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BACKGROUND AND PURPOSE: Changes to hospital systems were implemented from March 2020 in Australia in response to the coronavirus disease 2019 pandemic, including decreased resources allocated to stroke units. We investigate changes in the quality of acute care for patients with stroke or transient ischemic attack during the pandemic according to patients' treatment setting (stroke unit or alternate ward). METHODS: We conducted a retrospective cohort study of patients admitted with stroke or transient ischemic attack between January 2019 and June 2020 in the Australian Stroke Clinical Registry (AuSCR). The AuSCR monitors patients' treatment setting, provision of allied health and nursing interventions, prescription of secondary prevention medications, and discharge destination. Weekly trends in the quality of care before and during the pandemic period were assessed using interrupted time series analyses. RESULTS: In total, 18,662 patients in 2019 and 8,850 patients in 2020 were included. Overall, 75% were treated in stroke units. Before the pandemic, treatment in a stroke unit was superior to alternate wards for the provision of all evidence-based therapies assessed. During the pandemic period, the proportion of patients receiving a swallow screen or assessment, being discharged to rehabilitation, and being prescribed secondary prevention medications decreased by 0.58% to 1.08% per week in patients treated in other ward settings relative to patients treated in stroke units. This change represented a 9% to 17% increase in the care gap between these treatment settings during the period of the pandemic that was evaluated (16 weeks). CONCLUSIONS: During the first 6 months of the pandemic, widening care disparities between stroke units and alternate wards have occurred.

We present information on acute stroke care for the first wave of the COVID-19 pandemic in Australia using data from the Australian Stroke Clinical Registry (AuSCR). The first case of COVID-19 in Australia was recorded in late January 2020 and national restrictions to control the virus commenced in March. To account for seasonal effects of stroke admissions, patient-level data from the registry from January to June 2020 were compared to the same period in 2019 (historical-control) from 61 public hospitals. We compared periods using descriptive statistics and performed interrupted time series analyses. Perceptions of stroke clinicians were obtained from 53/72 (74%) hospitals participating in the AuSCR (80% nurses) via a voluntary, electronic feedback survey. Survey data were summarized to provide contextual information for the registry-based analysis. Data from the registry covered locations that had 91% of Australian COVID-19 cases to the end of June 2020. For the historical-control period, 9,308 episodes of care were compared with the pandemic period (8,992 episodes). Patient characteristics were similar for each cohort (median age: 75 years; 56% male; ischemic stroke 69%). Treatment in stroke units decreased progressively during the pandemic period (control: 76% pandemic: 70%, p < 0.001). Clinical staff reported fewer resources available for stroke including 10% reporting reduced stroke unit beds. Several time-based metrics were unchanged whereas door-to-needle times were longer during the peak pandemic period (March-April, 2020; 82 min, control: 74 min, p = 0.012). Our data emphasize the need to maintain appropriate acute stroke care during times of national emergency such as pandemic management.

We present information on acute stroke care for the first wave of the COVID-19 pandemic in Australia using data from the Australian Stroke Clinical Registry (AuSCR). The first case of COVID-19 in Australia was recorded in late January 2020 and national restrictions to control the virus commenced in March. To account for seasonal effects of stroke admissions, patient-level data from the registry from January to June 2020 were compared to the same period in 2019 (historical-control) from 61 public hospitals. We compared periods using descriptive statistics and performed interrupted time series analyses. Perceptions of stroke clinicians were obtained from 53/72 (74%) hospitals participating in the AuSCR (80% nurses) via a voluntary, electronic feedback survey. Survey data were summarized to provide contextual information for the registry-based analysis. Data from the registry covered locations that had 91% of Australian COVID-19 cases to the end of June 2020. For the historical-control period, 9,308 episodes of care were compared with the pandemic period (8,992 episodes). Patient characteristics were similar for each cohort (median age: 75 years; 56% male; ischemic stroke 69%). Treatment in stroke units decreased progressively during the pandemic period (control: 76% pandemic: 70%, p < 0.001). Clinical staff reported fewer resources available for stroke including 10% reporting reduced stroke unit beds. Several time-based metrics were unchanged whereas door-to-needle times were longer during the peak pandemic period (March-April, 2020; 82 min, control: 74 min, p = 0.012). Our data emphasize the need to maintain appropriate acute stroke care during times of national emergency such as pandemic management.© Copyright © 2021 Cadilhac, Kim, Tod, Morrison, Breen, Jaques, Grimley, Jones, Cloud, Kleinig, Hillier, Castley, Lindley, Lannin, Middleton, Yan, Hill, Clissold, Mitchell, Anderson, Faux, Campbell and the AuSCR COVID-19 Reporting Consortium Group.

