5,367, Q3 52,669, n = 63) for Usual Care, $26,923 (Q1 7,303, Q3 76,174, n = 70) for Usual Care Plus and $31,143 (Q1 7,001. Q3 62,390, n = 69) for VERSE. No differences in costs and outcomes were detected between groups. Usual Care Plus was inferior (i.e. more costly and less effective) in 64% of iterations, and in 18% was less costly and less effective compared to Usual Care. VERSE was inferior in 65% of samples and less costly and less effective in 12% compared to Usual Care. Conclusion: There was limited evidence that additional intensively delivered aphasia therapy within the context of usual acute care provided was worthwhile in terms of costs for the outcomes gained.

Background: Improving stroke services is critical for reducing the global stroke burden. The World Stroke Organization–World Health Organization–Lancet Neurology Commission on Stroke conducted a survey of the status of stroke services in low and middle-income countries (LMICs) compared to high-income countries. Methods: Using a validated World Stroke Organization comprehensive questionnaire, we collected and compared data on stroke services along four pillars of the stroke quadrangle (surveillance, prevention, acute stroke, and rehabilitation) in 84 countries across World Health Organization regions and economic strata. The World Health Organization also conducted a survey of non-communicable diseases in 194 countries in 2019. Results: Fewer surveillance activities (including presence of registries, presence of recent risk factors surveys, and participation in research) were reported in low-income countries than high-income countries. The overall global score for prevention was 40.2%. Stroke units were present in 91% of high-income countries in contrast to 18% of low-income countries (p < 0.001). Acute stroke treatments were offered in ∼ 60% of high-income countries compared to 26% of low-income countries (p = 0.009). Compared to high-income countries, LMICs provided less rehabilitation services including in-patient rehabilitation, home assessment, community rehabilitation, education, early hospital discharge program, and presence of rehabilitation protocol. Conclusions: There is an urgent need to improve access to stroke units and services globally especially in LMICs. Countries with less stroke services can adapt strategies from those with better services. This could include establishment of a framework for regular monitoring of stroke burden and services, implementation of integrated prevention activities and essential acute stroke care services, and provision of interdisciplinary care for stroke rehabilitation.

Stroke is the second leading cause of death and the third leading cause of disability worldwide and its burden is increasing rapidly in low-income and middle-income countries, many of which are unable to face the challenges it imposes. In this Health Policy paper on primary stroke prevention, we provide an overview of the current situation regarding primary prevention services, estimate the cost of stroke and stroke prevention, and identify deficiencies in existing guidelines and gaps in primary prevention. We also offer a set of pragmatic solutions for implementation of primary stroke prevention, with an emphasis on the role of governments and population-wide strategies, including task-shifting and sharing and health system re-engineering. Implementation of primary stroke prevention involves patients, health professionals, funders, policy makers, implementation partners, and the entire population along the life course.Copyright © 2022 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license

Introduction: Facilitated implementation of nurse-initiated protocols to manage fever, hyperglycaemia (sugar) and swallowing (FeSS) following stroke significantly reduces 90-day death and disability. We present results on FeSS protocol uptake in multiple European countries, including low-and-middle income countries, following implementation facilitation arising from our international collaboration with the European Stroke Organisation, Angels Initiative, and Registry of Stroke Care Quality. Method(s): Our multi-country, multi-centre, pre-test/post-test study was conducted between 2017- 2021. Data were provided at baseline and three months after FeSS protocol implementation. Nursing clinical champions, with support from the Project team (European Liaison Officer, Angels Consultants, Country Coordinators and the Nursing Research Institute) conducted multidisciplinary workshops to examine baseline results, identify barriers and facilitators to protocol implementation, and held education sessions. Outcomes were adjusted for clustering by country and hospital controlling for age/ sex/NIHSS. Result(s): Data from 76 hospitals (18 countries) were received for 3999 patients at baseline, and from 64 hospitals (17 countries) for 3257 patients post-implementation (Total n=7256). Significantly increased proportion of patients received care from pre to post according to the: fever protocol (Pre: 16%, Post: 51%, p<0.0001): hyperglycaemic protocol (Pre: 16%, Post: 52%, p<0.0001): swallow protocol (Pre: 41%, Post: 67%, p<0.0001); and the FeSS Protocols overall (Pre: 3.2%, Post: 35%, p<0.0001). Significant improvements were also found in low-and-middle income countries. Conclusion(s): Facilitated implementation of nurse-initiated FeSS protocols demonstrated successful large-scale translation of evidence into countries with different health care systems, many of which with no access to reperfusion therapies-a European first. This will reduce death and disability post-stroke.

