management of patients with stroke or tia: assessment - sign

Management of patients with stroke or TIA: assessment, investigation,

immediate management and secondary prevention

A clinical and resource impact assessmentMay 2009

© NHS Quality Improvement Scotland 2009 NHS Quality Improvement Scotland (NHS QIS) consents to the photocopying, electronic reproduction by ‘uploading’ or ‘downloading’ from the website, retransmission, or other copying of this report for the purpose of implementation in NHSScotland and educational and ‘not-for-profit’ purposes. No reproduction by or for commercial organisations is permitted without the express written permission of NHS QIS.

CONTENTS 1 EXECUTIVE SUMMARY ......................................................................................... 1 2 INTRODUCTION...................................................................................................... 8

2.1 Objective........................................................................................................... 8 2.2 Key recommendations ...................................................................................... 8 2.3 Document overview ........................................................................................ 10

3 BACKGROUND AND METHODOLOGY............................................................... 12 3.1 Introduction ..................................................................................................... 12 3.2 Methodology to estimate clinical benefit ......................................................... 12 3.3 Methodology to estimate resources required/associated costs and savings... 13 3.4 Methodology to estimate cost of resources and associated savings............... 14 3.5 Limitations....................................................................................................... 18

4 SCOTTISH STROKE EPIDEMIOLOGY ................................................................ 19 4.1 Introduction ..................................................................................................... 19 4.2 Incidence of a first hospital admission as a result of stroke or TIA.................. 19

5 TIMELY THROMBOLYSIS .................................................................................... 25 5.1 Background..................................................................................................... 25 5.2 Patient group................................................................................................... 25 5.3 Clinical benefit and associated resource savings............................................ 25 5.4 Resource requirements................................................................................... 26 5.5 Costs............................................................................................................... 28 5.6 Sensitivity analysis.......................................................................................... 28 5.7 Analyses by NHS board.................................................................................. 29

6 TIMELY CAROTID IMAGING AND CAROTID ENDARTERECTOMY .................. 34 6.1 Background..................................................................................................... 34 6.2 Patient group................................................................................................... 34 6.3 Clinical benefit and associated resource savings........................................... 35 6.4 Resource requirements................................................................................... 36 6.5 Costs............................................................................................................... 36 6.6 Sensitivity analysis.......................................................................................... 36 6.7 Analyses by NHS board.................................................................................. 37

7 TIMELY CT DIAGNOSTICS ................................................................................. 41 7.1 Background..................................................................................................... 41 7.2 Patient group................................................................................................... 42 7.3 Clinical benefits............................................................................................... 42 7.4 Resources....................................................................................................... 42 7.5 Costs............................................................................................................... 44 7.6 Sensitivity analysis.......................................................................................... 44

8 REFERENCES....................................................................................................... 45 9 APPENDICES........................................................................................................ 47

Appendix 1 Key recommendations .................................................................. 47 Appendix 2 Acknowledgements ....................................................................... 49 Appendix 3 Resource impact assessment process.......................................... 50 Appendix 4.1 ICD-10 codes for stroke or TIA...................................................... 51 Appendix 4.2 ICD-10 codes for other cerebrovascular diseases ........................ 52 Appendix 5.1 Incidence of first ever hospital admission for stroke and TIA for year ending 31 March 2007 .......................................................... 53 Appendix 5.2 Survival rates for stroke and TIA after a first ever hospital admission for year ending 31 March 2007 .................................... 54 Appendix 5.3 Re-admission rates for stroke and TIA after a first ever hospital admission for year ending 31 March 2007 .................................... 55 Appendix 5.4 Prior admission of patients who had a first ever admittance for stroke or TIA for year ending 31 March 2007................................ 56 Appendix 5.5 Incidence of stroke and TIA resulting in a first ever hospital admission by NHS board for year ending 31 March 2007............. 57 Appendix 5.6 Predicted mortality for patients with first admission of ischaemic stroke for year ending 31 March 2007........................................... 58 Appendix 5.7 Predicted mortality and disability for patients with first admission of ischaemic stroke for year ending 31 March 2007.......................... 59 Appendix 6.1 Estimated first hospital admissions for stroke or TIA..................... 60 Appendix 6.2 Estimated survival rates for patients following a first admission to hospital for stroke or TIA ............................................................... 61 Appendix 6.3 Estimated re-admission rates for patients following a first admission to hospital for stroke or TIA .......................................... 62 Appendix 6.4 Estimated prior admission rates for patients later admitted for stroke or TIA for the first time........................................................ 63 Appendix 6.5 Estimated admission rates for patients who have attended a neurovascular outpatient clinic ...................................................... 64 Appendix 7.1 Costs for the Scottish Ambulance Service .................................... 65 Appendix 7.2 Costs for attendance at an A&E department................................. 66 Appendix 7.3 Costs per event for CT, MRI and ultrasound diagnostics .............. 67 Appendix 7.4 Costs for a stroke consultant outpatient attendance ..................... 68 Appendix 7.5 Costs for a consultant vascular surgeon outpatient attendance.... 69 Appendix 7.6 Mean variable cost per day (excluding overheads and theatre costs) in a surgical ward................................................................ 70 Appendix 7.7 Mean variable cost per day (excluding overheads and theatre costs) in a general medical ward................................................... 71 Appendix 7.8 Costs per hour for theatre time inclusive of overheads, staff costs and consumables .......................................................................... 72

Appendix 7.9 Costs by function in NHS Greater Glasgow and Clyde ................. 73 LIST OF TABLES Table 1-1 Clinical benefits measured as the number of bed days saved................... 4 Table 1-2 Additional costs required to implement key recommendations ................. 6 Table 1-3 Total budgetary impact for Scotland and NHS board ................................ 7 Table 3-1 Gross salary costs for non-consulting staff ............................................. 15 Table 3-2 Gross salary costs for consulting staff .................................................... 15 Table 3-3 Consolidated surgical costs for carotid endarterectomy .......................... 17 Table 4-1 Re-admission rates.................................................................................. 21 Table 4-2 Annual re-admission rates estimated from first ever hospital admissions 21 Table 4-3 Classification of the subtypes of cerebral infarcts .................................... 22 Table 4-4 Extending OCSP model of infarction subtypes to population age groups 23 Table 5-1 Clinical benefits of additional thrombolytic therapy .................................. 26 Table 5-2 Additional costs to deliver thrombolytic therapy ....................................... 28 Table 5-3 Additional costs if patients not directed to hospitals with CT scanners .... 29 Table 5-4 Additional costs to deliver thrombolytic therapy ....................................... 29 Table 5-5 Anticipated patients by NHS board .......................................................... 30 Table 5-6 Additional benefit from timely thrombolysis by NHS board ...................... 31 Table 5-7 Additional costs from timely thrombolysis by NHS board......................... 32 Table 5-8 Sensitivity analysis: SAS unable to deliver patients to specified.............. 33 Table 6-1 Calculation to estimate number of patients eligible for surgery................ 35 Table 6-2 Patients who are potential candidates for carotid endarterectomy........... 38 Table 6-3 Estimated clinical benefit from timely carotid endarterectomy ................. 39 Table 6-4 Estimated additional cost to achieve timely carotid endarterectomy........ 39 Table 6-5 Sensitivity analyses of higher costs incurred if carotid Doppler required . 40 Table 7-1 Patient groups requiring CT scanning facilities ........................................ 42 Table 7-2 Operational CT scanning hours per week in Scottish hospitals ............... 43 Table 7-3 Costs to provide capacity to scan 24,300 people with stroke symptoms . 44

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1 EXECUTIVE SUMMARY

In their recent report, Reducing Brain Damage: Faster access to better stroke care1, the National Audit Office stated that in England and Wales, stroke costs the NHS and the economy approximately £7 billion a year. Of this sum, £2.8 billion is estimated to be in direct costs to the NHS, £2.4 billion of informal care costs borne by the patients’ family and other carers, with a further £1.8 billion being lost productivity and disability income for those under the age of 65 who are unable to work as a result of their condition. Translating these numbers to Scotland suggests that the cost to the Scottish economy as a result of stroke is in the region of some £700 million. Whilst stroke is primarily associated with age and ageing, it is important to note that the number of patients under the age of 65 who are being admitted to Scottish hospitals due to stroke is increasing. This group now represents 26.5% of all stroke admissions; up 32.5% from the 20.0% of admissions reported in 2000 as part of the Scottish Borders Stroke Study2. Moreover, while the reported incidence of stroke has decreased marginally over the last 10 years, this trend may not continue because of the population demographics. In the next 10 years, one of the largest population deciles, the 55–65 age group, or the ‘baby boomers’, will progressively move into the next of the higher risk stroke age groups. The objective of this clinical and resource impact assessment is to facilitate more rapid implementation of the key recommendations in SIGN Guideline 108 Management of patients with stroke or TIA: assessment, investigation, immediate management and secondary prevention3. The report provides each NHS board with an estimate of the resources and costs required to implement the key recommendations, together with the associated clinical benefits, including potential cost savings. The guideline development group judged 15 recommendations to be clinically very important and should be prioritised for implementation. Following discussion with members of the group it was agreed that eight recommendations would not change current practice and therefore would not have a material impact on current resource use. These have been excluded from further analysis. A short explanation of each recommendation including commentary for those that have been excluded is provided in Appendix 1. Seven recommendations were judged to be clinically important and to require significant resources on implementation. The associated clinical benefits, resources and costs to implement these key recommendations are estimated in this report. These have been grouped into two headings; timely thrombolysis and timely carotid imaging and carotid endarterectomy. Implementing these two interventions are the key challenges for NHS boards. The individual recommendations for each intervention are:

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Recommendations for timely thrombolysis • Emergency medical services should be redesigned to facilitate rapid access to

specialist stroke services.

• Stroke patients requiring admission to hospital should be admitted to a stroke unit staffed by a co-ordinated multidisciplinary team with a special interest in stroke care.

• All patients with suspected stroke should have brain imaging immediately on presentation.

• Patients admitted with stroke within 4.5 hours of definite onset of symptoms, who are considered suitable, should be treated with 0.9 mg/kg (up to maximum 90 mg) intravenous recombinant tissue plasminogen activator (rt-PA).

Recommendations for timely carotid imaging and carotid endarterectomy • All patients with non-disabling acute stroke syndrome/transient ischaemic attack

(TIA) in the carotid territory who are potential candidates for carotid surgery should have carotid imaging.

• All patients with carotid artery territory stroke (without severe disability, modified Rankin Scale [mRS] ≤2) or TIA should be considered for carotid endarterectomy as soon as possible after the index event.

• Carotid endarterectomy (on the internal carotid artery ipsilateral to the cerebrovascular event) should be considered in all:

- male patients with a carotid artery stenosis of 50–99% (by NASCET method) - female patients with a carotid artery stenosis of 70–99%.

• For all patients, carotid endarterectomy should be performed as soon as the patient is stable and fit for surgery, ideally within 2 weeks of the initial event.

Implementing both interventions requires the use of radiological diagnostics to assist in the primary determination of specific stroke type. The analysis contained in Section 7 on timely computed tomography (CT) diagnostics suggests approximately 24,300 CT scans will be required annually for all patients with potential strokes, to include those scanned immediately after thrombolysis. The resources and costs to manage a service to deliver these are also discussed.

The methodology used to develop this report adopts proven processes and principles4-7. Members of the guideline development group and other experts have provided advice and participated in peer review. The draft findings were presented to representatives from NHS Dumfries & Galloway, NHS Ayrshire & Arran, NHS Lanarkshire and NHS Greater Glasgow and Clyde. Due to time constraints, it was not possible to visit all NHS boards in Scotland. However, the remaining boards were provided with drafts of all the underlying analyses for comment and feedback. The boards visited represent the

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varying spatial diversity of all boards, namely those that have one major hospital, two major hospitals, three major hospitals and multiple sites. The feedback from the visits has been adapted for the remaining boards. The information contained within this report at a national level represents the clinical, resource and budget impact consolidation of each of the individual mainland NHS boards, with the boards of NHS Orkney, NHS Shetland and NHS Western Isles combined into a single entity, the NHS island boards. The epidemiological variations that exist between the boards in Scotland have been taken into account in the preparation of this work through extensive epidemiological modelling covering the last 3 years. Estimated clinical benefits of implementing the key recommendations Implementing SIGN 108 is forecast to require: • 810 more patients receiving thrombolysis, compared to the current number of 205,

and

• 608 more patients receiving a carotid endarterectomy, and improving the timeliness of the current 552 procedures such that these are delivered within 14 days from event.

Diagnosing and managing these patients will require radiology departments to provide CT scanning and other imaging services for approximately 24,300 patients per year. The clinical benefits forecast following these interventions are estimated to be: • 82 patients making a full recovery and 364 having an improved outcome following

thrombolysis, and

• 217 recurrent strokes avoided from timely carotid endarterectomy. The associated bed days saved are estimated at 10,611, of which 4,752 are achieved by timely thrombolysis and 5,859 from timely carotid endarterectomy. The financial benefits are estimated at £2.94 million. This is calculated by applying a weighted average variable cost for Scotland (excluding overheads) of £277 per bed day. Table 1–1 gives the benefits by NHS board for each intervention. No account has been taken of the savings that successful implementation will have in the longer term, particularly from lower rehabilitation costs. Further analysis is provided in Sections 5 and 6 of this report.