Background: There is uncertainty on whether the expected standards of acute stroke care have been maintained during the COVID-19 pandemic in Australia. Aim(s): To assess the quality of acute stroke care provided in the state of Victoria (most affected by COVID-19) compared to other states and territories of Australia during the pandemic. Method(s): Patients admitted with acute stroke or transient ischaemic attack from 61 hospitals contributing data to the Australian Stroke Clinical Registry in both 2019 and 2020 were included in this study. 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 (9/7/2020-20/10/2020) of COVID-19 cases in Australia. Result(s): There were 37,392 patients (mean age 73 years, 56% male), including 26,117 with a clinical diagnosis of ischaemic stroke. Overall, 73% were treated in a stroke unit and 11% received intravenous thrombolysis (if ischaemic stroke). In the state of Victoria, the proportion of patients treated in a stroke unit decreased by 0.24% per week during the second wave (p=0.04). There was no change in door-toneedle times in Victoria during the second wave (p=0.246), but there was a concurrent decrease of 1.13 minutes per week in other states and territories (p<0.001). Trends in proportions of patients provided intravenous thrombolysis were similar between Victoria and other states. Conclusion(s): The COVID-19 pandemic has affected the quality of acute stroke care provided in Victoria in contrast to other states that were less impacted by the COVID-19 pandemic.

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.

OBJECTIVE: To compare the processes and outcomes of care in patients who had a stroke treated in urban versus rural hospitals in Australia. DESIGN: Observational study using data from a multicentre national registry. SETTING: Data from 50 acute care hospitals in Australia (25 urban, 25 rural) which participated in the Australian Stroke Clinical Registry during the period 2010-2015. PARTICIPANTS: Patients were divided into two groups (urban, rural) according to the Australian Standard Geographical Classification Remoteness Area classification. Data pertaining to 28 115 patients who had a stroke were analysed, of whom 8159 (29%) were admitted to hospitals located within rural areas. PRIMARY AND SECONDARY OUTCOME MEASURES: Regional differences in processes of care (admission to a stroke unit, thrombolysis for ischaemic stroke, discharge on antihypertensive medication and provision of a care plan), and survival analyses up to 180 days and health-related quality of life at 90-180 days. RESULTS: Compared with those admitted to urban hospitals, patients in rural hospitals less often received thrombolysis (urban 12.7% vs rural 7.5%, p<0.001) or received treatment in stroke units (urban 82.2% vs rural 76.5%, p<0.001), and fewer were discharged with a care plan (urban 61.3% vs rural 44.7%, p<0.001). No significant differences were found in terms of survival or overall self-reported quality of life. CONCLUSIONS: Rural access to recommended components of acute stroke care was comparatively poorer; however, this did not appear to impact health outcomes at approximately 6 months.

Background: Uncertainty exists over attributable causes for the excess mortality after stroke, and of any differences by sex. Method(s): First-ever strokes (2010-2013) admitted to 35 hospitals enrolled in the Australian Stroke Clinical Registry (AuSCR) were linked to national death registrations. For this analysis, one-year causes of death due to stroke, ischemic heart disease (IHD), other vascular conditions (e.g. hypertension), and cancer were investigated. Age and sex specific death rates by calendar year expected in the general population were derived from Australian Government data. Expected numbers of deaths were estimated for each sex by multiplying the age-specific person-years of observation by death rate. Standardised mortality rates (SMR; observed/expected deaths) were estimated for causes of death. Result(s): Among 9,441 first-ever events, 46% were women (median age 78 years) who were 6 years older than men (p<0.001) and had higher all-cause one-year mortality (25.4% vs 19.1%, p<0.001). Compared to population norms, those surviving to 30-days had >8 fold increased risk of death from stroke/recurrent events within 1 year irrespective of sex (SMR: men 8.3 vs. women 8.8). For first-ever strokes, the excess risk of death from other vascular conditions was greater in women than men (SMR 4.0 vs 2.8; p=0.04). Compared to population norms, the excess mortality after stroke was greater for IHD (SMR: men 3.5, women 3.0) and cancer (SMR: men 2.6, women 2.6). Conclusion(s): Excess mortality after stroke is mostly attributed to stroke and recurrent events, other cardiovascular conditions and cancer. Secondary stroke prevention should target vascular risk factors and co-morbidity.

