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Introduction: Fabry disease (FD) is an X-linked lysosomal storage disorder characterized by a deficiency or absence of alpha-galactosidase A (alpha-GAL A) enzyme, where stroke can be a serious complication. The aim of this study is to determine the feasibility of centralized screening for FD, among young stroke adults registered in the national Australian Stroke Clinical Registry (AuSCR). Method(s): The study was conducted in young (age 18 - 55 years) survivors of acute stroke of unknown etiology registered in AuSCR at hospitals in Queensland, Tasmania, New South Wales, and Victoria during 2014 - 2015; and who, at the 3-month outcome assessment, agreed to be re-contacted for future research. Descriptive analyses of case identification from responses and specific enzyme and DNA sequencing analyses were conducted for alpha-galactosidase A (alpha-GLA) from dried blood spot (DBS) testing. Result(s): Of 326 AuSCR-identified patients invited to participate, 58 (18%) provided consent but six were subsequently unable to provide a blood sample and two later withdrew consent to use their data. Among the remaining 50 participants (median age 53 years [48 - 56 years]; 47% female), 67% had experienced an acute ischemic stroke. All males (n = 27) had an initial screen for alpha-GLA enzyme activity of whom seven with low enzyme levels had normal secondary alpha-GLA gene analysis. All females (n = 23) had genetic analysis, with one shown to have a pathogenic c.352C>T p.(Arg118Cys) missense mutation of the alpha-GLA gene for FD. Conclusion(s): These findings provide logistical data for embedding a process of automated central stroke registry screening for an additional case-finding tool in FD.© Copyright © 2020 Malavera, Cadilhac, Thijs, Lim, Grabsch, Breen, Jan and Anderson.

Following publication of the original article [1], the authors reported an error in one of the authors' names. In this Correction the incorrect and correct author name are shown. The original article has been corrected. Originally the author name was published as: - Enna Striol-Salama The correct author name is: - Enna Stroil-Salama.

Background: The quality of stroke care may diminish on weekends. Aim(s): We aimed to compare the quality of care and outcomes for patients with stroke/transient ischemic attack discharged on weekdays compared with those discharged on weekends. Method(s): Data from the Australian Stroke Clinical Registry from January 2010 to December 2015 (n = 45 hospitals) were analyzed. Differences in processes of care by the timing of discharge are described. Multilevel regression and survival analyses (up to 180 days postevent) were undertaken. Result(s): Among 30,649 registrants, 2621 (8.6%) were discharged on weekends (55% male; median age 74 years). Compared to those discharged on weekdays, patients discharged on weekends were more often patients with a transient ischemic attack (weekend 35% vs. 19%; p < 0.001) but were less often treated in a stroke unit (69% vs. 81%; p < 0.001), prescribed antihypertensive medication at discharge (65% vs. 71%; p < 0.001) or received a care plan if discharged to the community (47% vs. 53%; p < 0.001). After accounting for patient characteristics and clustering by hospital, patients discharged on weekends had a 1 day shorter length of stay (coefficient = -1.31, 95% confidence interval [CI] = -1.52, -1.10), were less often discharged to inpatient rehabilitation (aOR = 0.39, 95% CI = 0.34, 0.44) and had a greater hazard of death within 180 days (hazard ratio = 1.22, 95% CI = 1.04, 1.42) than those discharged on weekdays. Conclusion(s): Patients with stroke/transient ischemic attack discharged on weekends were more likely to receive suboptimal care and have higher long-term mortality. High quality of stroke care should be consistent irrespective of the timing of hospital discharge.Copyright © 2018 World Stroke Organization.

Background: The quality of care and outcomes for people who experience stroke whilst in hospital for another condition has not been previously studied in Australia. Aim(s): To explore differences in long-term outcomes among patients with in-hospital events treated in stroke units (SUs) compared to those managed in other hospital wards. Method(s): Forty-five hospitals participating in the Australian Stroke Clinical Registry between January 2010 and December 2014 contributed data. Survival of all patients with in-hospital stroke to 180 days after stroke and health-related quality of life, using EQ-5D-3L among 73% eligible, were compared using multilevel, multivariable regression models. Models were adjusted for age, sex, index of relative socioeconomic disadvantage, ability to walk, stroke type, transfer from another hospital, and history of stroke. Result(s): Among 20,786 stroke events, 1182 (5.1%) occurred in-hospital (median age 77 years, 49% male). Patients with in-hospital stroke treated in SUs died less often within 30 days (Hazard Ratio 0.56; 95% CI 0.39-0.81) than those not admitted to SUs. Survivors reported similar health-related quality of life between 90 and 180 days compared to those treated in other wards (coefficient = 0.01, 95% CI -0.06-0.09, P =.78). Patients managed in SUs more often received recommended management (e.g. swallowing screening). Conclusion(s): The benefits of SU care may extend to patients experiencing in-hospital stroke. Validation, including accounting for potential residual confounding factors, is required.Copyright © 2019 Elsevier Inc.

Following publication of the original article [1], the authors reported an error in one of the authors' names. In this Correction the incorrect and correct author name are shown. The original article has been corrected.