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Table 1-1 Clinical benefits measured as the number of bed days saved

NHS board Timely

thrombolysisTimely carotid

Total bed days saved

Average weighted

cost Total

savings NHS Ayrshire & Arran 621 405 1,026 £193 £198,018NHS Borders 153 135 288 £204 £58,752NHS Dumfries & Galloway 234 189 423 £323 £136,629NHS Fife 423 351 774 £439 £339,786NHS Forth Valley 243 243 486 £176 £85,536NHS Grampian 414 405 819 £223 £182,637NHS Greater Glasgow and Clyde 801 1,809 2,610 £233 £608,130NHS Highland 180 270 450 £410 £184,500NHS Island Boards 36 54 90 £295 £26,550NHS Lanarkshire 657 945 1,602 £210 £336,420NHS Lothian 585 702 1,287 £368 £473,616NHS Tayside 405 351 756 £415 £313,740NHSScotland 4,752 5,859 10,611 £277 £2,944,314 Additional staff required to implement the key recommendations Timely thrombolysis Additional staff will be required to assess, deliver and immediately manage patients receiving thrombolytic therapy. Each NHS board is assumed to require: • a band 7 specialist nurse who spends 1 hour assessing each of the 1,900 patients

who may be eligible for the therapy. If the responses indicate that the patient may be eligible for the therapy then the nurse is assumed to call for a consultant. Thereafter the nurse will attend patients receiving the therapy for a further 6 hours as the drug is administered and to oversee the initial management.

• consultant stroke physicians. Each NHS board is assumed to manage with no additional consultant resource during the core weekday hours. The additional workload associated with thrombolysing patients who present during core hours is assumed to displace the existing workload. However, this should reduce as the upfront investment in delivering the therapy is rewarded by having more patients with improved outcomes and consequently discharged earlier. This assumption will be particularly challenging for smaller boards where the consultant may have duties to conduct outwith the main hospital. Seven NHS boards, being those forecast to have more than 30 patients a year presenting for this therapy in the early evening, are forecast to recruit an extra 0.5 whole time equivalent (WTE) consultant each to

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cover five planned activities per week, providing cover until 8pm. All other out of hours work is assumed to be undertaken by on-call arrangements.

The total staff required is estimated to be 4.2 WTE nurses, 35 additional planned activities per week to provide consultant resource in the early evening and 760 out of hours call-outs. An analysis of the staffing required by NHS board is provided in Section 5.7. Carotid endarterectomy Delivery of a timely carotid endarterectomy service will require staff to perform an additional 608 carotid endarterectomy procedures. The additional staff required are 1.1 WTE vascular surgeons, 0.65 WTE band 5 and 0.65 WTE band 6 theatre nurses and 0.65 WTE anaesthetist. Most inpatients should be able to receive the procedure during their initial inpatient stay, whilst outpatients are assumed to be admitted for 2 nights, one before and one after the procedure. The benefits from fewer recurrent strokes will reduce the demand for bed days over time. For example, undertaking five carotid endarterectomy procedures within 14 days of the original events, will require a total of 10 bed days (2 night stay in a surgical ward as a maximum) initially but may be rewarded by preventing one recurrent stroke, saving some 27 bed days. However, there may be a timing issue for hospitals since the extra beds and associated services are needed immediately but the overall long term benefit could potentially be over 5 years8. Timely CT diagnostics The total number of staff required to provide a timely CT scanning service for patients suspected of a stroke or TIA, and their subsequent management, is estimated to be almost 740 planned activity sessions for stroke consultants to read the images and approximately six band 7 radiographers, six band 6 radiographers, six band 3 helpers and six band 2 clerical officers. Many of these staff will be in place. However, it has not been possible to identify whether any additional staff could be required. Rather, an analysis of the current service provision suggests there is sufficient capacity in the system. An estimated 3.8 WTE additional band 6 business administration managers are forecast to be required across Scotland, in the first year, to support implementation. Estimated costs required to implement the key recommendations The estimated costs of implementing the key recommendations are £3.5 million in the first year. Thereafter the £0.13 million for business support should fall, leaving additional costs to the service of around £3.4 million.

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Table 1–2 analyses the cost by NHS board for each of the three interventions. These costs exclude any costs for additional diagnostics. Provision of an efficient CT scanning service could cost approximately £0.95 million a year. It is not possible to estimate the current costs and thus whether additional costs are required. Table 1-2 Additional costs required to implement key recommendations in

SIGN 108

NHS board Timely

thrombolysis

Timely carotid

endarterectomy

Business admin

support Total costs

NHS Ayrshire & Arran £210,140 £33,439 £10,300 £253,879NHS Borders £34,314 £32,707 £5,150 £72,171NHS Dumfries & Galloway £52,696 £10,469 £5,150 £68,315NHS Fife £179,205 £69,429 £10,300 £258,934NHS Forth Valley £64,006 £17,460 £5,150 £86,616NHS Grampian £297,275 £29,960 £10,300 £336,534NHS Greater Glasgow and Clyde £294,679 £591,189 £36,049 £921,917NHS Highland £259,096 £22,427 £5,150 £286,673NHS Island Boards £5,133 £7,502 0 £12,635NHS Lanarkshire £229,262 £285,210 £15,449 £529,921NHS Lothian £217,764 £210,573 £15,449 £443,786NHS Tayside £178,759 £67,819 £10,300 £256,878NHSScotland £2,022,329 £1,377,185 £128,747 £3,528,260 Estimated net costs required to implement the key recommendations Comparing the total cost of implementing the guideline with a valuation based on the bed days saved is difficult to interpret. This is because reducing bed days seldom releases additional funding or staff resources; rather the beds are used to manage additional patients or non-stroke patients and staff are re-deployed elsewhere in the board. Despite that caveat, the estimated net cost (before any enhancements are made to the provision of diagnostic services) from implementing SIGN 108 is estimated at approximately £0.6 million in year one, as detailed in Table 1–3.

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Table 1-3 Total budgetary impact for Scotland and NHS boards of SIGN 108

NHS board Estimated savings Total costs

Net cost impact

NHS Ayrshire & Arran £198,018 £253,879 £55,861NHS Borders £58,752 £72,171 £13,419NHS Dumfries & Galloway £136,629 £68,315 (£68,314)NHS Fife £339,786 £258,934 (£80,852)NHS Forth Valley £85,536 £86,616 £1,080NHS Grampian £182,637 £337,535 £153,898NHS Greater Glasgow and Clyde £608,130 £921,917 £313,787NHS Highland £184,500 £286,673 £102,173NHS Island Boards £26,550 £12,635 (£13,915)NHS Lanarkshire £336,420 £529,921 £193,501NHS Lothian £473,616 £443,786 (£29,830)NHS Tayside £313,740 £256,878 (£56,862)NHSScotland £2,944,314 £3,528,261 £583,946 NHS board reports In support of this national report, each NHS board (with the islands combined) has received spreadsheets covering: • data from ISD on the incidence and outcome of stroke that has resulted in a hospital

admission over the last 3 years, and

• the assumptions, values for each key parameter and analysis used to estimate their individual cost and savings.

It is hoped that these spreadsheets will provide a framework for boards to enable them to model potential solutions to the challenges presented in implementing the key recommendations in SIGN 108.

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2 INTRODUCTION

2.1 Objective

The objective of this clinical and resource impact assessment is to facilitate more rapid implementation of the key recommendations in SIGN Guideline 108 Management of patients with stroke or TIA: assessment, investigation, immediate management and secondary prevention3. The report provides each NHS board with an estimate of the resources and costs required to implement the recommendations, together with the associated clinical benefits. This report does not reproduce the SIGN guideline and should be read in conjunction with it. A recent Audit Commission report concluded that the lack of robust information on the resources required and associated costs including any potential savings was one of the biggest difficulties in developing plans to implement clinical guidelines9. This report aims to provide such information to support implementation of the recommendations in NHS boards. It does not attempt to cost all aspects of the current diagnosis and management of patients with stroke or transient ischaemic attack (TIA). No cost effectiveness analyses are presented within this report.

2.2 Key recommendations

Timing is a central theme throughout SIGN 108. The changes in practice that are required to facilitate implementation of the key recommendations are not necessarily a marked departure from current clinical practice or the patient pathway of care within the acute setting. Rather, successful implementation requires doing the same things to a more demanding timescale. Stroke and TIA’s share common morbidity or co-morbidities with primarily, coronary heart disease, peripheral vascular disease and diabetes10, each of which in turn require the same resources, be that the Scottish Ambulance Service (SAS), radiological diagnostics or indeed theatre time. For each of the key recommendations, a synopsis of the relevant considerations that have been taken into account as part of the workflow arrangements which led to the preparation of this report is noted below.

Timely thrombolysis

Emergency medical services should be redesigned to facilitate rapid access to specialist stroke services (recommendation 2.1) The costings have focussed on the front line diagnostics required to determine the stroke type; a computed tomography (CT) scanner in the first instance. Adopting a protocol for SAS that enables the paramedics to recognise a potential stroke patient and to deliver the person to a hospital with a CT scanner rather than the nearest ‘place of safety’ should reduce the number of secondary transfers from non-CT scanning Accident & Emergency (A&E) departments. However, this may result in potentially

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longer journeys in both distance and time. Under these circumstances, the use of the air ambulance service may be required as the only method of transport suitable to move patients to an appropriate place for thrombolytic therapy within the period of 4.5 hours of symptom onset.

Stroke patients requiring admission to hospital should be admitted to a stroke unit staffed by a co-ordinated multidisciplinary team with a special interest in stroke care (recommendation 2.2) All of Scotland’s hospitals which have a CT scanner also have a stroke unit associated11; either as an acute receiving unit, a rehabilitation unit or a combination of both. Geographical variations between and within NHS boards means that not all hospitals are in a position to offer thrombolytic therapy or to provide surgical facilities for carotid endarterectomy. Recruiting specialist nurses to deliver timely thrombolysis is judged to be sufficient to ensure all hospitals admitting stroke patients are staffed by a co-ordinated multidisciplinary team with a special interest in stroke care. All patients with suspected stroke should have brain imaging immediately on presentation (recommendation 2.3.1) The imaging may take place following assessment at A&E or by elective attendance at a neurovascular clinic. The report has quantified the demand for CT scanning services in all settings and assessed the capacity required to meet this demand. Patients requiring assessment for timely thrombolysis would still require to be seen on an urgent basis. Patients admitted with stroke within 4.5 hours of definite onset of symptoms, who are considered suitable, should be treated with 0.9 mg/kg (up to maximum 90 mg) intravenous rt-PA (recommendation 2.4) The process of delivery of the thrombolytic agent can, depending on the weight of the particular patient, take up to 1.5 hours to be delivered. Thereafter a period of 6 hours must be allowed for patient recovery in an environment akin to either a high dependency unit or an intensive care unit and thus require dedicated specialist care. Timely carotid endarterectomy All patients with non-disabling acute stroke syndrome/TIA in the carotid territory who are potential candidates for carotid surgery should have carotid imaging (recommendation 2.3.2) All patients with carotid artery territory stroke or TIA should be considered for carotid endarterectomy as soon as possible after the index event (recommendation 2.6.1)

Carotid endarterectomy (on the internal carotid artery ipsilateral to the cerebrovascular event) should be considered in all: - male patients with a carotid artery stenosis of 50–99% (by NASCET method) - female patients with a carotid artery stenosis of 70–99%

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For all patients, carotid endarterectomy should be performed as soon as the patient is stable and fit for surgery, ideally within 2 weeks of the initial event (recommendation 2.6)

Implementing these recommendations will require arrangements to be made for possible surgical intervention as soon as possible after initial symptom onset; ideally within less than 14 days for maximum potential benefit based on the number needed to treat (NNT) to avoid a single recurring stroke event. Given the tendency for this procedure to be geared towards those with mild strokes (modified Rankin Scale [mRS] ≤2) and TIA’s the provision of this service must encompass not only those who have been admitted, but also those who have had an initial referral to a neurovascular outpatient clinic.

2.3 Document overview

Section 3 describes the methodology used to estimate the clinical benefit (which is expressed as a number of bed days saved with the associated weighted average variable costs [excluding overheads]), the estimate of resources required (including cost calculations for consulting and non-consulting staff) and the provisions for consumable costs, theatre operating rates per hour and the weighted average cost of the essential radiological scans. Section 4 describes the methodology adopted together with the background with regards to stroke. This involved the development of a model to predict mortality at 1 month following a first hospital admission, and the predictability of recurrent events that result in a re-admission at 3 months following an initial discharge for those who have survived. Sections 5, 6 and 7 report the estimates for each of the key recommendation groupings; timely thrombolysis, timely carotid endarterectomy and timely CT diagnostics in more detail. Sensitivity analyses are provided within each section. The detailed appendices contain the following information: Appendix 1 lists the 15 clinically important recommendations and explains why some were excluded from further study. Appendix 2 acknowledges those who have contributed to the development of this report. Appendix 3 provides a flowchart on the resource impact assessment process and implementing guidelines. Appendix 4 details the International Classification of Disease (ICD 10) codes as they relate to cerebrovascular disease. Appendix 5 details the epidemiological model for Scotland that has been derived from the analysis of mortality records from the General Register Office for Scotland (GROS) and Scottish Morbidity Admission Records (SMR01) databases from Information Services Division (ISD). Appendix 6 illustrates how these data has been used to drive the consolidated demand for admissions, re-admissions and survival rates for patients who are both inside and outside the follow up window of one year.