Background and Aims: All-cause mortality after stroke is greater in women than men. Our aim was to examine whether there are sex differences in the causes of death (COD) or the potential contributing factors. Method(s): 1-year COD were obtained by linking first-ever strokes (2010- 2013) admitted to 35 hospitals participating in the Australian Stroke Clinical Registry to national death registrations. COD were categorised as stroke, ischemic heart disease (IHD), other cardiovascular disease (CVD, e.g. hypertension), cancer, and other causes. Competing risk models were used to estimate female:male specific hazard ratios (sHRs) of death with adjustment for factors that differed between men and women (sociodemographics, stroke severity assessed by ability to walk on admission). Result(s): Among 9,441 events (46% women), women were 7 years older (median age 78 vs 72, p<0.001) than men, had more severe stroke (32% vs 41% able to walk on admission, p<0.001), received similar acute care therapies, and had greater all-cause mortality (25.4% vs 19.1% p<0.001). Women had greater risk of death due to stroke (sHRunadjusted 1.65, 95% CI 1.42-1.91) and other CVD (sHRunadjusted 1.65, 95% CI 1.29-2.12), but these differences were substantially attenuated after adjusting for age, stroke severity (stroke: sHRadjusted 1.19, 95% CI 1.02-1.40; other CVD: sHRadjusted 1.12, 95% CI 0.85-1.48). In contrast, women less often died from IHD (sHRadjusted 0.58, 95% CI 0.43+/-0.77), or from cancer (sHRadjusted 0.67, 95% CI 0.49+/-0.91). Conclusion(s): COD after first stroke differ between genders with women having more deaths attributed to stroke or other CVD, reinforcing the need to manage cardiovascular risk factors.

Background: Given the potential differences in etiology and impact, the treatment and outcome of younger patients (aged 18-64 years) require examination separately to older adults (aged >=65 years) who experience acute stroke. Method(s): Data from the Australian Stroke Clinical Registry (2010-2015) including demographic and clinical characteristics, provision of evidence-based therapies and health-related quality of life (HRQoL) post-stroke was used. Descriptive statistics and multilevel regression models were used for group comparisons. Result(s): Compared to older patients (age >=65 years) among 26,220 registrants, 6,526 (25%) younger patients (age 18-64 years) were more often male (63 vs. 51%; p < 0.001), born in Australia (70 vs. 63%; p < 0.001), more often discharged home from acute care (56 vs. 38%; p < 0.001), and less likely to receive antihypertensive medication (61 vs. 73%; p < 0.001). Younger patients had a 74% greater odds of having lower HRQoL compared to an equivalent aged-matched general population (adjusted OR 1.74, 95% CI 1.56-1.93, p < 0.001). Conclusion(s): Younger stroke patients exhibited distinct differences from their older counterparts with respect to demographic and clinical characteristics, prescription of antihypertensive medications and residual health status.Copyright © 2017 S. Karger AG, Basel.