Background and Purpose-Hospital uptake of evidence-based stroke care is variable. We aimed to determine the impact of a multicomponent program involving financial incentives and quality improvement interventions, on stroke care processes. Methods-A prospective study of interventions to improve clinical care quality indicators at 19 hospitals in Queensland, Australia, during 2010 to 2015, compared with historical controls and 23 other Australian hospitals. After baseline routine audit and feedback (control phase, 30 months), interventions involving financial incentives (21 months) and then addition of externally facilitated quality improvement workshops with action plan development (9 months) were implemented. Postintervention phase was 13 months. Data were obtained for the analysis from a previous continuous audit in Queensland and subsequently the Australian Stroke Clinical Registry. Primary Outcome: change in median composite score for adherence to <=8 indicators. Secondary Outcomes: change in adherence to self-selected indicators addressed in action plans and 4 national indicators compared with other Australian hospitals. Multivariable analyses with adjustment for clustered data. Results-There were 17 502 patients from the intervention sites (median age, 74 years; 46% women) and 20 484 patients from other Australian hospitals. Patient characteristics were similar between groups. There was an 18% improvement in the primary outcome across the study periods (95% CI, 12%-24%). The largest improvement was following introduction of financial incentives (14%; 95% CI, 8%-20%), while indicators addressed in action plans provided an 8% improvement (95% CI, 1%-17%). The national score (4 indicators) improved by 17% (95% CI, 13%-20%) versus 0% change in other Australian hospitals (95% CI,-0.03 to 0.03). Access to stroke units improved more in Queensland than in other Australian hospitals (P<0.001). Conclusions-The quality improvement interventions significantly improved clin

BACKGROUND: Organizational context is one factor influencing the translation of evidence into practice, but data pertaining to patients with acute stroke are limited. We aimed to determine the associations of organizational context in relation to four important evidence-based stroke care processes. METHOD(S): This was a mixed methods cross-sectional study. Among 19 hospitals in Queensland, Australia, a survey was conducted of the perceptions of stroke clinicians about their work using the Alberta Context Tool (ACT), a validated measure covering 10 concepts of organizational context, and with additional stroke-specific contextual questions. These data were linked to the Australian Stroke Clinical Registry (AuSCR) to determine the relationship with receipt of evidence-based acute stroke care (acute stroke unit admission, use of thrombolysis for those with acute ischemic stroke, receipt of a written care plan on discharge, and prescription of antihypertensive medications on discharge) using quantile regression. Exploratory cluster analysis was used to categorize hospitals into high and low context groups based on all of the 10 ACT concepts. Differences in adherence to care processes between the two groups were examined. RESULT(S): A total of 215 clinicians completed the survey (50% nurses, 37% allied health staff, 10% medical practitioners), with 81% being in their current role for at least 1year. There was good reliability ( 0.83) within the cohort to allow pooling of professional groups. Greater ACT scores, especially for social capital (mu 9.00, 95% confidence interval [CI] 4.86 to 13.14) and culture (mu 7.33, 95% CI 2.05 to 12.62), were associated with more patients receiving stroke unit care. There was no correlation between ACT concepts and other care processes. Working within higher compared to lower context environments was associated with greater proportions of patients receiving stroke unit care (88.5% vs. 69.0%) and being prescribed antihypertensive medicati

The Australian Stroke Clinical Registry (AuSCR) collects patient-reported outcomes at 90-180 days post-stroke. During telephone interviews, stroke survivors or their carers/family members often explain why they did not respond to a previously mailed survey. This feedback is useful to explore respondents' experiences of the follow-up process. Three main reasons for not returning surveys included: health-related time constraints, confusion about survey questions, and stroke denial. Such information is helpful in improving procedures for clinical quality disease registries and researchers using postal questionnaires.Copyright © 2018 World Stroke Organization.

Background: Organizational context is one factor influencing the translation of evidence into practice, but data pertaining to patients with acute stroke are limited. We aimed to determine the associations of organizational context in relation to four important evidence-based stroke care processes. Methods: This was a mixed methods cross-sectional study. Among 19 hospitals in Queensland, Australia, a survey was conducted of the perceptions of stroke clinicians about their work using the Alberta Context Tool (ACT), a validated measure covering 10 concepts of organizational context, and with additional stroke-specific contextual questions. These data were linked to the Australian Stroke Clinical Registry (AuSCR) to determine the relationship with receipt of evidence-based acute stroke care (acute stroke unit admission, use of thrombolysis for those with acute ischemic stroke, receipt of a written care plan on discharge, and prescription of antihypertensive medications on discharge) using quantile regression. Exploratory cluster analysis was used to categorize hospitals into high and low context groups based on all of the 10 ACT concepts. Differences in adherence to care processes between the two groups were examined. Results: A total of 215 clinicians completed the survey (50% nurses, 37% allied health staff, 10% medical practitioners), with 81% being in their current role for at least 1 year. There was good reliability (∞ 0.83) within the cohort to allow pooling of professional groups. Greater ACT scores, especially for social capital (μ 9.00, 95% confidence interval [CI] 4.86 to 13.14) and culture (μ 7.33, 95% CI 2.05 to 12.62), were associated with more patients receiving stroke unit care. There was no correlation between ACT concepts and other care processes. Working within higher compared to lower context environments was associated with greater proportions of patients receiving stroke unit care (88.5% vs. 69.0%) and being prescribed antihypertensive medication a

Following publication of the original article [1], the authors reported an error in one of the authors' names. In this Correction the incorrect and correct author name are shown. The original article has been corrected.