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Appendix 7 provides an index to the sources of information which are published annually by ISD in relation to costs in NHSScotland. Further information For further information on this report, to obtain a copy, or to provide feedback on its usefulness please contact: Joyce Craig Lead Health Economist NHS Quality Improvement Scotland Delta House 50 West Nile Street GLASGOW G1 2NP 0141 225 6985 [email protected]

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3 BACKGROUND AND METHODOLOGY

3.1 Introduction

Stroke is the third biggest cause of mortality and the primary cause of acquired disability in the adult population1. It is estimated that hospital care for patients with a stroke accounts for 7% of total beds occupied in Scottish hospitals and that the total cost of care represents nearly 5% of the entire NHSScotland budget11. The outcome for patients following stroke is generally referred to in terms of survival, functional status (dependence and disability) and the risk of recurrence12-14. Recurrent stroke carries a higher risk of mortality and can lead to profound long term disability in those who have survived their initial stroke, depending on the base level of impairment from that event. Implementing the key recommendations in SIGN 108 is anticipated to improve patient outcomes by enabling the appropriate therapies to be administered in the optimal time frames. Delivery of timely carotid endarterectomy should reduce the risk of a recurrent cerebrovascular event. Delivery of timely thrombolysis should reduce the level of possible dependency following a stroke and facilitate earlier hospital discharge.

3.2 Methodology to estimate clinical benefit

The mean length of stay as a result of stroke in Scottish hospitals is estimated at 27 days per event. This is a weighted average of the mean length of stay of 25.4 days reported by the Scottish Stroke Care Audit (SSCAS)11 and the mean length of stay of 28.9 days for ischaemic stroke and 27.2 days for inconclusive stroke, reported by ISD15. Preventing a stroke event that would otherwise result in either a repeat admission (if the patient had already been admitted previously and then subsequently discharged) or a first ever admission (if the patient had previously been seen at a neurovascular outpatient clinic) is assumed to save 27 bed days. SIGN 108 reports the clinical studies that demonstrate treatment with recombinant tissue plasminogen activator (rt-PA) within 4.5 hours of symptom onset improves the outcome of some but not all patients who are eligible for treatment. It should not be seen as a ‘cure’ for ischaemic stroke, including the possibility of preventing recurrent events; rather for some patients successful therapy can reduce the severity, including the level of disability or impairment, which can accompany the event. In the pathway from admission to final discharge the outcome from thrombolytic therapy has been estimated to enable 10% of patients to make a full recovery and be discharged early (the ‘Lazarus Effect’), whilst 45% of patients will have a significantly improved outcome enabling earlier discharge16. The question of time from symptom onset is fundamental in the delivery of thrombolytic therapy. Patients who arrive at hospital where the time of symptom onset is judged to be greater than 4.5 hours will not be eligible for therapy under the current licence for use. In the preparation of this report, the ICD 10 code for inconclusive stroke (I64) has been taken as an indicator, given the geographical variations within the epidemiology

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(see Section 4) of the percentage of patients who currently do not arrive within the appropriate time frame for thrombolytic consideration. The time from symptom onset is also relevant for the effective provision of carotid endarterectomy. Section 11.1.1 of SIGN 108 demonstrates that the NNT to prevent one recurrent event rises as the time from symptom onset progresses. To calculate the clinical benefit from carotid endarterectomy, this report assumes NHS boards are able to provide the procedure within 14 days of the event, in line with the SIGN recommendation. This maximises the potential clinical benefit. This section of SIGN 108 also notes that ‘A proportion of patients who are severely disabled immediately following their stroke event can make rapid recovery such that they meet the criteria used in the studies’ for carotid endarterectomy’. This report assumes thrombolysis can improve the outcome of patients sufficiently to enable them to be considered for carotid evaluation and possible surgical intervention prior to discharge. Following administration of thrombolytic therapy, carotid artery occlusion and the anterior circulation infarcts that stem from this type of underlying cause have been reported as a determinant of poor outcome in the 3 months following treatment17, when by inference the risk of a recurrent event is greatest in this particular subtype of ischaemic stroke (see Section 4)12-14. This may be reduced by carotid endarterectomy. Not all patients who arrive within 4.5 hours of symptom onset will be eligible for thrombolytic therapy. The Summary of Product Characteristics (http://emc.medicines.org.uk/medicine/308/SPC/Actilyse/) does not recommend use for patients over the age of 80 years. Other contraindications include patients with severe stroke as assessed clinically and/or by appropriate imaging techniques, patients receiving oral anticoagulants and evidence of any haemorrhage events, including liver disease. These exclusions have been modelled in this report by assuming a specialist nurse trained in thrombolytic therapy undertakes an assessment in an A&E environment. For those patients who are assessed as unsuitable for thrombolysis but candidates for carotid endarterectomy, rapid access to carotid imaging and potential surgical intervention should be facilitated in order to meet the 14 day timeline for maximum clinical benefit. Due to the current low numbers being treated for thrombolysis this element has been difficult to model for this report, however it will be a significant factor to consider as implementation progresses.

3.3 Methodology to estimate resources required and associated costs and savings

Appendix 3 outlines the process developed and adopted to produce this report. Once the key themes and associated recommendations had been identified, draft patient pathways showing the changes required to implement each key recommendation were developed. These were informed by the results of a literature search on the epidemiology of stroke. ISD also provided extensive data on Scottish epidemiology and the facilities available at each NHS board. These data were combined with knowledge gained from intensive discussions with a number of the members of the guideline development group, feedback from members of the stroke managed clinical networks

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and on-site visits. Discussions were also held with representatives from SAS. Planners from SAS modelled the implications of changing the destination for potential stroke patients, depending on the availability of CT scanning facilities. The data from these sources were combined into several models. An independent expert, with extensive knowledge of SSCAS was asked to validate the outcomes of the epidemiological model and other clinical experts were asked to validate the pathways assumed for their NHS board. Where possible published resource and cost data from ISD were used and supplemented by other published data as appropriate. Occasionally, unpublished sources were used and referenced. The models were made available to clinicians in all mainland NHS boards for review, supported, where possible, by meetings to discuss the findings. Data values and associated spreadsheets were quality assured by an independent health economist. An evaluation of the usefulness of this report to NHS boards as they seek to implement the recommendations in SIGN 108 will be commissioned by NHS Quality Improvement Scotland.

3.4 Methodology to estimate cost of resources and associated savings

The cost of rt-PA alteplase was taken from BNF 56 (www.bnf.org) being:

• 10 mg £135 excluding VAT; £158.63 including VAT at 17.5% • 20 mg £180 excluding VAT; £211.50 including VAT at 17.5% • 50 mg £300 excluding VAT; £352.50 including VAT at 17.5%.

For the purpose of this report the cost of alteplase has been taken as an average of 80 mg at a cost of £723 including VAT. Costs for events such as SAS journeys, A&E attendance, radiology attendance, outpatient consultation, inpatient stay and theatre costs per hour are routinely published by ISD (http://www.isdscotland.org/isd/5822.html). The costs adopted in this report are a weighted average taking into consideration the total costs (overheads, staff resources, supplies and consumables) and dividing this by the number of events or patients who have attended. To calculate the value of a ‘bed day saved’ the inpatient rate per day has been adjusted to remove overheads and theatre costs, leaving primarily staff costs plus some consumables that would normally be required during an inpatient stay. This approach, primarily applied to the cost data for the mainland NHS boards, gives a Scottish mean weighted cost for an overnight stay in a general medical ward, where stroke unit costs are recorded, of £277 per day (see Table 1–1).

15

Appendix 7 details all of the costs that have been used in this report. These are available to download from the ISD website at www.isdscotland.org/isd/4434.html. On an individual NHS board level the supporting excel spreadsheets have the facility to change the cost matrix should the need arise. The mean staff costs for the additional staff required as a result of implementing SIGN 108 have been taken as the mid-point within the Agenda for Change pay scales as it affects both consulting and non-consulting staff. This salary mid-point is ‘grossed up’ by 22% to take account of the current rate of national insurance contributions and pension overhead. Translating costs into the relevant WTE for the additional members of staff requires a further adjustment [52/42] to account for abstractions due to holiday entitlement and training. Table 3–1 details the mid-point on the pay scale bands under the current terms of employment in the NHS effective from 1 April 2008 for non- consulting staff. Table 3–2 details the mid-point on the pay scale bands under the current terms of employment in the NHS effective from 1 April 2008 for consulting staff. Full details of NHS employment contracts for both consulting and non_consulting staff are available from http://www.nhsemployers.org/PayAndContracts/Pages/Pay-and-contracts.aspx. Table 3-1 Gross salary costs taken as mid-point within each salary band

including and adjustment for WTE costs for non-consulting staff (Agenda for Change)

Band Mid-point Base Overhead @ 22% Gross Gross WTE

2 6 £14,428 £3,174 £17,602 £21,7933 10 £16,307 £3,588 £19,895 £24,6324 15 £19,038 £4,188 £23,226 £28,7565 21 £22,797 £5,015 £27,812 £34,4346 27 £28,141 £6,191 £34,332 £42,5067 32 £33,603 £7,393 £40,996 £50,757

Table 3-2 Gross salary costs taken as the mid-point salary band including and

adjustment for WTE costs for consulting staff (pay circular M&D 3/2008)

Pay Scale Point Base Overhead @ 22% Gross Gross WTE

MC72/LC72 9 £88,049 £19,371 £107,420 £132,996Clinical Excellence Awards 5 £14,565 £3,204 £17,769 £22,000Total £102,614 £22,575 £125,189 £154,996 Cost per individual session £397 Annual cost of one session per week £20,666

16

The cost for carotid endarterectomy as a weighted average for NHSScotland has been derived from the total expected costs of surgery in each of the individual NHS boards to include; a consultant outpatient appointment with a vascular surgeon, a secondary confirmation of carotid disturbance (MRI equivalent) in order to guide the surgical procedure, theatre time at 1.5 hours and a post-surgical carotid Doppler examination. Table 3–3 details the calculation for carotid endarterectomy across the NHS boards in Scotland for those patients who either return to a stroke ward or are cared for in a surgical ward having been previously discharged or attended a neurovascular outpatient clinic.

17

Tabl

e 3-

3 C

onso

lidat

ed s

urgi

cal c

osts

for c

arot

id e

ndar

tere

ctom

y, b

ased

on

whe

ther

the

patie

nt re

turn

s to

a

stro

ke w

ard

or h

as a

sep

arat

e ad

mis

sion

to a

sur

gica

l war

d

Co

stin

g m

etho

doly

for p

roce

dure

s car

ried

out o

n ex

istin

g in

patie

nts w

here

afte

r sur

gery

the

patie

nt

retu

rns b

ack

to th

e st

roke

(gen

eral

med

icin

e) w

ard

NH

S Sc

otla

nd

tota

l po

pula

tion

NH

S

Ay

rshi

re &

Ar

ran

NH

S

Bo

rder

s

NH

S

Dum

frie

s &

Gal

low

ay

NH

S

Fi

feN

HS

Fort

h Va

lley

NH

S

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mpi

an

NH

S

G

reat

er

Gla

sgow

&

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e

NH

S

Hig

hlan

d

NH

S

Is

land

Bo

ards

NH

S La

nark

shire

NH

S

Lo

thia

nN

HS

Tays

ide

Tota

l Num

ber o

f Cas

es39

532

913

2719

3599

228

4852

31

Con

sulta

nt O

utpa

tient

- V

ascu

lar S

urge

ry£1

02£1

14£1

14£1

05£8

2£1

14£1

20£1

68£1

14£1

14£1

36£1

14Se

cond

ary

Con

firm

atio

n - M

RI E

quiv

alen

t£1

63£8

9£1

44£3

02£3

05£1

53£2

40£6

04£2

28£1

61£1

19£2

36Th

eatre

Cos

ts -

1.5

Hou

rs£1

,289

£1,5

63£1

,463

£1,3

17£1

,116

£1,4

25£1

,674

£1,2

89£1

,025

£1,3

20£1

,721

£1,2

98Se

cond

ary

Con

firm

atio

n - U

ltras

ound

Pos

t Sur

gery

£39

£42

£68

£38

£77

£66

£63

£79

£134

£53

£48

£31

Tota

l Uni

t Cos

ts -

Inpa

tient

Car

otid

Sur

gery

£1,8

55£1

,593

£1,8

07£1

,789

£1,7

62£1

,580

£1,7

59£2

,097

£2,1

40£1

,500

£1,6

47£2

,023

£1,6

79£0

Tota

l Cos

ts fo

r Inp

atie

nt C

arot

id S

urge

ry£7

32,6

96£5

0,96

8£1

6,26

6£2

3,25

8£4

7,58

1£3

0,02

3£6

1,55

2£2

07,6

40£4

7,07

4£1

2,00

3£7

9,07

5£1

05,2

10£5

2,04

5

Estim

ated

num

ber o

f cas

es c

arrie

d ou

t to

31 M

arch

20

08 fo

r ana

lysis

of a

dditi

onal

cas

es20

125

411

1416

2934

193

822

16

Cost

ing

met

hodo

logy

for p

roce

dure

s car

ried

out o

n pa

tient

s req

uirin

g a

new

adm

issio

n to

a su

rgic

al

war

d ei

ther

from

out

patie

nt a

ttend

ance

or f

ollo

win

g ea

rly d

ischa

rge

from

a st

roke

war

d

NH

S Sc

otla

nd

tota

l po

pula

tion

NH

S

Ay

rshi

re &

Ar

ran

NH

S

Bo

rder

s

NH

S

Dum

frie

s &

Gal

low

ay

NH

S

Fi

feN

HS

Fort

h Va

lley

NH

S

Gra

mpi

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NH

S

G

reat

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Gla

sgow

&

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e

NH

S

Hig

hlan

d

NH

S

Is

land

Bo

ards

NH

S La

nark

shire

NH

S

Lo

thia

nN

HS

Tays

ide

Tota

l Num

ber o

f Cas

e s76

550

1720

4132

4426

337

012

794

40

Con

sulta

nt O

utpa

tient

- V

ascu

lar S

urge

rgy

£102

£114

£114

£87

£82

£108

£120

£168

£114

£134

£105

Seco

ndar

y C

onfir

mat

ion

- MRI

Equ

ival

ent

£163

£89

£144

£302

£305

£153

£240

£604

£161

£119

£236

Inpa

tient

Sur

gery

- C

ost P

er D

ay's

Stay

£636

£560

£508

£582

£540

£548

£562

£528

£422

£704

£574

Thea

tre C

osts

- 1.