Introduction: Women may receive evidence-based care less often than men after stroke. It is uncertain whether this contributes to sex differences in outcomes. Method(s): We included first-ever strokes admitted to 39 hospitals in the AuSCR during 2010-2014. Mortality 1-year after stroke was obtained from the National Death Index. HRQoL was measured by EQ5D-3L at 3-6 months follow-up. For women compared to men, we estimated the mortality rate ratio (MRR) using multilevel Poisson modelling (accounting for hospital) and the median differences (MD) in HRQoL using quantile regression. Study factors included sociodemographics, stroke type, severity (walking ability on admission) and evidence-based therapies (stroke unit care, thrombolysis, secondary prevention medications, dysphagia screening and mobilisation). Result(s): Data were available for 14,118 strokes (46% women, 81% ischaemic, median age: 75). Women were 7 years older and less able to walk on admission (29% vs 37%, p<0.001) than men. The only difference in evidence-based therapy was that women were less often administered aspirin<=48 hours (51% vs 58%, p=0.014) in a Queensland subset (n=5,224). Mortality was greater in women (MRRcrude 1.45 [95% CI 1.33, 1.59]). Women's lower aspirin administration, advanced age and stroke severity explained the difference (MRRadjusted 1.07 [0.97, 1.17]. About 60% (n=6852) had HRQoL assessments. Only older women compared to older men had poorer EQ5D utility (MD - 0.103 [-0.160, -0.047]) independent of severity. The evidence-based care measures did not contribute to the difference. Conclusion(s): Worse outcomes in women were associated with age, severity and aspirin administration suggesting targets to reduce sex differences in outcomes.

Background and Purpose-Uncertainty exists over whether quality improvement strategies translate into better health-related quality of life (HRQoL) and survival after acute stroke. We aimed to determine the association of best practice recommended interventions and outcomes after stroke. Methods-Data are from the Australian Stroke Clinical Registry during 2010 to 2014. Multivariable regression was used to determine associations between 3 interventions: received acute stroke unit (ASU) care and in various combinations with prescribed antihypertensive medication at discharge, provision of a discharge care plan, and outcomes of survival and HRQoL (EuroQoL 5-dimensional questionnaire visual analogue scale) at 180 days, by stroke type. An assessment was also made of outcomes related to the number of processes patients received. Results-There were 17 585 stroke admissions (median age 77 years, 47% female; 81% managed in ASUs; 80% ischemic stroke) from 42 hospitals (77% metropolitan) assessed. Cumulative benefits on outcomes related to the number of care processes received by patients. ASU care was associated with a reduced likelihood of death (hazard ratio, 0.49; 95% confidence interval, 0.43-0.56) and better HRQoL (coefficient, 21.34; 95% confidence interval, 15.50-27.18) within 180 days. For those discharged from hospital, receiving ASU+antihypertensive medication provided greater 180-day survival (hazard ratio, 0.45; 95% confidence interval, 0.38-0.52) compared with ASU care alone (hazard ratio, 0.64; 95% confidence interval, 0.54-0.76). HRQoL gains were greatest for patients with intracerebral hemorrhage who received care bundles involving discharge processes (range of increase, 11%-19%). Conclusions-Patients with stroke who receive best practice recommended hospital care have improved long-term survival and HRQoL.Copyright © 2017 American Heart Association, Inc.

Background and purpose: Stroke has devastating consequences at all ages but particularly so among younger adults, with impacts on health-related quality-of-life (HRQoL), roles and usual activities including work. We aimed to compare patient characteristics, quality of hospital care indicators, and outcomes for younger (age <65 years) compared with older (65+ years) adults with stroke. Method(s): Data were from the prospective Australian Stroke Clinical Registry (AuSCR) obtained January 2010 to December 2013 (40 hospitals). Multilevel regression models were used in group comparisons HRQoL was assessed with the EQ-5D visual analogue scale (VAS) at 90-180 days; median VAS scores of AuSCR participants were compared to population norm scores (VAS of 100 = perfect health). Result(s): Among 16,780 registrants, 4,149 (33%) were aged <65 years. Compared to older patients, younger patients were more likely male (63% vs. 51%) and could walk on admission (49% vs. 35%; p < 0.001). Fewer younger patients were discharged on an antihypertensive agent(s) (57% vs. 71%; p < 0.001). After accounting for patient and hospital characteristics, younger patients were more likely to be discharged home (adjusted odds ratio [aOR] 1.88, 95% CI 1.72-2.06) and less often received inpatient rehabilitation (aOR 0.09, 95% CI 0.07-0.15). The net difference in median VAS score was greater in younger patients (DELTA10 points AuSCR 76 vs. norms 86) compared to older patients (DELTA5 points AuSCR: 70 vs. norms 75). Conclusion(s): Compared to older patients, younger patients have different characteristics and in-hospital management, and experience greater HRQoL declines after stroke compared to the age-matched normal population.