Background: We require high-quality information on the current burden, the types of therapy and resources available, methods of delivery, care pathways and long-term outcomes for people with aphasia. Aim: To document and inform international delivery of post-stroke aphasia treatment, to optimise recovery and reintegration of people with aphasia. Methods & Procedures: Multi-centre, prospective, non-randomised, open study, employing blinded outcome assessment, where appropriate, including people with post-stroke aphasia, able to attend for 30 minutes during the initial language assessment, at first contact with a speech and language therapist for assessment of aphasia at participating sites. There is no study-mandated intervention. Assessments will occur at baseline (first contact with a speech and language therapist for aphasia assessment), discharge from Speech and Language Therapy (SLT), 6 and 12-months post-stroke. Our primary outcome is changed from baseline in the Amsterdam Nijmegen Everyday Language Test (ANELT/Scenario Test for participants with severe verbal impairments) at 12-months post-stroke. Secondary outcomes at 6 and 12 months include the Therapy Outcome Measure (TOMS), Subjective Index of Physical and Social Outcome (SIPSO), Aphasia Severity Rating Scale (ASRS), Western Aphasia Battery Aphasia Quotient (WAB-AQ), stroke and aphasia quality of life scale (SAQoL-39), European Quality of Life Scale (EQ-5D), lesion description, General Health Questionnaire (GHQ-12), resource use, and satisfaction with therapy provision and success. We will collect demography, clinical data, and therapy content. Routine neuroimaging and medication administration records will be accessed where possible; imaging will be pseudonymised and transferred to a central reading centre. Data will be collected in a central registry. We will describe demography, stroke and aphasia profiles and therapies available. International individual participant data (IPD) meta-analyses will examin

Background: We require high-quality information on the current burden, the types of therapy and resources available, methods of delivery, care pathways and long-term outcomes for people with aphasia. Aim: To document and inform international delivery of post-stroke aphasia treatment, to optimise recovery and reintegration of people with aphasia. Methods & Procedures: Multi-centre, prospective, non-randomised, open study, employing blinded outcome assessment, where appropriate, including people with post-stroke aphasia, able to attend for 30 minutes during the initial language assessment, at first contact with a speech and language therapist for assessment of aphasia at participating sites. There is no study-mandated intervention. Assessments will occur at baseline (first contact with a speech and language therapist for aphasia assessment), discharge from Speech and Language Therapy (SLT), 6 and 12-months post-stroke. Our primary outcome is changed from baseline in the Amsterdam Nijmegen Everyday Language Test (ANELT/Scenario Test for participants with severe verbal impairments) at 12-months post-stroke. Secondary outcomes at 6 and 12 months include the Therapy Outcome Measure (TOMS), Subjective Index of Physical and Social Outcome (SIPSO), Aphasia Severity Rating Scale (ASRS), Western Aphasia Battery Aphasia Quotient (WAB-AQ), stroke and aphasia quality of life scale (SAQoL-39), European Quality of Life Scale (EQ-5D), lesion description, General Health Questionnaire (GHQ-12), resource use, and satisfaction with therapy provision and success. We will collect demography, clinical data, and therapy content. Routine neuroimaging and medication administration records will be accessed where possible; imaging will be pseudonymised and transferred to a central reading centre. Data will be collected in a central registry. We will describe demography, stroke and aphasia profiles and therapies available. International individual participant data (IPD) meta-analyses will ex

Background Aboriginal Australians are known to suffer high levels of acquired brain injury (stroke and traumatic brain injury) yet experience significant barriers in accessing rehabilitation services. The aim of the Healing Right Way trial is to evaluate a culturally secure intervention for Aboriginal people with newly acquired brain injury to improve their rehabilitation experience and quality of life. Following publication of the trial protocol, this paper outlines the statistical analysis plan prior to locking the database. Methods The trial involves a stepped wedge design with four steps over 3 years. Participants were 108 adult Aboriginal Australians admitted to one of eight hospitals (four rural, four urban) in Western Australia within 6 weeks of onset of a new stroke or traumatic brain injury who consented to follow-up for 26 weeks. All hospital sites started in a control phase, with the intervention assigned to pairs of sites (one metropolitan, one rural) every 26 weeks until all sites received the intervention. The two-component intervention involves training in culturally safe care for hospital sites and enhanced support provided to participants by Aboriginal Brain Injury Coordinators during their hospital stay and after discharge. The primary outcome is quality of life as measured by the Euro QOL–5D-3L VAS. A mixed effects linear regression model will be used to assess the between-group difference at 26 weeks post-injury. The model will control for injury type and severity, age at recruitment and time since commencement of the trial, as fixed effects. Recruitment site and participant will be included as random effects. Secondary outcomes include measurements of function, independence, anxiety and depression, carer strain, allied health occasions of service received and hospital compliance with minimum processes of care based on clinical guidelines and best practice models of care. Discussion The trial will provide the first data surrounding the effectiven