5 H

ours

£1,2

89£1

,563

£1,4

63£1

,317

£1,1

16£1

,425

£1,6

74£1

,289

£1,3

20£1

,721

£1,2

98Se

cond

ary

Con

firm

atio

n - U

ltras

ound

Pos

t Sur

gery

£39

£42

£68

£38

£77

£66

£63

£79

£53

£48

£31

Tota

l Uni

t Cos

ts -

Inpa

tient

Car

otid

Sur

gery

£2,4

43£2

,229

£2,3

67£2

,297

£2,3

26£2

,120

£2,3

01£2

,660

£2,6

68£0

£2,0

69£2

,725

£2,2

44

Tota

l Cos

ts fo

r Out

patie

nt C

arot

id S

urge

ry£1

,869

,010

£111

,438

£40,

245

£45,

941

£95,

376

£67,

844

£101

,228

£699

,501

£98,

706

£0£2

62,8

01£2

56,1

75£8

9,75

5

Estim

ated

num

ber o

f cas

es c

arrie

d ou

t to

31 M

arch

20

08 fo

r ana

lysis

of a

dditi

onal

cas

es35

140

717

2126

3692

310

2139

21

18

3.5 Limitations

The current report has a number of limitations in that it is primarily based on an overall model which encompasses a number of smaller models. The epidemiological model balances across Scotland and is within 10% for individual NHS boards. It has therefore been assumed to be robust and to generalise to events in future. Other important assumptions are set out below. • On full implementation of SIGN 108, NHS boards will not transfer patients across

boundaries for thrombolysis or carotid endarterectomy. • An appropriate number of beds are available in the short term to accommodate the

anticipated demand for patients receiving timely thrombolysis and carotid endarterectomy. Such interventions will reduce the demand for beds in the longer term but there will be a mismatch between the immediate requirements and realising the longer term benefit.

• Each hospital modelled to deliver thrombolysis has sufficient beds in a high dependency or intensive care unit available to accommodate the patients receiving such therapy. These patients should be monitored for adverse events during the immediate few hours after delivery of the drug.

• No growth in the number of stroke patients managed beyond the 2007 mid-year population baseline is assumed.

• Staff and facilities will be shared efficiently across Scotland. For example, there may be a need for an extra 4 WTE specialist nurses across Scotland to provide timely thrombolysis. This may equate to, say, 0.2 WTE of a nurse in one hospital. Recruiting such small increments of staff may not be possible, in which case the staff numbers required will be a material underestimate.

• The terminology refers to bed days ‘saved’, being bed days that will no longer be required because the intervention reduces the risk of future strokes. In reality these beds are likely to be occupied by patients with other conditions and thus the beds will still be used.

• The analyses do not aggregate the resources required to implement a revised service with the potential savings from fewer clinical events. This is partly because of timing differences, but also because the two estimates are made using different approaches. However, users may wish to consider a net table.

• Some significant cost categories have been excluded, particularly the cost of service redesign and associated training and recruitment costs.

• The role of telemedicine has also not been considered. The analysis is not intended to be an absolute definitive solution to the implementation challenges that are faced by NHS boards in Scotland either currently or when implementing SIGN 108. Much of the work which is being presented here will have to be repeated as time progresses, particularly as the true admission pattern for thrombolytic therapy is revealed at individual board level.

19

4 SCOTTISH STROKE EPIDEMIOLOGY

4.1 Introduction

In order to better understand how implementing the key recommendations in SIGN 108 can improve patient outcomes it has been necessary to undertake an epidemiological study of stroke as it relates to hospital admissions, rates of survival, the possibility of recurrence and by inference the likelihood of dependency. The principal drivers behind this study have been taken by way of extension from the published work of the Oxfordshire Community Stroke Project 1981-1986 (OCSP)12-14 and the Community-Based Stroke Incidence in a Scottish Population, the Scottish Borders Stroke Study 1998-2000 (SBSS)2. This section details the work that has been undertaken at both a national and local level in relation to stroke for the years ended 31 March 2006, 2007 and 200818. From the information gathered, a model has been developed at a national level which predicts the mortality of patients who have been admitted to hospital for the first time as a result of their stroke to within 99% accuracy. At NHS board level the same model can predict mortality, to within 90% or greater accuracy, in each of the 3 years.

4.2 Incidence of a first hospital admission as a result of stroke or TIA

Scotland has some of the best health service data in the world, in particular the SMR01 database of hospital admission records and the GROMR database of mortality records, which are held by ISD and GROS respectively. The high quality data, consistency, national coverage and the specific ability to link data between the two databases in order to allow patient based analysis and follow up has been fundamental in the analysis of patients who have been admitted to hospital for stroke or TIA. Following the protocols defined in both the SBSS and OCSP in relation to first ever stroke both ISD and GROS were asked to deliver data based on the following selection criteria from the ICD 10 codes for cerebrovascular disease. Full details of the codes are provided in Appendix 4: • For hospital admissions:

Include all patients who had a unique admission record (with subsequent discharge) in the range of ICD 10 codes specified for cerebrovascular disease including TIA’s for each of the years ended 31 March 2006–31 March 2008 inclusive.

• For mortality records: Include all deaths recorded (including autopsy) in the range of ICD 10 codes specified for cerebrovascular disease including TIA’s for each of the years ended 31 March 2006–31 March 2008 inclusive.

20

• Linked data: For hospital admissions, link the patient identification number and scan through the historical database records for a period of up to 10 years and eliminate any corresponding record that has had a previous entry in any of the ICD 10 codes specified. For mortality records, link the patient identification number and scan through the SMR01 database records and eliminate any corresponding admission record found that had an entry in any of the ICD 10 codes specified.

The resultant output combines unique records for patients who have either been admitted on the first occasion with a diagnosis of stroke or TIA (discharge code) or have died in the community as a result of their stroke, having never been admitted to hospital historically for the condition. The unique records of hospital admissions can be indexed within each of the individual years and linked back into the SMR01 database to search for further information based on the patients’ identification number. Historical information such as the last known hospital admission prior to the current event has revealed the growing problem of liver toxicity, brought about through drug and alcohol abuse, particularly in the younger cohort of patients being admitted for stroke in Scotland. Whilst for older patients, the increasing significance of diabetes type 2 and clinical obesity in relation to stroke is becoming more evident. Likewise, cross referencing the linked patient identification numbers for each of the years in question to the GROMR database has provided detailed information on the survival rates following stroke at 1, 3, 6 and 12 months, regardless of whether the patient died in hospital or in the community after having been discharged19. Appendices 5–1 to 5–5 provide details of the consolidated results for Scotland for the year ending 31 March 2007, which is the most recent year where all data collected through the SMR01 database is most complete. As a result of the extensive epidemiological studies carried out in the preparation of this report, there is some evidence to suggest that the rate of recurrence of stroke, but not TIA, in patients who have originally presented for a hospital admission in an historical period in excess of 1 year is increasing. Table 4–1 analyses hospital admissions in the years ending 31 March 2005, 2006 and 2007, being the last three years in which the ISD SMR01 database has complete hospital submission records for patient admittance and subsequent re-admittance following discharge. Recurrent events are linked to a first ever admission in each of the years in question. The difference between total first ever events and actual admissions indicates that a patient cohort has been admitted from a prior period and that the percentage of patients this number represents is increasing.

21

Table 4-1 Re-admission rates estimated from data collected from the ISD

SMR01 database

Stroke Classifications

Annual readmission rates calculated from total admissions & first ever stroke presentations

First ever event

Recurrent events

Total events

Total actual admissions

Recurrent event from

a prior year

% Additional recurrence

Readmission rate for 2005 1,557 247 1,804 2,040 236 15.2%Readmission rate for 2006 1,545 252 1,797 2,011 214 13.9%Readmission rate for 2007 1,625 240 1,865 2,061 196 12.1%Average readmission from prior years 1,576 246 1,822 2,037 215 13.7%

Readmission rate for 2005 1,185 126 1,311 1,544 233 19.7%Readmission rate for 2006 1,165 137 1,302 1,498 196 16.8%Readmission rate for 2007 1,198 131 1,329 1,561 232 19.4%Average readmission from prior years 1,183 131 1,314 1,534 220 18.6%

Readmission rate for 2005 6,334 1,033 7,367 8,706 1,339 21.1%Readmission rate for 2006 6,112 965 7,077 8,339 1,262 20.6%Readmission rate for 2007 5,879 881 6,760 8,198 1,438 24.5%Average readmission from prior years 6,108 960 7,068 8,414 1,346 22.1%

Ischaemic Stroke

Transient Ischaemic Attack

Haemorrhagic Stroke

While there is evidence that a simple score (ABCD or ABCD2) can be used to identify patients who, following an initial TIA, are likely to be at risk of developing an ischaemic stroke event, the admissions history from the SMR01 database will not record all of these, unless the stroke results in a hospital admission. What can be established is that the relationship between age and the percentage of multiple hospital re-admissions differs between TIA and both haemorrhagic and ischaemic stroke. For those suffering a TIA, multiple re-admissions are more prevalent in the over 65 age groups, whilst in either haemorrhagic or ischaemic stroke a greater percentage of stroke patients under the age of 65 are presenting for repeat admissions, as detailed in Table 4–2. Table 4-2 Annual re-admission rates estimated from first ever hospital

admissions


Annual readmission rates calculated from first ever stroke presentations

Total population

0 - 44 years

45 - 54 years

55 - 64 years

65 - 74 years

75 - 84 years

85+ years

Readmission rate for 2005 15.9% 15.4% 15.2% 17.8% 13.8% 16.5% 16.7%Readmission rate for 2006 16.3% 3.6% 15.2% 15.3% 16.1% 18.3% 19.4%Readmission rate for 2007 14.8% 10.8% 7.0% 8.1% 14.4% 20.2% 18.5%Average readmission rate - current year 15.6% 9.9% 12.5% 13.7% 14.8% 18.4% 18.2%




Haemorrhagic Stroke

Ischaemic Stroke

22

The relationship between mortality and recurrent events which are likely to result in a hospital re-admission can be explained by way of a clinical model. Clinical model The classification and natural history of clinically identifiable subtypes of cerebral infarction has been described in detail as part of the OCSP12-14. In summary the four different subtypes of infarct describe the estimated size of the lesion involved, the likelihood of the cause and, where practicable, the level of recurrence that might be expected for each of the groups on an annual basis. Table 4–3 details the four clinically identifiable subtypes of cerebral infarction; Lacunar Infarcts (LACI or Lacunar Syndrome LACS), Total Anterior Circulation Infarcts (TACI or Total Anterior Circulation Syndrome TACS), Partial Anterior Circulation Infarcts (PACI or Partial Anterior Circulation Syndrome PACS) and Posterior Circulation Infarcts (POCI or Posterior Circulation Syndrome POCS). Rates of recurrence, population split, mortality and functional outcome are from the original OCSP model. Information in relation to the likelihood of carotid distortion and cardio-embolic origins, together with the estimated size of the lesion, have also been included in Table 4–3 to illustrate the relationship between anterior circulation infarcts and the disturbances in the carotid territory that are associated with them. Table 4-3 Classification of the subtypes of cerebral infarcts

OCSP classification of cerebral infarcts

LACI TACI PACI POCI

Clinical features: Size of lesion small large medium small to

medium Likelihood of carotid disturbance low high high not

applicable Likelihood of cardio-embolic source low high high medium Likelihood of recurrent event 9% 6% 17% 20% Average population split 25% 17% 34% 24% Outcome at one year: Mortality 11% 60% 16% 19% Functional dependence 28% 36% 29% 19% Functional independence 61% 4% 55% 62% Total 100% 100% 100% 100% The population split between the four subtypes is an average of the population taken over the 5 years of this particular study between 1981–1986, where the average age range was more heavily concentrated in the region of 60–85 years (72.5 ± 12.6 standard deviation). While the general stroke population of those who have been admitted to hospital in Scotland is also predominantly concentrated within this group, this should not detract from the fact that there are patients outside of this age range who

23

are also being admitted. Closer inspection of the age specific incidence rates published in the OCSP illustrates that, although a very rare occurrence at that time, Partial Anterior Infarcts were predominantly evident in the under 45 age group and thereafter diminishing across the age groups as the other types of infarcts took prominence. The current adaptation of the four subtypes of infarction is shown in Table 4–4 where the number of potential infarcts is exclusive of the estimates for cryptogenic stroke. The allocation between the four subtypes is based on a ‘best fit’ to reach the population average reported in the original study. Table 4-4 Extending the OCSP model of infarction subtypes to population age

groups Original known admissions reported by ISD as at 31 March 2008

Total population

0 - 44 years

45 - 54 years

55 - 64 years

65 - 74 years

75 - 84 years

85+ years

Number of FES - TIA's Admitted 1,607 70 168 301 400 442 226Number of FES - Haemorrhagic Admitted 1,193 95 102 173 288 343 192Number of FES - Infarcts Admitted 5,743 204 380 774 1,298 1,871 1,216Total Admissions 8,543 369 650 1,248 1,986 2,656 1,634

Cryptogenic Stroke - Not Included 5% 40% 20% 10% 5% 0% 0%Cryptogenic Stroke - Patients Excluded 300 82 76 77 65 0 0