Background and Purpose- Hospital uptake of evidence-based stroke care is variable. We aimed to determine the impact of a multicomponent program involving financial incentives and quality improvement interventions, on stroke care processes. Methods- A prospective study of interventions to improve clinical care quality indicators at 19 hospitals in Queensland, Australia, during 2010 to 2015, compared with historical controls and 23 other Australian hospitals. After baseline routine audit and feedback (control phase, 30 months), interventions involving financial incentives (21 months) and then addition of externally facilitated quality improvement workshops with action plan development (9 months) were implemented. Postintervention phase was 13 months. Data were obtained for the analysis from a previous continuous audit in Queensland and subsequently the Australian Stroke Clinical Registry. Primary outcome: change in median composite score for adherence to ≤8 indicators. Secondary outcomes: change in adherence to self-selected indicators addressed in action plans and 4 national indicators compared with other Australian hospitals. Multivariable analyses with adjustment for clustered data. Results- There were 17 502 patients from the intervention sites (median age, 74 years; 46% women) and 20 484 patients from other Australian hospitals. Patient characteristics were similar between groups. There was an 18% improvement in the primary outcome across the study periods (95% CI, 12%-24%). The largest improvement was following introduction of financial incentives (14%; 95% CI, 8%-20%), while indicators addressed in action plans provided an 8% improvement (95% CI, 1%-17%). The national score (4 indicators) improved by 17% (95% CI, 13%-20%) versus 0% change in other Australian hospitals (95% CI, -0.03 to 0.03). Access to stroke units improved more in Queensland than in other Australian hospitals ( P<0.001). Conclusions- The quality improvement interventions significantly improved

Background and Purpose-In multicultural Australia, some patients with stroke cannot fully understand, or speak, English. Language barriers may reduce quality of care and consequent outcomes after stroke, yet little has been reported empirically. Methods-An observational study of patients with stroke or transient ischemic attack (2010-2015) captured from 45 hospitals participating in the Australian Stroke Clinical Registry. The use of interpreters in hospitals, which is routinely documented, was used as a proxy for severe language barriers. Health-Related Quality of Life was assessed using the EuroQoL-5 dimension-3 level measured 90 to 180 days after stroke. Logistic regression was undertaken to assess the association between domains of EuroQoL-5 dimension and interpreter status. Results-Among 34562 registrants, 1461 (4.2%) required an interpreter. Compared with patients without interpreters, patients requiring an interpreter were more often women (53% versus 46%; P<0.001), aged =75 years (68% versus 51%; P<0.001), and had greater access to stroke unit care (85% versus 78%; P<0.001). After accounting for patient characteristics and stroke severity, patients requiring interpreters had comparable discharge outcomes (eg, mortality, discharged to rehabilitation) to patients not needing interpreters. However, these patients reported poorer Health-Related Quality of Life (visual analogue scale coeffcient,-9; 95% CI,-12.38,-5.62), including more problems with self-care (odds ratio: 2.22; 95% CI, 1.82, 2.72), pain (odds ratio: 1.84; 95% CI, 1.52, 2.34), anxiety or depression (odds ratio: 1.60; 95% CI, 1.33, 1.93), and usual activities (odds ratio: 1.62; 95% CI, 1.32, 2.00). Conclusions-Patients requiring interpreters reported poorer Health Related Quality of Life after stroke/transient ischemic attack despite greater access to stroke units. These fndings should be interpreted with caution because we are unable to account for prestroke Health Related Quality of Life. Further

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: 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.

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.

Objectives: Stroke has devastating consequences at all ages and among patients with language barriers this may impact more substantially on health-related quality-of-life (HRQoL). We aimed to compare patient characteristics, quality of hospital care indicators, and outcomes between patients who did and did not require an interpreter. Method(s): Data from the Australian Stroke Clinical Registry (AuSCR) obtained January 2010 to December 2013 (n = 40 hospi- tals). Multilevel regression models were used in group comparisons. HRQoL was assessed with the EQ-5D-3L and EQ5D visual analogue scale (VAS) at 90-180 days. Result(s): Among 16,887 registrants, 701 (4.1%) required an interpreter. Compared to patients without language barriers, patients with language barriers were more likely to be aged 75 years or older (69% vs. 52%, p < 0.001) and be unable to walk on admission (72% vs. 61%, p < 0.001). Patients with language barriers had greater access to most quality indicators (stroke unit care 84% vs. 76%, p < 0.001). After accounting for patient characteristics and stroke severity, patients with language barriers had comparable discharge outcomes (e.g. mortality, discharged rehabilitation) to patients without language barriers. At median 101 days post stroke, patients with language barriers reported more problems with mobility (65% vs, 50%), self-care (56% vs, 32%), activity (73% vs, 57%), pain (66% vs, 49%) and anxiety or depression (60% vs, 46%) and lower median VAS score barriers (median 60 vs. 71; p < 0.001 for all comparisons). Conclusion(s): Patients who had language barriers presented to hospital with more severe strokes and although they received good access to quality stroke care they experienced poorer HRQoL after stroke. Determination of the underlying reasons for such differences in severity and outcome may be of value in the care of patients with stroke who require an interpreter.