Background: Access to rehabilitation services for Aboriginal people following acquired brain injury (ABI) is frequently hindered by challenges navigating: i) complex medical systems, ii) geographical distances from services and iii) culturally insecure service delivery. Healing Right Way is the first randomised control trial (RCT) to address these issues in partnership with multiple health service providers across Western Australia (WA). Aims: To outline the multicomponent Healing Right Way intervention by providing case studies, and describing challenges, facilitators and implications for rehabilitation services. Method: This stepped-wedge cluster RCT involved four metropolitan and four regional sites across WA. Aboriginal adults hospitalised for ABI were recruited from 2018-2021. Intervention components comprised ABI-related cultural security training (CST) for hospital staff, and employment of Aboriginal Brain Injury Coordinators (ABICs) to support ABI survivors for six months post-injury. The primary outcome was quality of life (measured with Euro QOL–5D-3L VAS) at 26 weeks. Secondary outcomes included participants’ overall function and disability, anxiety and depression, carer strain, and changes to service delivery across the 26-week follow-up period. Detailed process and cost evaluations were also undertaken. Results: 108 participants were recruited from the participating sites. The CST was delivered across all eight participating hospitals with 250 hospital staff trained. ABICs supported 61 participants, 70% residing in regional, rural or remote areas. Challenges to implementation of the intervention included impacts from COVID-19 responses, hospital staff turnover and availability, recruitment of people with traumatic brain injury and methods for maintaining contact with participants and next-of-kin across locations. Collaboration with Aboriginal health providers and community networks were invaluable to maintaining contact with participants during follow-u

BACKGROUND: Treatment fidelity is inconsistently reported in aphasia research, contributing to uncertainty about the effectiveness of types of aphasia therapy following stroke. We outline the processes and outcomes of treatment fidelity monitoring in a pre-specified secondary analysis of the VERSE trial. METHODS: VERSE was a 3-arm, single-blinded RCT with a 12-week primary endpoint comparing Usual Care (UC) to two higher intensity treatments: Usual Care-Plus (UC-Plus) and VERSE, a prescribed intervention. Primary outcome results were previously reported. This secondary analysis focused on treatment fidelity. Video-recorded treatment sessions in the higher intensity study arms were evaluated for treatment adherence and treatment differentiation. Treatment components were evaluated using a pre-determined fidelity checklist. PRIMARY OUTCOME: prescribed amount of therapy time (minutes); secondary outcomes: (i) adherence to therapy protocol (%) and (ii) treatment differentiation between control and high intensity groups. RESULTS: Two hundred forty-six participants were randomised to Usual Care (n=81), Usual Care-Plus (n=82), and VERSE (n=83). One hundred thirty-five (82%) participants in higher intensity intervention arms received the minimum prescribed therapy minutes. From 10,805 (UC 7787; UC-Plus 1450; VERSE 1568) service events, 431 treatment protocol deviations were noted in 114 participants. Four hundred thirty-seven videos were evaluated. The VERSE therapists achieved over 84% adherence to key protocol elements. Higher stroke and aphasia severity, older age, and being in the UC-Plus group predicted more treatment deviations. CONCLUSIONS: We found high levels of treatment adherence and differentiation between the intervention arms, providing greater confidence interpreting our results. The comprehensive systems for intervention fidelity monitoring and reporting in this trial make an important contribution to aphasia research and, we argue, should set a new standard

BACKGROUND: Aboriginal Australians are known to suffer high levels of acquired brain injury (stroke and traumatic brain injury) yet experience significant barriers in accessing rehabilitation services. The aim of the Healing Right Way trial is to evaluate a culturally secure intervention for Aboriginal people with newly acquired brain injury to improve their rehabilitation experience and quality of life. Following publication of the trial protocol, this paper outlines the statistical analysis plan prior to locking the database. METHODS: The trial involves a stepped wedge design with four steps over 3 years. Participants were 108 adult Aboriginal Australians admitted to one of eight hospitals (four rural, four urban) in Western Australia within 6 weeks of onset of a new stroke or traumatic brain injury who consented to follow-up for 26 weeks. All hospital sites started in a control phase, with the intervention assigned to pairs of sites (one metropolitan, one rural) every 26 weeks until all sites received the intervention. The two-component intervention involves training in culturally safe care for hospital sites and enhanced support provided to participants by Aboriginal Brain Injury Coordinators during their hospital stay and after discharge. The primary outcome is quality of life as measured by the Euro QOL-5D-3L VAS. A mixed effects linear regression model will be used to assess the between-group difference at 26 weeks post-injury. The model will control for injury type and severity, age at recruitment and time since commencement of the trial, as fixed effects. Recruitment site and participant will be included as random effects. Secondary outcomes include measurements of function, independence, anxiety and depression, carer strain, allied health occasions of service received and hospital compliance with minimum processes of care based on clinical guidelines and best practice models of care. DISCUSSION: The trial will provide the first data surrounding the effect