Clinically identifiable subtypes of cerebral infarction

Total population

0 - 44 years

45 - 54 years

55 - 64 years

65 - 74 years

75 - 84 years

85+ years

LACI - Lacunar Infarcts 25% 5% 35% 25% 25% 24% 25%TACI - Total Anterior Circulation Infarcts 17% 5% 10% 15% 15% 17% 25%PACI - Partial Anterior Circulation Infarcts 34% 85% 40% 35% 35% 34% 25%POCI - Posterior Circulation Infracts 24% 5% 15% 25% 25% 25% 25%

Subtotal 100% 100% 100% 100% 100% 100%Outcome of Infarct Analysis

LACI - Lacunar Infarcts 1,347 6 106 174 308 449 304TACI - Total Anterior Circulation Infarcts 948 6 30 105 185 318 304PACI - Partial Anterior Circulation Infarcts 1,842 104 122 244 432 636 304POCI - Posterior Circulation Infracts 1,306 6 46 173 308 469 304

Total Infarcts excluding Cryptogenic Stroke 5,443 122 304 696 1,233 1,872 1,216

Predictive Outcome Model (Adapted from OCSP 1986) - Identifying the Four Subtypes of Infarction

Having established the prominence of the four subtypes of infarct the model has been extended to look at the relationship between mortality in the first month and the possibility of re-admission for those who have survived in the first 3 months following discharge, as these are the only events which can be counted in the SMR01 database. Appendices 5.6 and 5.7 detail the full extension of the OCSP model as a best fit within the population groups for the total population of Scotland for the year ending 31 March 2007. These show the relationship between admission, survival and re-admittance. It is not possible to state that all patients who are being re-admitted to Scottish hospitals are as a result of a recurrent cerebrovascular event as this would require access to individual clinical patient information. Nonetheless, this model provides a best fit explanation to help predict the number of surviving patients who are likely to be re-

24

admitted following discharge, together with an estimate of the level of dependency. Its outputs are consistent with the observed data for Scotland and for each NHS board over the last 3 years. Hence it is considered to be robust and to generalise to the future. Given the robustness of the model, which has predicted mortality at 1 month and re-admission at 3 months to within 98.9% and 97.2% respectively over the same period, these data have been applied to underpin a principle assumption in this report. In order to ‘save beds’ through effective implementation of the recommendation in SIGN 108, there has to be the correct number of beds available (or allocated) in the first instance so that they can be ‘saved’ or reallocated within the general medical ward, where most stroke units are contained. Appendix 6 details the expected number of patients who are due for admittance in Scottish hospitals for the year ending 31 March 2009 based on the mid-year population estimate provided by the GROS as at 30 June 2007.

25

5 TIMELY THROMBOLYSIS

5.1 Background

SIGN 108 recommended administration of thrombolytic therapy with alteplase, within 4.5 hours from stroke onset. The guideline noted this significantly reduces death and disability at 90 days. The recommendations analysed within this report as required to deliver such a service include: • Emergency medical services should be redesigned to facilitate rapid access to

specialist stroke services.

• Stroke patients requiring admission to hospital should be admitted to a stroke unit staffed by a co-ordinated multidisciplinary team with a special interest in stroke care.

• All patients with suspected stroke should have brain imaging immediately on presentation.

• Patients admitted with stroke within 4.5 hours of definite onset of symptoms, who are considered suitable, should be treated with 0.9 mg/kg (up to maximum 90 mg) intravenous rt-PA.

5.2 Patient group

The patient subgroup assumed to receive thrombolytic therapy are those with a NIH Stroke Scale (NIHSS) score between 5–22, be under 80 years old (in accordance with the recommendation in its licence) and not experiencing a recurrent stroke within 3 months of the previous stroke. This group is forecast to be approximately 1,900 patients annually. Of these almost 50% will not be able to be treated within the 4.5 hour window or will be contraindicated. The anticipated numbers receiving the therapy is 1,015. This compares to an estimated 205 patients who are currently receiving the therapy, an increase of 810 patients. Approximately 48% of these patients are assumed to present at hospital between the hours of 8am–6pm, Monday to Friday, 27% outside these hours on a weekday and the remainder at a weekend. No-one is presumed to present after 11pm. This arrival pattern is based on that known for myocardial infarction, revised to assume a cut-off at 11pm, following discussion with the clinical experts in NHS boards currently administering the therapy.

5.3 Clinical benefit and associated resource savings

SIGN 108 notes the main clinical benefit from delivery of effective thrombolytic therapy is that some patients are able to make a full or near-full recovery. A pooled analysis suggests that approximately 10% of patients may make a full recovery, 45% will have a significantly improved outcome and 45% will have no change in outcome or an adverse outcome21.

26

The mean length of continuous inpatient stay for patients with a cerebrovascular disease diagnosis (excluding transient attacks) is 27 days (see Section 3.2). A full recovery is forecast to save 18 days, an improved recovery 9 days and no clinical change or an adverse outcome is assumed to save zero days. The mean cost for an inpatient bed in a medical ward has been estimated to be £277. This cost is a direct cost primarily comprising staff and consumables. It excludes all overheads. Table 5–1 provides an estimate of bed days saved and related costs. Table 5-1 Clinical benefits of additional thrombolytic therapy

Patients NHSScotland Estimated number of patients receiving thrombolytic therapy 205Forecast number of patients receiving thrombolytic therapy on implementation 1,015Additional number of patients likely to benefit 810Forecast outcome for these additional cases: 10% full recovery 8245% improved outcome 36445% no change in outcome or adverse outcome 323Number of bed days saved based on mean of 27 days: 10% full recovery saving 18 days 1,47645% improved outcome - saving 9 days 3,276Total number of additional bed days saved 4,752 Total bed days financial savings £1,316,304

5.4 Resource requirements

A key requirement to enable rapid access to specialist stroke services is that all patients with suspected stroke are identified early by paramedics and admitted to a hospital with a CT scanner as a minimum. Currently approximately 9% of stroke patients are estimated to be admitted to hospitals without such a scanner. Discussions with SAS have identified that: • ambulance paramedics and technicians who have undergone training on stroke

recognition are accurate in their assessment of potential stroke patients, and

• virtually all such patients could be taken to an alternative hospital with a scanner at no extra cost to the service and within SAS response time targets.

The analysis assumes NHS boards and SAS agree revised protocols such that all potential stroke patients are delivered to hospitals with a CT scanner. Adopting such protocols would be resource saving for both SAS and the NHS board, onward journeys to hospitals with scanners would be avoided, together with the requirement for two

27

clinical assessments, one at each hospital. The sensitivity analysis explores the costs of not adopting this approach. However, SAS estimates that approximately 100 additional patients will require air transport to enable them to reach hospital in sufficient time to be assessed for thrombolytic therapy. These patients are forecast to be in the Highlands and Grampian. Other key assumptions include that: • the protocol with SAS nominates a lead hospital (or hospitals) for stroke within the

NHS board area. Thus, no cross boundary services are assumed. This is different from the current position where NHS Greater Glasgow and Clyde provide services for other boards

• each board has sufficient high dependency beds to manage the additional 810 patients to receive thrombolysis, and

• staff can be trained to deliver the therapy at minimal cost. The staff resources required to deliver the drug are assumed to be:

• band 7 specialist nurse who is assumed to require 1 hour to establish time of onset of stroke and prior history for each of the 1,900 patients who may be eligible for the therapy. If the responses indicate that the patient may be eligible for the therapy then the nurse is assumed to call for a consultant. Thereafter the nurse will attend the patient receiving the therapy for a further 6 hours as the drug is administered and to oversee the initial management.

• consultant stroke physicians. Each NHS board is assumed to manage with no additional consultant resource during the core weekday hours. The additional workload from thrombolysing patients who present during weekday core hours is assumed to displace existing workload. However, this should reduce as the upfront investment in delivering the therapy is rewarded by having more patients with improved outcomes and consequently discharged earlier. This assumption will be particularly challenging for smaller boards where the consultant may have duties to conduct outwith the main hospital.

Seven NHS boards, being those forecast to have more than 30 patients per year presenting for this therapy in the early evening, are forecast to recruit an extra 0.5 WTE consultant each to cover five planned activities a week, providing cover until 8pm. All other out of hours work is assumed to be undertaken by on-call arrangements.

The total staff required is estimated at 4.2 WTE nurses, 35 additional planned activities per week to provide consultant resources in the early evening and 760 out of hours call-outs.

28

The other resources required are the alteplase itself and an additional CT scan after administration of the drug. The recruitment of these specialist nurses is judged to be sufficient to ensure all hospitals admitting stroke patients are staffed by a co-ordinated multidisciplinary team with a special interest in stroke care.

5.5 Costs

The unit costs for the resources required are: • air ambulance: £3,140 (Appendix 7.1) • band 7 specialist nurse: £40,996 (Section 3.4) • consultant stroke physician: £125,197 including overheads at 22% (Section 3.4) • out of hours call-out: £397 (Section 3.4) • alteplase: £723 including VAT (source www.bnf.org) • CT scan: £127 (Appendix 7.3). Table 5-2 provides the estimated cost of delivering thrombolytic therapy to an additional 810 patients in Scotland. Table 5-2 Additional costs to deliver thrombolytic therapy to an additional 810

patients

Event Total costs SAS for air ambulance £317,415Alteplase £585,630CT scan £102,682Specialist nurse £172,183Additional consultant sessions £542,360Additional call-out sessions £302,059 Total costs £2,022,329

5.6 Sensitivity analysis

Two sensitivity analyses have been performed on the delivery of thrombolytic therapy. The first models the cost of failure to put in place robust protocols between SAS and the NHS boards for the delivery of possible stroke patients to hospitals equipped with a CT scanner. The analysis by NHS board identifies that almost 1,100 additional journeys would be incurred, of which over 800 are out of hours. Each journey is associated with two A&E admissions, one of which could be saved by adopting the appropriate protocol. The unit costs and total costs of these events are set out in Table 5–3. This optimisation of delivery of patients could save almost £350,000 per annum.

29

Table 5-3 Additional costs if patients are not directed to hospitals with CT scanners

Event Unit costs Total costs

Unnecessary SAS journeys £213 £235,873Unnecessary A&E assessments £101 £111,483Total costs £347,356 The second sensitivity analysis assumes that NHS boards prioritise commissioning services Monday to Friday during core hours only. The additional number of patients to be treated falls to around 390, or by just over 50%. All costs, other than for consultants, fall in line with the patient numbers. Under the assumptions, no additional consultant costs would be required, with thrombolysis displacing other activities. The total cost falls to around £567,149, equivalent to £1,455 per patient. This compares to a cost per patient of almost £2,500 for the 7 days a week, 24 hours a day service (see Table 5–4). Table 5-4 Additional costs to deliver thrombolytic therapy to an additional 390

patients

Event Total costs SAS for air ambulance £152,829Alteplase £281,970CT scan £49,530Specialist nurse £82,820Additional consultant sessions 0Additional call-out sessions 0Total costs £567,149

5.7 Analyses by NHS board

Tables 5–5 to 5–8 provide further information on the epidemiology, costs and benefits from timely thrombolysis by NHS board. Table 5–5 presents the anticipated patients, Table 5–6 the additional clinical benefit, Table 5–7 the additional costs and Table 5–8 the sensitivity analysis assuming SAS are not able to deliver patients to the specified hospital for timely thrombolysis.

30

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Tabl

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lysi

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AS

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ient

s to

be d

eliv

ered

dire

ctly

to th

e ta

rget

hos

pita

l for

thro

mbo

lysis

. If

time

of o

nset

is

esta

blish

ed a

t the

clo

sed

plac

e of

dia

gnos

tics,

ther

e w

ill b

e du

plic

ate

patie

nt tr

ansf

ers a

nd d

uplic

ate

A&E

adm

issio

ns:

NH

S Sc

otla

nd

tota

l pop

ulat

ion

NH

S

Ay

rshi

re &

Ar

ran

NH

S

Bo

rder

s

NH

S

Dum

frie

s &

Gal

low

ay

NH

S

Fi

feN

HS

Fort

h Va

lley

NH

S

Gra

mpi

an

NH

S

G

reat

er

Gla

sgow

&

Clyd

e

NH

S

Hig

hlan

dN

HS

Lana

rksh

ireN

HS

Loth

ian

NH

S

Ta

ysid

e

Num

ber o

f In

Hou

rs T

rans

fers

for T

hrom

boly

sis

297

400

918

013

101

2073

022

Num

ber o

f Out

of H

ours

Tra

nsfe

rs fo

r Thr

ombo

lysi

s81

179

019

350

2534

143

134

8649

Uni

t Cos

t of A

mbu

lanc

e Tr

ansf

er£2

13£2

42£4

95£4

60£1

92£1

76£2

64£1

63£4

89£1

70£1

71£2

92P

oten

tial a

dditi

onal

cos

ts to

the

Ambu

lanc

e Se

rvic

e£2

35,8

73£2

8,90

4£0

£12,

973

£10,

261

£0£1

0,13

7£7

2,13

9£3

0,99

2£3

5,14

5£1

4,71

8£2

0,60

5U

nit C

ost o

f A&E

Atte

ndan

ce£1

01£9

9£1

23£9

7£8

4£9

7£9

2£9

2£1

44£9

0£1

54£1

02P

oten

tial a

dditi

onal

cos

ts th

roug

h du

plic

ate

atte

ndan

ce in

A

&E£1

11,4

83£1

1,82

4£0

£2,7

36£4

,489

£0£3

,533

£40,

717

£9,1

26£1

8,60

6£1

3,25

5£7

,198

34

6 TIMELY CAROTID IMAGING AND CAROTID ENDARTERECTOMY

6.1 Background

SIGN 108 refers to the randomised controlled trials and related pooled data that report best medical treatment plus carotid endarterectomy is clinically effective compared to best medical treatment only in preventing recurrent stroke. The greatest benefit was seen in patients with severe stenosis. This evidence base informed the SIGN 108 recommendations on carotid endarterectomy to include that: • all patients with carotid artery stroke without severe disability, (mRS ≤2) or TIA

ischaemic attack should be considered for carotid endarterectomy as soon as possible after the index event

• carotid endarterectomy should be considered in all: - male patients with a carotid artery stenosis of 50–99%

- female patients with a carotid artery stenosis of 70–99% and

• carotid endarterectomy should be performed as soon as the patient is stable and fit for surgery, ideally within 2 weeks of event.