Background/Objectives: In multicultural Australia, there are patients with stroke are unable to speak or fully understand English. It remains unclear if patients with stroke who require an interpreter during hospitalisation receive poorer quality of care or experience worse outcomes. Design/Method: Data from 45 hospitals participating in the Australian Stroke Clinical Registry from 2010-2014 were used. Health-related quality of life (HRQoL) was assessed using the EQ-5D-3L at 90-180 days. Propensity score matching of patients using age, sex and ability to walk on admission was undertaken to reduce selection bias. Between group comparisons were analysed using multilevel, multivariable regression. Result(s): Among 25,531 registrants, 1,049 (4.1%) required an interpreter. Compared to patients without interpreters, patients with interpreters were more often female (52% vs 46%), aged <=75 years (68% vs 51%) and unable to walk on admission (71% vs 62%). Patients needing interpreters had greater access to stroke unit care (84% vs 77%; p<0.001) and were more often discharged on antihypertensive medication (72% vs 69%;p=0.03). After accounting for patient characteristics and stroke severity, patients requiring interpreters had comparable discharge outcomes to patients not needing interpreters, but reported poorer HRQoL (Coefficient -0.10; 95%CI -0.13,-0.07) including more problems with self-care (OR 2.08, 95% CI 1.55, 2.79), activity (OR:1.52; 95%CI 1.12, 2.07) and pain (OR:1.78, 95%CI 1.32, 2.38). Conclusion(s): Patients requiring interpreters reported poorer HRQoL 90- 180 days after stroke despite receiving recommended care more often than those not needing an interpreter. Understanding the reasons for these differences may assist in providing better support for these patients.

Background: Little is known about the factors that contribute to readmission after discharge from hospital following acute stroke or transient ischaemic attack. Aim(s): To describe the patient and clinical factors associated with all-cause readmission to hospital within 90 days after discharge from stroke. Method(s): Cohort design linking data from the Australian Stroke Clinical Registry (2009-2013), national death registration registry and hospital separations from Victoria, Queensland, New South Wales and Western Australia. Time to first readmission was examined using competing risks regression accounting for death within 90-days. Prior history of risk factors for stroke and prior comorbidities (using the Elixhauser Index) were derived using ICD-10 codes from separations data in the preceding 5-years. Result(s): Data for 13,676 patients were linked (45% female; 79% ischaemic stroke). Among 12,549 patients discharged (excluding discharges inpatient rehabilitation), 23% were readmitted within 90 days; 27% among those discharged directly to home. In univariable analyses readmission was associated with older age, being Australian born, greater stroke severity, shorter length of stay and having more risk factors or comorbidities, but not stroke unit care. After adjustment, factors independently associated with a higher rate of 90-day readmission were higher Elixhauser comorbidity scores (HR:1.09, 95%CI:1.05,1.14) and a history of hypertension (HR:1.33, 95%CI:1.09,1.63), smoking (HR:1.20,95%CI:1.08,1.35), high cholesterol (HR:1.20, 95%CI:1.07,1.36) or atrial fibrillation (HR:1.12, 95%CI:1.03,1.22). Conclusion(s): Patients with a larger burden of comorbidities and risk factors before stroke are at greater risk of readmission within 90 days after discharge. Closer follow-up of these patients is needed to reduce readmissions within 90 days.

Rationale: The effectiveness of clinician-focused interventions to improve stroke care is uncertain. Aim(s): To determine whether an organizational intervention can improve the quality of stroke care over usual care. Sample size estimates: To detect an absolute 10% difference in overall performance (composite outcome), a minimum of 21 hospitals and 843 patients per group was determined. Methods and design: Before and after controlled design in hospitals in Queensland, Australia. Intervention(s): Externally facilitated program (StrokeLink) using outreach workshops incorporating clinical performance feedback, patient outcomes (survival, quality of life at 90-180 days), local barrier assessments to best practice care, action planning, and ongoing support. Descriptive and multivariable analyses adjusted for patient correlations by hospital (intention-to-treat method). Context: Concurrent implementation of financial incentives to increase stroke unit access and use of the Australian Stroke Clinical Registry for performance monitoring. Study outcome(s): Primary outcome: net change in composite score (i.e. total number of process indicators achieved divided by the sum of eligible indicators for each cohort). Secondary Outcomes: change in individual indicators, change in composite score comparing hospitals that did or did not develop action plans (per-protocol analysis), impact on 90-180-day health outcomes. Sensitivity analyses: hospital self-rated status, alternate cross-sectional audit data (Stroke Foundation). To account for temporal effects, comparison of Queensland hospital performance relative to other Australian hospitals will also be undertaken. Discussion(s): Twenty-one hospitals were recruited; however, one was unable to participate within the study time frame. Workshops were held between 11 March 2014 and 7 November 2014. Data are ready for analysis.Copyright © 2017 World Stroke Organization.