INTRODUCTION: Telemedicine can alleviate the problems faced in rural settings in providing access to specialist stroke care. The evidence of the cost-effectiveness of this model of care outside high-income countries is limited. This study aimed to conduct: (a) a systematic review of economic evaluations of telestroke and (b) a cost-utility analysis of telestroke, using China as a case study. METHOD(S): We systematically searched Embase, Medline Complete and Cochrane databases. Inclusion criteria: full economic evaluations of telemedicine/telestroke networks examining the use of thrombolysis in patients with acute ischaemic stroke, published in English. A cost-utility analysis was undertaken using a Markov model incorporating a decision tree to simulate the delivery of telestroke for acute ischaemic stroke in rural China, compared to no telestroke from a societal and healthcare perspective. One-way deterministic sensitivity analyses and probabilistic sensitivity analyses were performed to test the robustness of results. RESULT(S): Of 559 publications found, eight met the eligibility criteria and were included in the systematic review (two cost-effectiveness analyses and six cost-utility analyses, all performed in high-income countries). Telestroke was a cost-saving/cost-effective intervention in five out of the eight studies. In our modelled analysis for rural China, telestroke was the dominant strategy, with estimated cost savings of Chinese yuan 4,328 (US$627) and additional 0.0925 quality-adjusted life years per patient. Sensitivity analyses confirmed the base case results. DISCUSSION: Consistent with published economic evaluations of telestroke in other jurisdictions, telestroke represents a cost-effective solution to enhance stroke care in rural China.

Background: Little is known about factors influencing the transition to Permanent Residential Aged Care (PRAC) for those living in the community following stroke. Aim(s): To identify factors associated with new entry into PRAC 6-18 months following stroke. Method(s): Retrospective cohort, assembled for the PRECISE study, involving person-level linkages between the Australian Stroke Clinical Registry (AuSCR, 2012-2016), Medicare, Pharmaceutical, National Aged Care Data Clearinghouse (NACDC), Death and hospital data for Adult registrants from Queensland and Victoria. New entries to PRAC within 6-18 months following stroke admission was determined using items from the Medicare and NACDC datasets. Multivariable competing risks survival analysis, adjusted for death as a competing risk, was performed to determine factors associated with new PRAC entry. Result(s): 15,872 of the linked cohort were eligible for inclusion (median age 71 years, 42% female, 45% severe stroke). In the 6-18 months following stroke, there were 883 (6%) new entries into PRAC (median 326 days post-admission). Factors associated with transition to PRAC included having a severe stroke (subhazard ratio 1.30 [95% confidence interval 1.10, 1.54], p=0.002), being discharged to in-patient rehabilitation (1.79 [1.50, 2.12], p<0.001), having >=3 comorbidities (1.70 [1.39, 2.09], p<0.001), having dementia (2.48 [1.88, 3.27], p<0.001), and receiving a government-subsidised home care package (2.29 [1.84, 2.84], p<0.001). Conclusion(s): We provide new data that afford insights into transition to PRAC following stroke. Results suggest that survivors needing increased support to delay transition to PRAC after stroke, include those with greater stroke severity and comorbidity, including dementia.

Background And Aims: While there is an increased stroke prevalence in working age adults, the strength of association between stroke type, rehabilitation, self-efficacy and independence level has received scarce attention. Our aim was to determine the relationships between stroke type, functional capacity and hospital quality of care after stroke. Method(s): Descriptive correlational design. Included participants were working age (<70 years) adults with stroke admitted to an inpatient rehabilitation facility between 07-01-2014 and 06-31-2019. Data were extracted from medical records; selfcare activities were clinically assessed using the Functional Independence Measure (FIMTM) and instrumental activities using the Functional Autonomy Measure. FIMTM efficiency (FIMTM/length of stay (LOS)) was calculated to indicate rehabilitation benefit. Result(s): From 131 eligible patients, 116 had confirmed stroke type. There weren't significant age differences comparing stroke types, however more males had ischaemic stroke (75.6% males). Compared with ischaemic stroke, patients with haemorrhagic stroke were less disabled when admitted to rehabilitation (FIMTM 45+/-29.1 vs 34+/-18.7, p = 0.03), had greater functional independence on discharge based on total FIMTM (81+/-37.5 vs 71+/-30.7, p =0.13) and slightly higher FIM efficiency (total FIMTM efficiency median 0.27 vs 0.20; FIMTM motor efficiency median 0.22 vs 0.16) though not statistically significant. Adjusting for sex and age, stroke severity, relationships between LOS and selfefficacy will be discussed. Conclusion(s): Compared to patients with ischaemic stroke, those with haemorrhagic stroke were less functionally disabled when admitted into rehabilitation, and appeared to benefit more in functional outcomes from their rehabilitation stay.