6.2 Patient group

The relevant patient group for this intervention is those patients with severe stenosis who are fit enough for surgery as measured by the modified Rankin Scale or mRS ≤2. The epidemiological model predicts that the annual incidence could be approximately 11,865 people. Approximately 6,060 of these will be inpatients and the balance will be identified at neurovascular outpatient clinics. The inpatients include some 500 patients who recover sufficiently following thrombolysis to benefit from surgery. It is estimated that around 50% of these patients will not be judged suitable for surgery for various reasons, to include co-morbidities. As noted in the guideline age in itself is not a restriction. Of the remaining 6,010 it is predicted that the carotid Doppler results will show that 80% of the TIA’s and 75% of relevant inpatients have stenosis, with 25% being sufficiently severe to require surgery. Thus approximately 1,160 patients are judged to meet the criteria in SIGN 108 for carotid endarterectomy; of these 395 (35%) will be inpatients and the remaining 765 outpatients. This information is presented in Table 6–1. Currently approximately 552 carotid endarterectomy procedures are performed in Scotland annually; 200 on inpatients and 350 on outpatients. The forecast additional number of procedures is 608, being 194 on inpatients and 414 on outpatients.

35

Table 6-1 Calculation to estimate number of patients eligible for surgery

Patient groups

Number of patients

in Scotland TIA's admitted mRS ≤2 2,084 TIA's in outpatients mRS ≤2 3,187 Infarcts admitted mRS ≤2 3,980 Infarcts in outpatients mRS ≤2 2,615 Total patients including thrombolysis with mRS ≤2 11,866 Of these patients fit for surgery: TIA's admitted 1,093 TIA's outpatients 1,584 Infarcts admitted 2,037 Infarcts outpatients 1,294 Total patients fit for surgery 6,008 Of these patients with stenosis: TIA’s with stenosis 2,141 Infarcts with stenosis 2,497 Total patients with stenosis 4,638 Patients with severe stenosis and fit for surgery 1,160 Of which: inpatients 395 outpatients 765

6.3 Clinical benefit and associated resource savings

SIGN 108 notes the main clinical benefit from performing timely carotid endarterectomy is to prevent future strokes. The guideline provides the NNT to prevent one ipsilateral stroke at 5 years in patients with severe stenosis. The NNT rises steeply with the delay between time of surgery and the primary event. Surgery performed within 2 weeks of the event is associated with a NNT of 5 but at longer than 12 weeks the NNT rises to 125. Records from SSCAS show that of the 552 patients currently undergoing this procedure only 150 have it within 30 days of the event. Applying a NNT of 10 to these 150 events suggests the current intervention is preventing approximately 15 strokes at 5 years. Successful implementation of the recommendations in SIGN 108 could result in NHS boards treating 1,160 patients within 14 days, thereby achieving a NNT of 5 and preventing 232 strokes at five years. The additional 217 strokes prevented are equivalent to approximately 5,860 bed days assuming a mean bed day stay of 27 days per stroke patient (source ISD). The financial savings, assuming a mean direct cost for an inpatient bed of £277 (see Section 3.2) is £1.62 million.

36

6.4 Resource requirements

The clinical resources required to perform a carotid endarterectomy on a patient who is already in hospital is assumed to be an additional MRI or equivalent scan, 1.5 hours in theatre (to include recovery) and an ultrasound post-surgery to inform the prognosis. It is assumed each outpatient will receive the scan and theatre time and spend 2 nights in hospital immediately prior to and post-surgery. Some surgeons may choose to perform the operation without routinely requiring the patient to be hospitalised for 2 nights once they are familiar with the procedure and associated risks and complications. The additional procedure related staff requirements are assumed to be:

• a surgeon who spends 2 hours with each patient,

• two theatre nurses (a band 5 and band 6 specialist nurse) who each require 1.5 hours, and

• an anaesthetist incurring 1.5 hours. The additional staff required to carry out 608 extra procedures are 1.1 WTE surgeons, 0.65 WTE each of a band 5 and band 6 theatre nurse and 0.65 WTE anaesthetist. The staff required for the additional scans is addressed in Section 7.

6.5 Costs

The unit costs associated with performing a carotid endarterectomy during an inpatient stay are estimated at £1,855 (see Section 3.4 and Table 3–3). Conducting the procedure on an outpatient is estimated to incur a cost of £2,443, with the difference being the cost of 2 overnight stays in a surgical ward. Applying these costs to an additional 194 inpatient and 414 outpatient procedures gives a total incremental cost of £1.38 million. This is the central estimate of the additional costs of performing carotid endarterectomy in line with the recommendations in SIGN 108.


An obvious sensitivity analysis is around patient numbers. For example, if an extra 300 patients are eligible for such a procedure then the costs would increase in proportion. Thus the cost to manage 608 patients is estimated to be £1.38 million, and the costs to manage 908 estimated at £2.06 million [being £1.38*908/608]. The analysis assumes that consultants can identify the 50% who are unlikely to be fit for surgery without undertaking a carotid Doppler examination. If, however, this is not the case then the cost is underestimated by £0.93 million; the cost of 5,570 visits to a general surgery outpatient clinic plus a carotid Doppler examination. The combined mean cost of these is £167 for each NHS board (see Section 3.4 and Table 3–3).

37

6.7 Analyses by NHS board

Tables 6–2 to 6–5 provide further information on the epidemiology, costs and benefits from timely carotid endarterectomy by NHS board. Table 6–3 presents the estimated clinical benefit, Table 6–4 the estimated additional costs to achieve timely carotid endarterectomy, and Table 6–5 the sensitivity analysis of the higher costs that would be incurred if a carotid Doppler scan is required to assess patients before surgery.

38

Tabl

e 6-

2 Pa

tient

s w

ho a

re p

oten

tial c

andi

date

s fo

r car

otid

end

arte

rect

omy

In

depe

nden

cy A

naly

sis o

f Isc

haem

ic S

trok

es &

CB

V Ev

ents

mRS

<=

2 pr

e th

rom

boly

sis

NH

S Sc

otla

nd

tota

l po

pula

tion

NH

S

Ay

rshi

re &

Ar

ran

NH

S

Bo

rder

s

NH

S

Dum

frie

s &

Gal

low

ay

NH

S

Fi

feN

HS

Fort

h Va

lley

NH

S

Gra

mpi

an

NH

S

G

reat

er

Gla

sgow

&

Clyd

e

NH

S

Hig

hlan

d

NH

S

Is

land

Bo

ards

NH

S La

nark

shire

NH

S

Lo

thia

nN

HS

Tays

ide

No

of T

IA's

Adm

itted

2,08

416

153

5814

779

171

524

149

3822

625

522

1N

o of

TIA

's in

NV

Out

patie

nts

3,18

720

678

6517

514

211

91,

226

131

058

834

511

3N

o of

Infa

rcts

- FES

Adm

itted

3,57

428

781

123

256

173

328

847

220

4140

850

430

6N

o of

Infa

rcts

- NV

Out

patie

nts

2,51

313

752

9811

794

179

817

131

039

242

175

Tota

l Pat

ient

s exc

ludi

ng T

hrom

boly

sis11

,358

791

263

344

695

488

797

3,41

463

080

1,61

51,

525

715

Addi

tions

as a

resu

lt of

Thr

ombo

lysis

NH

S Sc

otla

nd

tota

l po

pula

tion

NH

S

Ay

rshi

re &

Ar

ran

NH

S

Bo

rder

s

NH

S

Dum

frie

s &

Gal

low

ay

NH

S

Fi

feN

HS

Fort

h Va

lley

NH

S

Gra

mpi

an

NH

S

G

reat

er

Gla

sgow

&

Clyd

e

NH

S

Hig

hlan

d

NH

S

Is

land

Bo

ards

NH

S La

nark

shire

NH

S

Lo

thia

nN

HS

Tays

ide

Impr

ovem

ents

in m

RS <

=1

(Disc

harg

ed)

102

112

47

49

265

112

137

Impr

ovem

ents

in m

RS <

=2

(No

Disc

harg

e )40

642

1016

3017

3610

421

249

5227

Tota

l Add

ition

al P

atie

nts

508

5312

2037

2146

130

263

6265

34

Inde

pend

ency

Ana

lysis

of I

scha

emic

Str

okes

&

CBV

Even

ts m

RS <

=2

post

thro

mbo

lysis

NH

S Sc

otla

nd

tota

l po

pula

tion

NH

S

Ay

rshi

re &

Ar

ran

NH

S

Bo

rder

s

NH

S

Dum

frie

s &

Gal

low

ay

NH

S

Fi

feN

HS

Fort

h Va

lley

NH

S

Gra

mpi

an

NH

S

G

reat

er

Gla

sgow

&

Clyd

e

NH

S

Hig

hlan

d

NH

S

Is

land

Bo

ards

NH

S La

nark

shire

NH

S

Lo

thia

nN

HS

Tays

ide

No

of T

IA's

Adm

itted

2,08

416

153

5814

779

171

524

149

3822

625

522

1N

o of

TIA

's in

NV

Out

patie

nts

3,18

720

678

6517

514

211

91,

226

131

058

834

511

3N

o of

Infa

rcts

- FES

Adm

itted

3,98

032

991

139

286

189

365

951

241

4345

755

633

3N

o of

Infa

rcts

- NV

Out

patie

nts

2,61

514

854

102

124

9918

884

313

61

404

434

82To

tal P

atie

nts I

nclu

ding

Thr

ombo

lysis

11,8

6684

427

636

473

250

984

33,

544

656

821,

676

1,59

074

9

Rest

rictio

ns o

n Pa

tient

s bei

ng p

ut fo

rwar

d fo

r Su

rger

y

NH

S Sc

otla

nd

tota

l po

pula

tion

NH

S

Ay

rshi

re &

Ar

ran

NH

S

Bo

rder

s

NH

S

Dum

frie

s &

Gal

low

ay

NH

S

Fi

feN

HS

Fort

h Va

lley

NH

S

Gra

mpi

an

NH

S

G

reat

er

Gla

sgow

&

Clyd

e

NH

S

Hig

hlan

d

NH

S

Is

land

Bo

ards

NH

S La

nark

shire

NH

S

Lo

thia

nN

HS

Tays

ide

Estim

ate

of p

atie

nts t

oo in

firm

to su

rviv

e su

rger

y37

.2%

35.2

%38

.1%

40.9

%37

.2%

35.6

%37

.1%

35.0

%39

.4%

38.2

%34

.1%

38.3

%37

.1%

Cont

rain

dica

tions

- T2

DM

and

Clin

ical

Obe

sity

13.0

%14

.4%

14.5

%12

.0%

14.8

%12

.3%

13.8

%12

.2%

13.7

%8.

4%12

.1%

13.9

%13

.8%

Num

ber o

f Pat

ient

s Res

trict

ed fr

om S

urge

ry5,

858

419

145

193

381

244

430

1,67

534

938

775

829

381

Num

ber o

f Pat

ient

s Sch

edul

ed fo

r Car

otid

D

oppl

ar a

s Firs

t Lin

e In

vest

igat

ion

for C

arot

id

Sten

osis

NH

S Sc

otla

nd

tota

l po

pula

tion

NH

S

Ay

rshi

re &

Ar

ran

NH

S

Bo

rder

s

NH

S

Dum

frie

s &

Gal

low

ay

NH

S

Fi

feN

HS

Fort

h Va

lley

NH

S

Gra

mpi

an

NH

S

G

reat

er

Gla

sgow

&

Clyd

e

NH

S

Hig

hlan

d

NH

S

Is

land

Bo

ards

NH

S La

nark

shire

NH

S

Lo

thia

nN

HS

Tays

ide

No

of T

IA's

Adm

itted

1,09

386

2628

7342

8129

071

2013

313

011

3N

o of

TIA

's in

NV

Out

patie

nts

1,58

410

035

3081

7257

630

590

309

158

53N

o of

Infa

rcts

- FES

Adm

itted

2,03

716

645

6714

010

118

551

411

623

247

272

162

No

of In

farc

ts - N

V O

utpa

tient

s1,

294

7325

4758

5191

436

620

213

201

39To

tal P

atie

nts I

nclu

ding

Thr

ombo

lysis

6,00

842

513

117

235

226

541

31,

870

308

4490

176

136

8

Out

com

e fr

om C

arot

id D

oppl

ar E

xam

inat

ion

for

Leve

l of S

teno

sis

NH

S Sc

otla

nd

tota

l po

pula

tion

NH

S

Ay

rshi

re &

Ar

ran

NH

S

Bo

rder

s

NH

S

Dum

frie

s &

Gal

low

ay

NH

S

Fi

feN

HS

Fort

h Va

lley

NH

S

Gra

mpi

an

NH

S

G

reat

er

Gla

sgow

&

Clyd

e

NH

S

Hig

hlan

d

NH

S

Is

land

Bo

ards

NH

S La

nark

shire

NH

S

Lo

thia

nN

HS

Tays

ide

No

of T

IA's

Like

ly to

hav

e St

enos

is2,

141

149

4946

123

9111

073

610

416

353

231

133

No

of In

farc

ts Li

kely

to h

ave

Sten

osis

2,49

717

952

8514

811

320

771

213

318

345

354

151

Subt

otal

4,63

832

810

113

127

120

431

71,

448

237

3469

858

528

4N

umbe

r of P

atie

nts w

ith S

teno

sis se

vere

eno

ugh

to

requ

ire su

rger

y1,

160

8225

3368

5179

362

599

175

146

71

39

Tabl

e 6-

3 Es

timat

ed c

linic

al b

enef

it fr

om ti

mel

y ca

rotid

end

arte

rect

omy

Addi

tiona

l ben

efits

as a

resu

lt of

impr

oved

acc

ess t

o Ca

rotid

En

dart

erec

tom

yN

HS

Scot

land

to

tal p

opul

atio

n

NH

S Ay

rshi

re &

Ar

ran

NH

S Bo

rder

s

NH

S D

umfr

ies &

G

allo

way

NH

S Fi

feN

HS

Fort

h Va

lley

NH

S G

ram

pian

NH

S G

reat

er

Gla

sgow

&

Clyd

e

NH

S H

ighl

and

NH

S Is

land

Bo

ards

NH

S La

nark

shire

NH

S Lo

thia

nN

HS

Tays

ide

Cur

rent

est

imat

e of

the

num

ber o

f cas

es o

f pat

ient

s ha

ving

C

arot

id E

ndar

tere

ctom

y pe

form

ed in

Sco

tland

552

6511

2835

4265

126

503

2961

37C

urre

nt e

stim

ate

of th

e nu

mbe

r of c

ases

of p

atie

nts

havi

ng

Car

otid

End

arte

rect

omy

perfo

rmed

with

in 3

0 da

ys w

here

the

NN

T =

10

to a

void

one

recu

rren

t eve

nt (f

rom

SSC

AS

as a

t 31

Dec

embe

r 200

7)