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 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.

Objectives: To investigate differences in management and outcomes for patients admitted to the hospital with TIA according to care on a stroke unit (SU) or alternate ward setting up to 180 days post event. Method(s): TIA admissions from 40 hospitals participating in the Australian Stroke Clinical Registry during 2010-2013 were assessed. Propensity score matching was used to assess outcomes by treatment group including Cox proportional hazards regression to compare survival differences and other appropriate multivariable regression models for outcomes including health-related quality of life and readmissions. Result(s): Among 3,007 patients with TIA (mean age 73 years, 54% male), 1,110 pairs could be matched. Compared to management elsewhere in hospitals, management in an SU was associated with improved cumulative survival at 180 days post event (hazard ratio 0.57, 95% confidence interval 0.35-0.94; p 5 0.029), despite not being statistically significant at 90 days (hazard ratio 0.66, 95% confidence interval 0.33-1.31; p 5 0.237). Overall, there were no differences for being discharged on antihypertensive medication or with a care plan, and the 90- to 180-day self-reported outcomes between these groups were similar. In subgroup analyses of 461matched pairs treated in hospitals in one Australian state (Queensland), patients treated in an SU were more often prescribed aspirin within 48 hours (73% vs 62%, p , 0.001) and discharged on antithrombotic medications (84% vs 71%, p , 0.001) than those not treated in an SU. Conclusion(s): Hospitalized patients with TIA managed in SUs had better survival at 180 days than those treated in alternate wards, potentially through better management, but further research is needed.Copyright © 2016 American Academy of Neurology.

Background: There are several state-based and national quality improvement (QI) initiatives designed to support Australian hospitals in closing the gap between evidence and practice. Little is known about the influence of external support on these activities. Aim(s): To investigate the association between the amount and type of external support provided to hospitals participating in the Stroke123 Queensland sub-study and the extent to which a QI plan was implemented. Method(s): Participating hospitals (n = 21) were given external support (e.g. education) for QI activities by staff from the Australian Stroke Clinical Registry (AuSCR), StrokeLink program(National Stroke Foundation), and Queensland Statewide Stroke Clinical Network. Managers from each program submit data using a standardized template on the number of contacts and type of support given. The frequency of hospitals reviewing their AuSCR data is also recorded. Descriptive statistics presented using data from May 2013-December 2014. Result(s): The most common externally supported activities included educational outreach (30%), interprofessional collaboration (29%), and audit and feedback (8%). Face-to-Face contacts ranged from 2-8/site and telephone contacts 3-14/site. Most (95%) hospital staff reported accessing their AuSCR data for QI monitoring. Hospitals that developed action plans (AP) (n = 16) tended to have more contact time with external support managers (median [Q1:Q3] AP 20 hours [16:23] vs no AP 13 hours [12:16], p = 0.098) and reported accessing AuSCR data more often (median [Q1:Q3] AP 9 times [6:14], no AP 3 times [2:8], p = 0.097). Conclusion(s): Providing external support with accessible and current registry data appear important factors in facilitating hospital based QI activities.

Background: Limited information exists on the quality of care provided to patients with transient ischemic attack (TIA) who are admitted to hospitals. Aim(s): To compare the treatment of TIA with the treatment of ischemic stroke (IS) and to investigate differences in the treatment of TIA based on stroke unit management. Method(s): Data from the Australian Stroke Clinical Registry (AuSCR) from 2010-13 were utilized. Univariable analysis was conducted to assess differences in processes of care received because the processes of care we investigated were universally applicable to both groups. Due to the large sample size, statistical significance was defined as a p-value <=0.01. Result(s): There were 3007 episodes of TIA and 10576 episodes of IS. Compared to patients with IS, fewer patients with TIA were managed on a stroke unit (TIA 72% vs IS 85%, p < 0.001), fewer received a care plan at discharge (TIA 44% vs IS 58%, p < 0.001), and fewer received an antihypertensive medication at discharge (67% vs 71%, p = 0.002). The proportion of patients discharged on antithrombotic medication was similar between groups (77% for TIA and 76% for IS, p = 0.281). When compared to patients with TIA not managed on a stroke unit, those managed on a stroke unit were more often discharged with antihypertensive medications (70% vs 62%, p < 0.001) and with antithrombotic medications (81% vs 71%, p < 0.001). Conclusion(s): There are opportunities for improved stroke prevention in patients hospitalized with TIA. Greater access to stroke units for patients with TIA may improve access to prevention management.