Background and Aims: Interventions to reduce readmissions and support recovery on discharge from hospital after stroke are limited. Our aim was to test the feasibility of an innovative, electronic support package that includes educational and motivational messages aligned with patient-centred goals for recovery and secondary prevention for survivors of stroke. Method(s): Multicentre (n=3) randomised controlled feasibility trial of our novel 12-week electronic support package Patients were recruited in hospital. At 7-14 days after discharge consent was confirmed via telephone and participants randomised. Control participants received 6 administrative messages only, while intervention participants received up to 7 (range 4-7) messages/week aligned to their goals, plus the administrative messages. Feasibility was assessed by examining participation, completion of outcome measurements, and trial processes (with hospital and trial coordination staff). Outcomes obtained by a blinded assessor at 90-days post randomisation included readmission/s, goal achievement, disability/dependence and quality-of-life. Result(s): Among 105 eligible patients, 25 refused, 24 were discharged prior to consent, 37 (35%) were recruited (68% male, median age 64), and 33/37 were randomised (3 ineligible; 1 lost to follow-up). Participation in the trial was 85% (15/17 intervention; 14/16 control). One participant (intervention group) requested the messages to stop. Follow-up assessments were completed in 28/29 participants. Greatest barriers to recruitment were time constraints for comprehensive goal setting by hospital clinicians and early discharge. Conclusion(s): Findings from this Phase II feasibility trial confirmed acceptability of the ReCAPS intervention and informed the methods for the Phase III study which is currently underway in 12 Australian hospitals.

Background: Aphasia is associated with increased hospital stays and use of rehabilitation services. Little is known about the hospitalisation costs for patients with aphasia in Australia. Aim(s): To compare the costs of hospitalisation for patients with and without aphasia. Method(s): Data on patients admitted with stroke/TIA to Queensland hospitals (n=22) participating in the Australian Stroke Clinical Registry were linked to administrative datasets. The International Classification of Diseases 10th Revision codes were used to identify patients with aphasia (R470). These codes were selected from emergency department presentations and hospital admissions for linked cases using a 5-year look back period. Clinical costing data were obtained from Queensland Health and were inflated to a 2013/2014 financial year equivalent using the Total Health Price Index. The additional cost associated with aphasia was assessed using median regression analysis, with clustering by hospital. Result(s): There were 1043/4195 (26.5%) patients recorded as having aphasia (49% female; 78 median age; 83% ischaemic stroke). Greater overall costs per person were observed for medical (median cost $2273 vs. $1727, p<0.05), nursing ($3829 vs. $2748, p<0.05), non-clinical ($765 vs. $601, p<0.05), and allied health ($1138 vs. $720, p<0.05) activities. After adjustment for confounding factors, patients with aphasia had $2882 greater total costs of admission on average than patients without aphasia (95% confidence interval $1880 to $3884). Conclusion(s): Greater costs were associated with hospitalisation for patients with aphasia after stroke. This has implications for the economic burden of healthcare provision for patients with post-stroke aphasia in Australia.

Background and Aims: Initiatives at non-urban hospitals in New Zealand have improved access to reperfusion therapies for patients with stroke.We aimed to investigate if any additional costs are offset by improved outcomes and costs savings after discharge. Method(s): REGIONS Care involved consecutive patients admitted with stroke to all 28 acute stroke hospitals in New Zealand (12 urban) between May and October 2018. Costs from a societal perspective at 12 months after stroke were estimated using standardised data collected on the hospital stay and a follow-up survey. Estimated costs were assigned to the initial hospital patients presented to. Quality adjusted life years (QALYs) were estimated using outcomes at discharge from hospital, vital status and responses to the EuroQol-5D questionnaire at 12 months follow-up. Multiple imputation and multivariable regression analyses were used to assess differences between groups. Result(s): There were 946 patients from non-urban and 1419 from urban hospitals. Costs of acute care for patients presenting to urban hospitals were $1786 greater on average than those presenting to nonurban hospitals (p<0.001). Estimated costs until 12 months were no different between groups (urban $26137 vs non-urban $25067, p=0.396). The average QALYs per person was greater in the urban cohort than the non-urban cohort (0.58 vs 0.53, p=0.001). Conclusion(s): Despite greater costs of acute care, patients who presented to urban hospitals had similar costs at 12 months compared to non-urban counterparts. Further research is required to investigate if additional funding to non-urban hospitals can reduce downstream costs and improve outcomes.