150

74

07

717

4517

00

3016

Effe

ctiv

enes

s Rat

io c

urre

ntly

:27

.2%

10.8

%36

.4%

0.0%

20.0

%16

.7%

26.2

%35

.7%

34.0

%0.

0%0.

0%49

.2%

43.2

%C

urre

nt e

stim

ate

of th

e nu

mbe

r of e

vent

s avo

ided

:15

10

01

11

52

00

31

Futu

re e

stim

ate

of th

e nu

mbe

r of c

ases

of p

atie

nts

havi

ng

Car

otid

End

arte

rect

omy

pefo

rmed

in S

cotla

nd1,

160

8226

3368

5179

362

598

175

146

71As

sum

ing

100%

effe

ctiv

enes

s for

all

proc

edur

es c

arrie

d ou

t w

ithin

14

days

whe

re th

e N

NT

= 5

to a

void

one

recu

rren

t ev

ent w

ould

pot

entia

lly a

void

:23

216

57

1410

1672

122

3529

14

Addi

tona

l eve

nts a

void

ed:

217

155

713

915

6710

235

2613

Num

ber o

f bed

day

s sav

ed b

ased

on

aver

age

of 2

7 da

ys5,

859

405

135

189

351

243

405

1809

270

5494

570

235

1

Tabl

e 6-

4 Es

timat

ed a

dditi

onal

cos

t to

achi

eve

timel

y ca

rotid

end

arte

rect

omy

Addi

tiona

l cos

ts a

s a re

sult

of im

prov

ed ti

mel

y ca

rotid

en

dart

erec

tom

yN

HS

Scot

land

to

tal p

opul

atio

n

NH

S Ay

rshi

re &

Ar

ran

NH

S Bo

rder

s

NH

S D

umfr

ies &

G

allo

way

NH

S Fi

feN

HS

Fort

h Va

lley

NH

S G

ram

pian

NH

S G

reat

er

Gla

sgow

&

Clyd

e

NH

S H

ighl

and

NH

S Is

land

Bo

ard s

NH

S La

nark

shire

NH

S Lo

thia

nN

HS

Tays

ide

Estim

ated

futu

re n

umbe

r of p

roce

dure

s ca

rried

out

on

exist

ing

inpa

tient

s whe

re re

cove

ry p

ost s

urge

ry is

with

in th

e ex

istin

g st

roke

uni

t39

532

913

2719

3599

228

4852

31

Estim

ated

cur

rent

num

ber o

f pro

cedu

res c

arrie

d ou

t on

exis

ting

inpa

tient

s whe

re re

cove

ry p

ost s

urge

ry is

with

in th

e ex

istin

g st

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41

7 TIMELY CT DIAGNOSTICS

7.1 Background

SIGN 108 recommends that ‘All patients with suspected stroke should have brain imaging immediately on presentation’ (recommendation 2.3.1). The use of brain imaging is the first level of diagnostics necessary to distinguish whether a patient is presenting with a haemorrhagic stroke or an ischaemic stroke, including transient ischaemic events. The successful implementation of thrombolytic therapy within 4.5 hours of symptom onset requires the assessment of potential candidates using a CT head scanner immediately on arrival in hospital. This may require the patient to take precedent over others waiting for a scan, thereby interrupting the service for 15 minutes. Other stroke patients requiring scanning are less time critical and thus should be able to be planned within a daily schedule. No definite admission pattern for thrombolytic patients has been established. Feedback from some NHS boards indicates it is likely that a number of potential patients will present mid morning when radiology departments are often at their busiest. Extensive modelling has quantified the potential number of immediate scans required during this peak time to be twice per week in the larger boards and once per fortnight in the smaller boards. This assumes that all patients are delivered by SAS to the nominated target hospital in each NHS board. NHS Quality Improvement Scotland has published clinical standards on Stroke Services: Care of the Patient in the Acute Setting for all patients admitted with a stroke. These require that 80% of patients have CT/MRI imaging within 48 hours of admission. The standards are under review with a proposal to require that 80% of patients have CT/MRI imaging on the day of admission. A model has been developed to measure the demands that CT scanning for stroke places on radiology departments. This encompasses the resources and funding required solely to manage patients with suspected stroke including TIA. This model seeks to address some of the issues raised by members of the stroke managed clinical networks who reported significant delays in the radiological diagnostics service. Such services are tasked with delivering diagnostics to many other medical conditions, which are subject to their own timeframes and waiting time initiatives. The following analysis quantifies the resources required and costs of having a dedicated service for stroke. NHS boards may be able to compare these resources to current service levels to estimate whether additional resources are needed. In addition, in the first year, each NHS board is assumed to require additional support from a business administration manager to undertake the management and reporting of inpatients and outpatients and model patient flows. This activity should assist in optimising the resources required to support diagnostics, thrombolysis and carotid endarterectomy.

42

7.2 Patient group

The patient group for timely CT scanning includes all diagnosed stroke inpatients plus those who attend at a neurovascular outpatient clinic. In addition there are a number of known stroke mimics whose symptoms on presentation are sufficiently similar to require CT scanning as a first level diagnostic tool. The scan can eliminate this particular group of patients from the stroke care pathway. The total patient group that gives rise to the demand for CT diagnostics is detailed in Table 7–1. Table 7-1 Patient groups requiring CT scanning facilities

Patient groups Stroke Mimic Total

Attendance Inpatient admittance (ISD epidemiology): First ever hospital admission 8,814 Recurrent stroke event from current year 1,339 Recurrent stroke event from historical year 1,767 Uplift by 15% for mimics 1,759 Subtotal for inpatients 13,679Outpatient attendance (SSCAS): Estimated number of TIA patients 3,187 Estimated number of minor stroke patients 2,513 11% of patients with RAO or TMB 1,075 29% of patients with non CBV event 2,825 Subtotal for outpatients 9,600NHSScotland total 17,620 5,659 23,279 Key: Retinal Artery Occlusion (RAO); Transient Monocular Blindness (TMB) In addition, the 1,015 patients forecast to benefit from thrombolytic therapy are assumed to receive a scan to assess any potential haemorrhagic activity as a result of the drug administration. Thus, total demand is estimated to be almost 24,300 patients annually.

7.3 Clinical benefits

The clinical benefits associated with timely CT scanning are reported in Sections 5.3 and 6.3, being the clinical benefits attributable to timely thrombolysis and carotid endarterectomy.

7.4 Resources

The resources required to meet the demand for CT scanning services in Scotland’s hospitals have been calculated assuming 24,300 patients require a CT scan each year. The annual demand is then expressed as a weekly demand assuming 50 operational weeks per annum and no seasonality. Expressing this weekly demand in operational machine hours, with each scan event taking 15 minutes, suggests that for Scotland a

43

total of 122 hours are required (see Table 7–2). This is equivalent to operating 25 scanners for 1 hour per day Monday to Friday. For the majority of NHS boards this will be one scanner per hospital site providing acute stroke services, with the exception of NHS Grampian and NHS Greater Glasgow and Clyde where it is equivalent to 1 hour per weekday on two scanners per tertiary site. Table 7-2 Calculation of operational CT scanning hours per week in Scottish

hospitals

Resources required for timely CT scanning

First diagnostic

event

Additional scan post

thrombolysisTotal

demand

Number per

week (50)

Operational hours (15 min per scan)

No of scanners extended

time NHS Ayrshire & Arran 1,728 105 1,833 37 9.2 2NHS Borders 555 25 580 12 2.9 1NHS Dumfries & Galloway 748 40 788 16 3.9 1NHS Fife 1,475 74 1,549 31 7.7 2NHS Forth Valley 993 42 1,035 21 5.2 1NHS Grampian 1,864 91 1,955 39 9.8 2NHS Greater Glasgow and Clyde 6,561 261 6,822 136 34.1 7NHS Highland 1,369 51 1,420 28 7.1 1NHS Island Boards 179 5 184 4 0.9 0NHS Lanarkshire 2,979 123 3,102 62 15.5 3NHS Lothian 3,103 130 3,233 65 16.2 3NHS Tayside 1,723 68 1,791 36 9.0 2NHSScotland 23,277 1,015 24,292 486 121.5 25 The staff resources required to provide a weekday service for each scanner are assumed to be:

• one 0.5 planned activity session for a stroke consultant to read the scans

• 0.2 WTE band 7 radiographer specialising in CT head scanning

• 0.2 WTE band 6 radiographer with an interest in CT head scanning

• 0.2 WTE band 3 helper, and

• 0.2 WTE band 2 clerical officer. The annual resources required to provide a weekday service across Scotland are 625 planned activity sessions for consultants, 5 WTE band 7 radiographers, 5 WTE band 6 radiographers, 5 WTE band 3 helpers and 5 WTE band 2 clerical officers. This simplistic approach provides sufficient capacity to scan all patients on a weekday but not the two sevenths of inpatients; equivalent to approximately 4,340 inpatients who will require a service at weekends. Increasing the resources to provide scanning capability for those inpatients suggests the additional resources required are 737

44

planned activity sessions for consultants, 5.9 WTE band 7 radiographers, 5.9 WTE band 6 radiographers, 5.9 WTE band 3 helpers and 5.9 WTE band 2 clerical officers. Using this approach is consistent with assuming the number of appointments needed to manage 24,300 scans is 28,640. The additional 18% capacity recognises some outpatients will not attend the initial appointment and require a second appointment, the need for repeat scans and cases where the scan takes more than 15 minutes. An estimate of 3.8 WTE support from additional band 6 business administration managers is forecast to be required across Scotland, in the first year, to support implementation.

7.5 Costs

The unit costs and total costs for each resource are shown in Table 7–3. Table 7-3 Unit cost and total cost to provide capacity to scan 24,300 people

with stroke symptoms per year

Resource Resources required

Unit costs Total costs

Stroke consultant 15 planned

activities per week £20,660 per

planned activity £309,900 Band 7 radiographer 5.9 WTE £40,996 £241,590Band 6 radiographer 5.9 WTE £34,332 £202,319Band 3 helper 5.9 WTE £19,895 £117,241Band 2 clerical officer 5.9 WTE £17,602 £103,729Total for Scotland £974,779 The additional cost of the 3.8 WTE band 6 business administration managers is estimated at £128,745.


Information from SSCAS indicates that some NHS boards provide significantly more outpatient clinics than are indicated to be required to manage this patient group.

45

8 REFERENCES

1. National Audit Office. Report by the Comptroller and Auditor General. Department of Health. Reducing Brain Damage: Faster access to better stroke care. HC 452 Session 2005-2006. 16 November 2005.

2. Syme P., Byrne A., Chen R., Devenny R., Forbes J. Community-based stroke incidence in a Scottish population: the Scottish Borders Stroke Study. Stroke 2005; 36(9): 1837-43. (SBSS)

3. Scottish Intercollegiate Guidelines Network. Management of patients with stroke or TIA: assessment, investigation, immediate management and secondary prevention. A national clinical guideline. SIGN 108. 2008. Available from www.sign.ac.uk

4. Mauskopf J. et al. Principles of Good Practice for Budget Impact Analysis: Report of the ISPOR Task Force on Good Research Practice: Budget Impact Analysis. Value in Health 2007; 10(5): 336-347.

5. Trueman P., Hutton J., Drummond M. Developing Guidance for Budget Impact Analysis. Pharmacoeconomics 2001; 19(6): 609-621.

6. Trueman P., Cardow T. Independent Evaluation of the Resource Impact Tools Developed Alongside the SIGN CHD Guidelines. York Health Economics Consortium March 2008.

7. National Institute for Health and Clinical Excellence. Developing costing tools; Methods guide. January 2008. Available from: www.nice.org.uk

8. Rothwell P., Gutnikov S., Warlow C. European Carotid Surgery Trialist’s C. Reanalysis of the final results of the European Carotid Surgery Trial. Stroke 2003; 34(2): 514-23.