Introduction: Data collected in the Australian Stroke Clinical Registry (AuSCR) are used to monitor the quality of acute stroke care and its impact on patient outcomes. Survival is a main outcome and so these data must be reliable. We aimed to compare mortality data recorded in AuSCR with mortality data from the National Death Index (NDI). Method(s): Following ethics and other governance approvals, personal and clinical identifiers of all AuSCR registrants in 2009-2013 were securely submitted to the Australian Institute of Health and Welfare for linkage to the NDI. We calculated the sensitivity and specificity of clinician recorded in-hospital death data in AuSCR with the NDI. Identified deaths at 90-180 days post-discharge, recorded in AuSCR at patient follow-up, were compared to deaths during this period using the NDI. Result(s): Of the 16803 records in AuSCR submitted for linkage (mean age 73 years, 54% male), 1532 (11%) were identified as in-hospital deaths according to the NDI. Excellent agreement was demonstrated for in-hospital deaths between AuSCR and the NDI (98.8% sensitivity, 99.6% specificity). At 180 days after discharge from hospital 2913 deaths were identified from the NDI. In AuSCR, 2418 of the 2913 deaths (83%) were determined during follow-up at 90-180 days. Missed deaths were recorded as lost to follow-up. Conclusion(s): A good match between the AUSCR and the NDI for in-hospital deaths validates using the NDI to capture deaths outside hospital. Linkage with the NDI adds value to AuSCR and provides more comprehensive measure of post-discharge deaths for all registrants.

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

Background and Purpose: The quality of care for people who experience stroke whilst in hospital for another condition has not been previously studied in Australia. Our aim was to compare patient characteristics, quality of care indicators, and outcomes for in-hospital strokes with those for community-onset strokes. Method(s): We used data from the Australia Clinical Stroke Registry (AuSCR) obtained from January 2010 to December 2013 (40 hospitals). Outcomes were compared using multilevel regression models and linked to the National Death Index. Utility scores were derived from the EQ-5D health-related quality-of-life (HRQoL) questionnaire assessed in eligible survivors at 90-180 days. Result(s): Among 13,860 registrants, 817 (6%) had the onset of symptoms whilst in hospital. Patients with an in-hospital stroke were more likely to be female (51% vs. 46%) and older (median age 78 vs. 76 years, p = 0.015) compared to community-onset cases. Fewer patients with an in-hospital stroke received stroke unit care (61% vs. 79%; p < 0.001).After accounting for patient and hospital characteristics, patients with in-hospital strokes were less likely to be discharged home (adjusted OR 0.31, 95% CI 0.25- 0.39) and more likely to die within 180 days from onset (aOR 2.02, 95% CI 1.69-2.43) or report worse HRQoL (mean difference utility score -0.11, 95% CI -0.16 to -0.06) compared with community-onset strokes. Conclusion(s): Compared to community-onset strokes, patients with an in-hospital stroke receive less stroke unit care and experience worse outcomes. These findings suggest an important opportunity for focused strategies to improve outcomes for patients who experience a stroke whilst in hospital.

Background: Prescription of antihypertensive medication at discharge from hospital following stroke is recommended in clinical guidelines. How adherence to guidelines and associated outcomes vary by stroke subtype is unclear. Aim(s): To compare 90-180 day outcomes between patients who were and were not prescribed antihypertensive medication at discharge between transient ischemic attack (TIA), ischemic stroke and intracerebral hemorrhage (ICH). Method(s): We assessed patients discharged from 40 hospitals with a diagnosis of stroke and registered in the Australian Stroke Clinical Registry (AuSCR; 2010-2013). Multivariable analyses were adjusted for age, gender, previous stroke, socioeconomic status, stroke severity and patient clustering. Dependent variables were HRQoL (EQ-5D Visual Analogue Scale (VAS) 0-100) and 180-day mortality (National Death Index data). Combined HRQoL and death outcomes were calculated using the EQ-5D utility score (-1 to 1, deaths = 0). Result(s): Outcomes were available for 6,679 eligible registrants (median [Q1:Q3] age 76 [66:84] years, 45% female). Most (73%) were prescribed antihypertensive medications at discharge with minor variation by subtype (ICH 71%, ischemic 74%, TIA 72%, p = 0.02). Patients with ICH prescribed antihypertensive medications had better outcomes for the VAS (coefficient: 5.5, 95% CI 0.5, 10.4), survival at 180 days (aOR 3.3, 95% CI: 2.0, 5.6) and EQ-5D utility score (coefficient: 0.2, 95% CI: 0.1, 0.3) than those not prescribed these agents. Patients with ischemic stroke and prescribed antihypertensive medication had better survival (aOR: 2.1, 95% CI: 1.7, 2.6) than patients not prescribed these medications. Conclusion(s): Our findings highlight the importance of prescribing antihypertensive medications at discharge to improve stroke outcomes, especially for ICH.

OBJECTIVE: To evaluate the effectiveness of a complex intervention implementing best practice guidelines recommending clinicians screen and counsel young people across multiple psychosocial risk factors, on clinicians' detection of health risks and patients' risk taking behaviour, compared to a didactic seminar on young people's health. DESIGN: Pragmatic cluster randomised trial where volunteer general practices were stratified by postcode advantage or disadvantage score and billing type (private, free national health, community health centre), then randomised into either intervention or comparison arms using a computer generated random sequence. Three months post-intervention, patients were recruited from all practices post-consultation for a Computer Assisted Telephone Interview and followed up three and 12 months later. Researchers recruiting, consenting and interviewing patients and patients themselves were masked to allocation status; clinicians were not. SETTING: General practices in metropolitan and rural Victoria, Australia. PARTICIPANTS: General practices with at least one interested clinician (general practitioner or nurse) and their 14-24 year old patients. INTERVENTION: This complex intervention was designed using evidence based practice in learning and change in clinician behaviour and general practice systems, and included best practice approaches to motivating change in adolescent risk taking behaviours. The intervention involved training clinicians (nine hours) in health risk screening, use of a screening tool and motivational interviewing; training all practice staff (receptionists and clinicians) in engaging youth; provision of feedback to clinicians of patients' risk data; and two practice visits to support new screening and referral resources. Comparison clinicians received one didactic educational seminar (three hours) on engaging youth and health risk screening. OUTCOME MEASURES: Primary outcomes were patient report of (1) clinician detection o