Background and Aims: The QASC Europe project significantly improved nurse-initiated management of: fever, hyperglycaemia (sugar) and swallowing (FeSS) in European stroke units with varying health care systems. We examined pre-post management for low-and-middle-income-countries (LMIC). Method(s): Data from this multi-site, multi-country, pre-test/post-test study (2018-2021) were collected at baseline and three months after FeSS protocol implementation. Clinical champions conducted multidisciplinary workshops to feedback baseline audit data results, provided education, and identified barriers to protocol implementation. Outcomes were adjusted for age, sex, NIHSS, country and within clustering by site. Result(s): Data were received from 76 hospitals in 18 countries (n=4196 patients); and post-implementation, 64 hospitals in 17 countries (3348 patients). 13 hospitals (pre-implementation, n=648 patients) and 9 hospital (post-implementation, n=444 patients) from six LMIC Significant improvements were achieved from pre-to-post implementation in LMIC for: monitoring of temperature at least four times on day three (26% vs 62%, p=0.018); venous blood glucose level (BLG) on admission (86% vs 98%, p=0.0256); BGL monitored four times/day on day of admission to stroke unit (51% vs 84%, p=0.001); swallow screen/assessment performed before oral medication (73% vs 94%, p=0.039); and swallow screen/assessment before being given oral food or fluid (76% vs 93%, p=0.007). Results from LMIC were broadly consistent with those from high-income countries. Conclusion(s): Our nurse-initiated intervention was highly effective in improving stroke outcomes in LMIC. While LMIC are known to have reduced thrombolysis rates, that they are providing comparable evidenced-based care for fever, hyperglycaemia and swallowing is noteworthy. Upscaling of effective stroke interventions is essential to improving stroke outcomes globally.

Background and Aims: The Quality in Acute Stroke (QASC) trial demonstrated a significant reduction in death and disability when clinicians were assisted to introduce protocols to manage fever, hyperglycaemia (sugar) and swallowing (FeSS) following stroke. A unique international collaboration between the Nursing Research Institute, Australian Catholic University; the European Stroke Organisation; and the Angels Initiative is underway to implement the FeSS Protocols into 20 European countries. We present baseline (pre-FeSS implementation) results for management of these important physiological parameters post-stroke Methods: Data were entered into the European Registry of Stroke Care Quality (RES-Q) for 7 indicators of FeSS care between 2017-2019. Result(s): Forty hospitals from 13 countries completed baseline data entry (n=2266 patients). Paracetamol was administered within one hour following temperature >37.5degreeC C for 58% of patients (n=214/367). When glucose was >10mmols/L, 60% of patients (n=241/403) received insulin within one hour. 57% of patients (1293/2266) received a swallow screen or assessment before being given oral food, fluids or medications. Conclusion(s): All FeSS processes of care need improving, and we are actively working with the Angels Initiative and clinicians to implement the FeSS protocols which have been translated into 13 different languages. Successful large-scale implementation of these evidence-based, nurse-initiated protocols into countries with vastly different health care systems, many of whom also have no access to reperfusion therapies, is likely to make a significant impact on reducing death and disability after stroke.

Background and Aims: Globally, there were concerns about the quality of acute stroke care due to the COVID-19 pandemic. In this study, we compared the quality of acute stroke care provided in stroke units with alternate ward settings before and during the pandemic. Method(s): Patients admitted with stroke or transient ischaemic attack from 61 hospitals contributing data to the Australian Stroke Clinical Registry in 2019 and 2020 were included. Interrupted time series analysis was conducted to assess trends in the provision of acute stroke care before and after the first wave (starting 1/3/2020) and second wave (between 9/7/2020-20/10/2020) of COVID-19 cases in Australia. Result(s): Overall, 38, 295 patients were available for analysis (n=19, 164 in 2019, n=19, 131 in 2020 [provisional sample]). There were no differences in age and sex between years (mean age 73 years, 56% male). Fewer patients were provided treatment in a stroke unit in 2020 compared to 2019 (72% vs 77%, p<0.001). There were greater declines in the provision of hyperacute aspirin and secondary prevention at discharge in alternate wards than stroke units during the second wave (between 0.41% and 1.31% per week). Provision of mobilisation and swallow screening/assessment declined in alternate wards only. Provision of care planning at discharge improved in alternate wards relative to stroke units by 0.49% per week during the first wave and 1.14% per week during the second wave. Conclusion(s): The COVID-19 pandemic has affected the quality of acute stroke care. It is essential that patients continue to be treated in stroke units.

Background and Aims: The reasons people with post-stroke aphasia have poor health outcomes are not well understood. We aimed to determine factors associated with aphasia, and compare the frequency of post-stroke hospital readmissions amongst patients with and without aphasia. Method(s): Patient-level data from the Australian Stroke Clinical Registry (years 2009-2013) were linked to national death data, hospital emergency presentations and admissions data from Victoria, Queensland, New South Wales and Western Australia. Multivariable logistic regression was used to assess factors associated with aphasia identified from ICD10 discharge codes for the index stroke event. Cox regression was used for hospital readmissions within 30 days, 90 days, 180 days and 1-year. Comorbidities were identified using ICD-10 coded admission data from 5-years prior to the stroke event. Result(s): 12,690 adults with stroke were included (median age 76; 54% male; 77% ischaemic stroke); 26% identified with aphasia. The factors most strongly associated with aphasia were prior diagnosis of stroke (aOR 7.76, 95%CI 2.44-24.7; p<0.001), paraplegia (aOR 1.57, 95%CI 1.42-1.75; p<0.001), and atrial fibrillation (aOR 1.56, 95%CI 1.41-1.73; p<0.001). Compared to people without aphasia, people with aphasia more often had a hospital readmission within 180 days (HR 1.11, 95%CI 1.02-1.22; p=0.009), and 1-year (HR 1.12, 95%CI 1.03-1.21; p=0.005). Hospital readmissions within 30 days and 90 days were not significantly different. Conclusion(s): Patients with prior stroke are more likely to experience aphasia following a new stroke event. Early aphasia-specific secondary stroke prevention, education and support may help reduce the prevalence of post-stroke aphasia and hospital readmissions.