Supportive-Expressive Group Therapy (SEGT) has been developed and manualised in the research setting, but there have been few clinical accounts of its utility. In this qualitative review of its application in the Melbourne-based randomised control trial (RCT) for women with advanced breast cancer, SEGT is considered from the perspective of the structure and framework of therapy, its therapists, the issues that develop in exploring its common themes and what constitutes a well functioning group. Groups move through identifiable developmental phases. The mature group process transforms existential ambivalence into creative living, evidenced by humour, celebration, assertiveness, altruism, new creative pursuits and eventually courageous acceptance of dying. Challenges and pitfalls include avoidance, non-containment of ambivalence, intolerance of difference, anti-group phenomena and splitting. A key element is the medicalization of the group culture whereby members and co-therapists explore health beliefs and attitudes about care. This promotes compliance with anti-cancer treatments, including both the initiation of and perseverance with chemotherapy. This mechanism could prove to be a potentially important pathway in promoting longer survival. Copyright © 2004 John Wiley & Sons, Ltd.

Background: Mixed reports exist about the impact of supportive-expressive group therapy (SEGT) on survival. Method(s): From 485 women with advanced breast cancer recruited between 1996-2002, 227 (47%) consented and were randomized within an average 10 months of cancer recurrence in a 2:1 ratio to intervention with 1 year or more of weekly SEGT plus three classes of relaxation therapy (147 women) or to control receiving three classes of relaxation therapy (80 women). The primary outcome was survival; psychosocial well-being was appraised secondarily. Analysis was by intention-to-treat. Result(s): SEGT did not prolong survival (median survival 24.0 months in SEGT and 18.3 in controls; univariate hazard ratio for death 0.92 [95% CI, 0.69-1.26]; multivariate hazard ratio, 1.06 [95% CI, 0.74-1.51]). Significant predictors of survival were treatment with chemotherapy and hormone therapy (p < 0.001), visceral metastases (p < 0.001) and advanced disease at first diagnosis (p < 0.05). SEGT ameliorated and prevented new DSM-IV depressive disorders (p = 0.002), reduced hopeless-helplessness (p = 0.004), trauma symptoms (p = 0.04) and improved social functioning (p = 0.03). Conclusion(s): SEGT did not prolong survival. It improved quality of life, including treatment of and protection against depression. Copyright © 2007 John Wiley & Sons, Ltd.

Objective: To compare two self-report questionnaires for identifying possible depression in women with metastatic breast cancer. Method(s): 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. Result(s): 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 bur poor PPV; the HADS, with a cut-off of 7, had weak sensitivity and PPV. Conclusion(s): 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.

Objective: To assess psychosocial morbidity in women with breast cancer and to compare the differential rates between women with early stage and advanced disease. Method(s): In this report, 303 women with early stage breast cancer, psychiatrically assessed at baseline (as part of a study of cognitive-existential group therapy during adjuvant chemotherapy), are compared with 200 women with advanced breast cancer (similarly assessed in a trial of supportive-expressive group therapy). A structured psychiatric interview plus self-report measures were used to assess psychiatric morbidity, quality of life and cognitive attitude to cancer. Result(s): The early stage patients, whose mean age was 46 years, were on average 3 months post-surgery and had an overall prevalence of DSM-IV psychiatric diagnosis of 45%. The metastatic patients, whose mean age was 51 years, were on average 63 months post-primary diagnosis and had an overall prevalence of DSM-IV diagnosis of 42%; the difference between the two rates was not statistically significant. Of women with early stage breast cancer, 36.7% had mood disorders, 9.6% suffering from major depression and 27.1% from minor depression. In the metastatic sample 31% had mood disorders, 6.5% having major depression and 24.5% with minor depression. Anxiety disorders were present in 8.6% of the early stage group and 6% of women with advanced disease. Fatigue, a past history of depression, and cognitive attitudes of helplessness, hopelessness or resignation were significantly associated with depression in both groups. The women from the metastatic sample were significantly less distressed by hair loss but more dissatisfied with body image, and had higher rates of lymphoedema and hot flushes than the early stage women. Conclusion(s): The rates of psychosocial distress are high, and similar, across patients with both early and advanced stage breast cancer, although the illness related causes of distress are different. These data present a chal