Background And Aims: Little is known about long-term outcomes associated with access to inpatient rehabilitation after stroke. Aim(s): to compare long-term outcomes for patients discharged directly home with those discharged to inpatient rehabilitation after stroke. Method(s): Data collected in the Australian Stroke Clinical Registry (2010-2013) were linked to hospital admission records and the national death index as part of the Stroke123 study. Multilevel multivariable regression analyses were conducted, adjusting for patient and hospital factors. Outcomes were death and hospital readmissions up to 365-days and health-related quality of life (HRQoL) at 90-180days. Result(s): 7,847 patients were included (median age 71 years, 59% male, 83% ischemic stroke); 4405 (56%) were discharged home and 3,442 (44%) to inpatient rehabilitation. Patients discharged directly home were more likely to be aged under 65 years and to walk independently at hospital admission. Patients discharged to inpatient rehabilitation had more comorbidities and greater odds of having dementia. Hazard of death was not significantly different between the two groups. Patients discharged directly home were more likely to be readmitted to hospital than patients discharged to inpatient rehabilitation (adjusted subhazard ratio [aSHR]:90-days 0.54, 95%CI 0.49, 0.61; aSHR:180-days 0.74, 95%CI 0.67, 0.82; aSHR:365-days 0.85, 95%CI 0.78, 0.93). Patients discharged directly home had higher HRQoL scores, but were more likely to report mobility problems (adjusted OR 0.54, 95%CI 0.47, 0.63). Conclusion(s): Patients discharged directly home have higher risks of readmission and self-reported mobility problems than patients discharged to inpatient rehabilitation. To reduce this disadvantage, better support is indicated for people who are discharged directly home after stroke.

Background And Aims: The Shared Team Approach between Nurses and Doctors for Improved Risk Factor Management (STANDFIRM) trial was designed to test the use of chronic disease care management plan to modify risk factors among patients with ischemic and haemorrhagic stroke . The aim is to predict Framingham risk factors (FRS) at 12 months from recruitment and change in the score from baseline in the STANDFIRM cohort. Method(s): Data available for random forest regression (Python) included: demographic, social and education status, and electrolytes. Change in FRS was defined as baseline minus12 months scores divided by 12 months score and as raw difference. This supervised ensemble machine learning model was created from multiple decision trees. Data were split into training (75%, n=387) and test (25%, n=129). Variable importance was determined by estimating the Shapley values, a dimensionless measure of the marginal gain from coalition of covariates calculated by averaging the contribution over all possible combination of covariates. Result(s): Shapley values ranked the important variables in the random forest in order: age , male sex , glycosylated haemoglobin , systolic blood pressure , cholesterol , and educational status (Figure) . The Spearman correlation between the model and test data was 0.762. The random forest model performed less well at predicting change in the FRS (ratio and raw difference) in this trial cohort *Spearman correlation with test data were 0.291 for the ratio and 0.273 for the raw difference). Conclusion(s): Machine learning method can be used to predict future Framingham risk score but not change in score.

Background And Aims: Poor oral care can have negative consequences after stroke. Little is known about current oral care practices for patients with stroke in hospitals and whether this varies across different regions. This study explored current practices of oral care after stroke in the UK and Australia. Method(s): Surveys were mailed to hospitals known to provide inpatient care for patients with stroke. Result(s): Response rates were 86% (150/174) in the UK and 74% (120/163) in Australia. Only 69% of hospitals in the UK and 36% in Australia reported having an oral care protocol, with only 54% of UK and 14% of Australia reporting using oral care assessment tools. of those using tools, these were generally hospital-specific tools in both regions, with only seven standardised tools used across the UK compared to five in Australia. Oral care assessments were undertaken on admission in 73% of UK and 57% of Australian hospitals. Oral care was mostly provided twice a day, unless patients were nil by mouth when it was provided three times a day in both regions. Date, time and care provider were more likely to be recorded whereas the type of oral care provided was less likely. Over half of staff in the UK (55%) received oral care training in the last year compared to less than a third in Australia (30%). Conclusion(s): Unacceptable variability exists in oral care practices for stroke. Oral care is a neglected area of stroke clinical practice, particularly more so in Australian when compared to hospitals in the UK.