BACKGROUND: There are growing worldwide concerns about the ability of primary health care systems to manage the major burden of illness in young people. Over two thirds of premature adult deaths result from risks that manifest in adolescence, including injury, neuropsychiatric problems and consequences of risky behaviours. One policy response is to better reorientate primary health services towards prevention and early intervention. Currently, however, there is insufficient evidence to support this recommendation for young people. This paper describes the design and implementation of a trial testing an intervention to promote psychosocial risk screening of all young people attending general practice and to respond to identified risks using motivational interviewing. MAIN OUTCOMES: clinicians' detection of risk-taking and emotional distress, young people's intention to change and reduction of risk taking. SECONDARY OUTCOMES: pathways to care, trust in the clinician and likelihood of returning for future visits. The design of the economic and process evaluation are not detailed in this protocol. METHODS: PARTY is a cluster randomised trial recruiting 42 general practices in Victoria, Australia. Baseline measures include: youth friendly practice characteristics; practice staff's self-perceived competency in young people's care and clinicians' detection and response to risk taking behaviours and emotional distress in 14-24 year olds, attending the practice. Practices are then stratified by a social disadvantage index and billing methods and randomised. Intervention practices receive: nine hours of training and tools; feedback of their baseline data and two practice visits over six weeks. Comparison practices receive a three hour seminar in youth friendly practice only. Six weeks post-intervention, 30 consecutive young people are interviewed post-consultation from each practice and followed-up for self-reported risk taking behaviour and emotional distress three and 12 mo

OBJECTIVE: Our purpose was to determine the frequency of psychiatric morbidity and to assess the quality of life of women with advanced breast cancer. METHODS: The 227 women in the sample were recruited in Melbourne, Australia, and were interviewed (prior to intervention) for a randomized controlled trial of supportive-expressive group therapy. The main outcome measures were DSM-IV psychiatric diagnoses plus quality of life data based on the EORTC QLQ-C30 (core) and QLQ-BR23 (breast module) instruments. RESULTS: Forty-two percent of the women (97/227) had a psychiatric disorder; 35.7% (81) of these had depression or anxiety or both. Specific diagnoses were minor depression in 58 women (25.6%), major depression in 16 (7%), anxiety disorder in 14 (6.2%), and phobic disorder in 9 (4%). Seventeen (7.5%) women had more than one disorder. In terms of quality of life, one-third felt less attractive, one-quarter were dissatisfied with their body image, and, in most, sexual interest had waned. Menopausal symptoms such as hot flashes affected less than one-third, whereas symptoms of lymphedema were experienced by 26 (11.5%). SIGNIFICANCE: Women with advanced breast cancer have high rates of psychiatric and psychological disturbance. Quality of life is substantially affected. Clinicians need to be vigilant in monitoring psychological adjustment as part of a comprehensive biopsychosocial approach.

OBJECTIVE: To assess psychosocial morbidity in women with breast cancer and to compare the differential rates between women with early stage and advanced disease. METHOD: In this report, 303 women with early stage breast cancer, psychiatrically assessed at baseline (as part of a study of cognitive-existential group therapy during adjuvant chemotherapy), are compared with 200 women with advanced breast cancer (similarly assessed in a trial of supportive-expressive group therapy). A structured psychiatric interview plus self-report measures were used to assess psychiatric morbidity, quality of life and cognitive attitude to cancer. RESULTS: The early stage patients, whose mean age was 46 years, were on average 3 months post-surgery and had an overall prevalence of DSM-IV psychiatric diagnosis of 45%. The metastatic patients, whose mean age was 51 years, were on average 63 months post-primary diagnosis and had an overall prevalence of DSM-IV diagnosis of 42%; the difference between the two rates was not statistically significant. Of women with early stage breast cancer, 36.7% had mood disorders, 9.6% suffering from major depression and 27.1% from minor depression. In the metastatic sample 31% had mood disorders, 6.5% having major depression and 24.5% with minor depression. Anxiety disorders were present in 8.6% of the early stage group and 6% of women with advanced disease. Fatigue, a past history of depression, and cognitive attitudes of helplessness, hopelessness or resignation were significantly associated with depression in both groups. The women from the metastatic sample were significantly less distressed by hair loss but more dissatisfied with body image, and had higher rates of lymphoedema and hot flushes than the early stage women. CONCLUSIONS: The rates of psychosocial distress are high, and similar, across patients with both early and advanced stage breast cancer, although the illness related causes of distress are different. These data present a challenge t

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.

Supportive-Expressive Group Therapy (SEGT) has been developed and manualised in the research setting, but there have been few clinical accounts of its utility. In this qualitative review of its application in the Melbourne-based randomised control trial (RCT) for women with advanced breast cancer, SEGT is considered from the perspective of the structure and framework of therapy, its therapists, the issues that develop in exploring its common themes and what constitutes a well functioning group. Groups move through identifiable developmental phases. The mature group process transforms existential ambivalence into creative living, evidenced by humour, celebration, assertiveness, altruism, new creative pursuits and eventually courageous acceptance of dying. Challenges and pitfalls include avoidance, non-containment of ambivalence, intolerance of difference, anti-group phenomena and splitting. A key element is the medicalization of the group culture whereby members and co-therapists explore health beliefs and attitudes about care. This promotes compliance with anti-cancer treatments, including both the initiation of and perseverance with chemotherapy. This mechanism could prove to be a potentially important pathway in promoting longer survival.