Background: General Practitioners (GPs) are incentivised through Medicare funded Team Care Arrangements (TCAs) to provide multidisciplinary care. It is unknown whether these items are appropriately targeted among survivors of stroke. Aim(s): To describe, by impairment, the use of TCAs in survivors of stroke living in the community. Method(s): Data from the Australian Stroke Clinical Registry (AuSCR: 2010-2014, N=26 hospitals, five states) were linked with Medicare. Adults registrants who provided EQ-5D health status survey data between 90-180 days were included. Receipt of TCA items during the 18-month period following stroke were identified using Medicare data. Latent Class Analysis (LCA) was used to classify registrants based on their EQ-5D dimension responses (mobility, self-care, anxiety/depression, pain, usual activities). The relationships between LCA classes and TCAs were explored using multivariable logistic regression. Result(s): 5,432 AuSCR registrants were included (44% female, median age 74 years, 86% ischaemic). Of these, 34% received a TCA and 24% had an allied health claim (66% podiatry, 25% physiotherapy, others<5%). Most TCAs (86%) involved only one type of allied health professional. Registrants were classified into three latent classes defined as: minimal, moderate and severe impairment. Receipt of a TCA varied by class: mild (32%), moderate (40%), severe (25%). Compared with minimal impairment, the odds of receiving a TCA were greater for those in the moderate (aOR: 1.37, 95%CI: 1.21, 1.55), but lower for those in the severe impairment class (aOR: 0.75, 95%CI: 0.60, 0.94). Conclusion(s): While one in three survivors accessed TCAs for multidisciplinary care, rates were lower in those with more severe impairment. Greater uptake of these items could fill gaps in long-term care after stroke, especially for those who may benefit most.

Background And Aims: Dehydration and malnutrition are common in hospitalised stroke patients and are associated with poor outcomes including mortality. This study aimed to capture how nutrition and hydration is currently assessed and managed in the UK and Australia (AUS). Method(s): Cross-sectional survey of 337 hospitals (April to November 2019) providing inpatient care for stroke patients (UK N=174; AUS N=163). Responses were analysed using descriptive statistics. Result(s): 270 respondents (UK N=150 86%; AUS N=120 74%) from a range of clinical settings (121 acute stroke unit; 19 stroke ward; 63 integrated acute and rehabilitation; 56 rehabilitation; 11 other). Nutritional status was most likely to be assessed on admission (UK 79%; AUS 84%) by a Nurse (UK 97%; AUS 83%) or Dietician (UK 70%; AUS 85%). In the UK, 90% utilised the Malnutrition Universal Tool (MUST), compared with 50% in AUS. Management decisions regarding calorie-intake were the realm of Dieticians (UK 98%; AUS 97%). Hydration assessment was undertaken by Nurses (UK 87%; AUS 79%) or Doctors (UK 81%; AUS 88%) on admission (UK 62%; AUS 58%) and repeated daily (UK 65%; AUS 61%) using a combination of visual assessment (UK 65%; AUS 61%) and clinical tests (Urine Specific Gravity UK 22%; AUS 46%; Urea:creatinine UK 3%; AUS 20%). Hydration management decisions were primarily made by physicians (UK 84%; AUS 83%). Conclusion(s): Nutrition and hydration practices are broadly similar in the UK and AUS, with Nurses taking responsibility for assessment and monitoring, while Dieticians and Physicians undertake decisionmaking regarding management. The survey findings will inform further research and education.

Background And Aims: Prescription of multiple classes of medications (antihypertensive, antithrombotic and lipid-lowering) is recommended in clinical guidelines for ischemic stroke (IS) and transient ischemic attack (TIA) to prevent further vascular events. We aimed to determine the association between optimal combination medication treatment (supply of all three classes, "optimal treatment") and survival after IS/TIA. Method(s): Cohort of patients with first-ever IS/TIA from the Australian Stroke Clinical Registry (2010- 2014) linked with pharmaceutical claims data. We excluded patients who died within 30 days of admission. Cox regression was used to determine associations between optimal treatment and 1-year (from day 30 to 395) survival using landmark methods, adjusting for socio-demographics (age, sex, socioeconomic position) and clinical characteristics (stroke type, discharge destination). Result(s): Among 8136 survivors with first-ever IS/TIA satisfying inclusion criteria (45% female, median age 74 years), 75.5% received >=1 medication class, and 34.0% had optimal treatment. Patients with optimal treatment (N=2765) were more often aged >=75 years (51.3% vs 44.3%; p<0.001), discharged directly home (65.8% vs 49.5%; p<0.001) and experienced a less severe stroke (53.2% vs 43.5%; p<0.001), than those without optimal treatment. Compared to no medication, treatment with two medications was associated with a 42% lesser risk of death (95%CI: 27-55%); and optimal treatment, a 68% lesser risk of death (95% CI: 49-65%). Survival was similar between those with one or no medication. Conclusion(s): Patients with stroke/TIA who received optimal combination medication treatment within 30-days of admission had greater one-year-survival. Further research is required to understand reasons for sub-optimal medication treatment.