9. Audit Commission. National Report 2005. Managing the financial implications of NICE guidance. Available from www.audit-commission.gov.uk

10. Scottish Goverment. Coronary Heart Disease and Stroke: Strategy for Scotland. 3 October 2002. available from www.scotland.gov.uk

11. NHS National Services Scotland. Scottish Stroke Care Audit. Stroke Services in Scottish Hospitals; Data relating to 2005-2007. 2008 National Report. Available from www.isdscotland.org

12. Bamford J., Sandercock P., Dennis M. et al. A prospective study of acute cerebrovascular disease in the community: the Oxfordshire Community Stroke Project 1981-86. 1. Methodology, demography and incident cases of first-ever stroke. J Neurol Neurosurg Psychiatry 1988; 51: 1373-80

46

13. Bamford J., Sandercock P., Dennis M., Burn J., Warlow C. A prospective study of acute cerebrovascular disease in the community: the Oxfordshire Community Stroke Project 1981-86. 2. Incidence, case fatality rates and overall outcome at one year of cerebral infarction, primary Intracerebral haemorrhage and subarachnoid haemorrhage. J Neurol Neurosurg Psychiatry 1990; 53: 16-22

14. Bamford J., Sandercock P., Dennis M., Burn J., Warlow C. Classification and natural history of clinically identifiable subtypes of cerebral infarction. Lancet 1991; 337: 1521-26

15. Murphy D. Information Services Division (ISD). Cerebrovascular Disease Admissions in Scotland; episodes, continuous inpatient stays, number of patients and estimated costs in the patient pathway of care for the financial years 2002/03 to 2007/08 inclusive. File Reference IR2008-01983 in response to a request by Craig J. NHS Quality Improvement Scotland 13 August 2008.

16. Health Service Journal. Fast Thinking: Stroke Care 18-20. 12 March 2009 17. Caso V., Paciaroni M., Venti M., Palmerini F. et al. Determinant of outcome in

patients eligible for thrombolysis for ischaemic stroke. Vasc Health Risk Manag 2007; 3(5): 749-54

18. Murphy D. Information Services Division (ISD). Cerebrovascular Disease Admissions & Mortality in Scotland; first ever occurrence of cerebrovascular disease that has resulted in a hospital admission or that has resulted in death without admission as a unique once only event. File Reference IR2008-02372 in response to a request by Wallace G. NHS Quality Improvement Scotland 1 October 2008.

19. Murphy D. Information Services Division (ISD). Cerebrovascular Disease Unique First Ever Admissions for Stroke or TIA in Scotland: Linked database results for prior admission history, readmission and survival for the years 31 March 2006, 2007 and 2008. File Reference IR2008-02372 in response to a request by Wallace G. NHS Quality Improvement Scotland 1 October 2008.

20. Hacke W., Donnan G., Fieschi C., Kaste M., von Kummer R., Broderick JP et al. Association of outcomes with early stroke treatment: pooled analysis of ATLANTIS, ECASS and NINDS rt-PA stroke trials. Lancet 2004; 363 768-74.

47

9 APPENDICES

Appendix 1 Key recommendations The following recommendations were highlighted by the guideline development group as being clinically very important and to be prioritised for implementation. Each recommendation was then assessed as to whether it is a material change to current practice and likely to have a material resource impact. If so, then the recommendation is considered in this report. A brief commentary is provided for those recommendation judged not to have a material impact on resource use. SIGN 108 recommendation Commentary Emergency medical services should be redesigned to facilitate rapid access to specialist stroke services.

Included in report

Stroke patients requiring admission to hospital should be admitted to a stroke unit staffed by a co-ordinated multidisciplinary team with a special interest in stroke care.

Included in report

All patients with suspected stroke should have brain imaging immediately on presentation.

Included in report

All patients with non-disabling acute stroke syndrome/TIA in the carotid territory who are potential candidates for carotid surgery should have carotid imaging.

Included in report

Patients admitted with stroke within 4.5 hours of definite onset of symptoms, who are considered suitable, should be treated with 0.9 mg/kg (up to maximum 90 mg) intravenous rt-PA.

Included in report

For individuals aged up to 60 years who suffer an acute MCA territory ischaemic stroke complicated by massive cerebral oedema, surgical decompression by hemicraniectomy should be offered within 48 hours of stroke onset.

Included in report

Low-dose aspirin (75 mg daily) and dipyridamole (200 mg modified release twice daily) should be prescribed after ischaemic stroke or TIA for secondary prevention of vascular events.

Not included in report as this is current practice http://www.isdscotland.org/isd/servlet/File Buffer?namedFile=QOF_Scot_200405_to_200708_indicators_lookup.xls&pContentDispositionType=attachment

48

SIGN 108 recommendation Commentary Clopidogrel (75mg daily) monotherapy should be considered as an alternative to combination aspirin and dipyridamole after ischaemic stroke or TIA for secondary prevention of vascular events.


A statin should be prescribed to patients who have had an ischaemic stroke, irrespective of cholesterol level.


Statin therapy after haemorrhagic stroke is not routinely recommended unless the risk of further vascular events outweighs the risk of further haemorrhage.

Not included in report as this is current practice

All patients with carotid artery territory stroke (without severe disability, mRS ≤2) or transient ischaemic attack should be considered for carotid endarterectomy as soon as possible after the index event.

Included in report

Carotid endarterectomy (on the internal carotid artery ipsilateral to the cerebrovascular event) should be considered in all: • male patients with a carotid artery stenosis of

50–99% (by NASCET method) • female patients with a carotid artery stenosis

of 70–99%.

Included in report

For all patients, carotid endarterectomy should be performed as soon as the patient is stable and fit for surgery, ideally within two weeks of event.

Included in report

Information should be offered to patients and carers in a variety of formats, including easy access.

Judged not to require material additional resources or present system redesign

Care givers should be offered ongoing practical information and training individualised for the needs of the person for whom they are caring.

Judged not to require material additional resources or present system redesign

49

Appendix 2 Acknowledgements Authors (NHS Quality Improvement Scotland) Mr George M Wallace Senior Project Cost Accountant Ms Joyce Craig Lead Health Economist Authors’ acknowledgements We would like to thank all colleagues who contributed to the development of the report, provided responses to questionnaires and assisted in quality assuring the assumptions and pathways in individual NHS boards. In particular we would like to thank: Guideline development group members: Dr Anthony Byrne Stroke Consultant, Stirling Royal Infirmary Ms Hazel Fraser Lead MCN Nurse for Stroke, NHS Fife Professor Peter Langhorne Professor of Geriatric Medicine, Glasgow Royal Infirmary Dr Keith Muir Consultant Neurologist, Southern General Hospital, Glasgow Dr Scott Ramsay Stroke Consultant, St John’s Hospital, Livingstone Dr Giles Roditi Consultant Radiologist, Glasgow Royal Infirmary Dr Paul Syme Consultant Physician, Borders General Hospital, Melrose NHSScotland colleagues: Dr Mark Barber Lead Clinician Stroke, NHS Lanarkshire Ms Katrina Brennan Stroke MCN Manager, NHS Lanarkshire Ms Denise Brown Stroke MCN Manager, NHS Ayrshire & Arran Dr George Crooks Medical Director, Scottish Ambulance Service Professor Martin Dennis Professor of Stroke Medicine, University of Edinburgh Ms Anne Duthie Service Development Manager, Scottish Centre for Telehealth Dr Andrew Farrall Consultant Neuroradiologist, Royal Infirmary Edinburgh Dr James Godfrey Lead Clinician Stroke, NHS Ayrshire & Arran Mr Christian Goskirk Stroke MCN Manager, NHS Highland Dr Ian Hay Lead Clinician Stroke, NHS Dumfries & Galloway Dr Christine McAlpine Lead Clinician Stroke, NHS Greater Glasgow and Clyde Ms Pamela Mclauchlan Director of Finance, Scottish Ambulance Service Ms Morag Medwin Stroke MCN Manager, NHS Lothian Mr David Murphy Information Services Division Ms Stephanie Phillips Acting GM PPU, Scottish Ambulance Service Mr David Potter Stroke MCN Manager, NHS Dumfries & Galloway Ms Camilla Young Stroke MCN Manager, NHS Greater Glasgow and Clyde

50

Appendix 3 Resource impact assessment process Stage 1: Draft guideline at consultation stage Stage 2: Identify those recommendations likely to have a material resource impact Stage 3: Identify key cost drivers for each material recommendation and gather information on potential clinical benefits, pathways and cost evidence Stage 4: Develop model to estimate clinical benefits and associated resources and costs – incorporate sensitivity analysis Stage 5: Develop national clinical and resource impact report Stage 6: Determine links between national bodies and each NHS board and develop cost template where required Stage 7: Internal review with chair of the SIGN guideline development group and NHS Quality Improvement Scotland Stage 8: Circulate report and template to chair of guideline development group and others for peer review; update report based on feedback and any changes following consultations Stage 9: Final sign-off Stage 10: Publication, dissemination and impact assessment

51

Appendix 4.1 ICD-10 codes for stroke or TIA G45 Transient cerebral ischaemic attacks and related syndromes Excludes: neonatal cerebral ischaemia (P91.0) G45.0 Vertebro-basilar artery syndrome G45.1 Carotid artery syndrome (hemispheric) G45.2 Multiple and bilateral precerebral artery syndromes G45.3 Amaurosis fugax G45.4 Transient cerebral ischaemic attacks and related syndromes G45.8 Other transient cerebral ischaemic attacks and related syndromes G45.9 Transient cerebral ischaemic attack, unspecified I61 Intracerebral haemorrhage Excludes: sequelae of intracerebral haemorrhage (I69.1) I61.0 Intracerebral haemorrhage in hemisphere, subcortical I61.1 Intracerebral haemorrhage in hemisphere, cortical I61.2 Intracerebral haemorrhage in hemisphere, unspecified I61.3 Intracerebral haemorrhage in brain stem I61.4 Intracerebral haemorrhage in cerebellum I61.5 Intracerebral haemorrhage, intraventricular I61.6 Intracerebral haemorrhage, multiple localised I61.8 Other intracerebral haemorrhage I61.9 Intracerebral haemorrhage, unspecified I62 Other nontraumatic intracranial haemorrhage Excludes sequelae of intracranial haemorrhage (169.2) I62.0 Subdural haemorrhage (acute)(nontraumatic) I62.1 Nontraumatic extradural haemorrhage I62.9 Intracranial haemorrhage (nontraumatic), unspecified I63 Cerebral infarction Excludes: sequelae of cerebral infarction (I69.3) I63.0 Cerebral infarction due to thrombosis of precerebral arteries I63.1 Cerebral infarction due to embolism of precerebral arteries I63.3 Cerebral infarction due to thrombosis of cerebral arteries I63.4 Cerebral infaction due to embolism of cerebral arteries I63.6 Cerebral infarction due to cerebral venous thrombosis, nonpyogenic I63.8 Other cerebral infarction I63.9 Cerebral infarction, unspecified I64 Stroke, not specified as haemorrhage or infarction Cerebrivascular accident NOS Excludes: sequelae of stroke (I69.4) Source: International Statistical Classification of Diseases and Related Health

Problems. Tenth Revision Volume 1. World Health Organisation, Geneva 1992

52

Appendix 4.2 ICD-10 codes for other cerebrovascular diseases I65 Occlusion and senosis of precerebral arteries, not resulting in cerebral infarction Excludes: when causing cerebral infarction (I63.-) I65.0 Occlusion and stenosis of vertebral artery I65.1 Occlusion and stenosis of basilar artery I65.2 Occlusion and stenosis of carotid artery I65.3 Occlusion and stenosis of multiple and bilateral precerebral arteries I65.8 Occlusion and stenosis of other precerebral artery I65.9 Occlusion and stenosis of unspecified precerebral artery I66 Occlusion and stenosis of cerebral arteries, not resulting in cerebral infarction Excludes: when causing cerebral infarction (163.-) I66.0 Occlusion and stenosis of middle cerebral artery I66.1 Occlusion and stenosis of anterior cerebral artery I66.2 Occlusion and stenosis of posterior cerebral artery I66.3 Occlusion and stenosis of cerebellar arteries I66.4 Occlusion and stenosis of multiple and bilateral cerebral arteries I66.8 Occlusion and stenosis of other cerebral artery I66.9 Occlusion and stenosis of unspecified cerebral artery I67 Other cerebrovascular diseases Excludes: sequelae of the listed conditions (I69.8) I67.0 Dissection of cerebral arteries, nonruptured I67.1 Cerebral aneurysm, nonruptured I67.2 Cerebral atherosclerosis I67.3 Progressive vascular leukoencephalopathy I67.4 Hypertensive encephalopathy I67.5 Moyamoya disease I67.6 Nonpyogenic thrombosis of intracranial venous system I67.7 Cerebral arteritis, not elsewhere classified I67.8 Other specified cerebrovascular diseases I67.9 Cerebrivascular disease, unspecified I69 Sequelae of cerebrovasular disease I69.0 Sequelae of subarachnoid haemorrhage I69.1 Sequelae of intracerebral haemorrhage I69.2 Sequelae of other non traumatic intracranial haemorrhage I69.3 Sequelae of cerebral infarction I69.4 Sequelae of stroke, not specified as haemorrhage or infarction I69.8 Sequelae of other and unspecified cerebrovascular diseases Source: International Statistical Classification of Diseases and Related Health

Problems. Tenth Revision Volume 1. World Health Organisation, Geneva 1992

53

Appendix 5.1 Incidence of first ever hospital admission for stroke and TIA for year ending 31 March 2007

Population statistics mid year estimate provided by GRO as at 30 June 2006

Total population

0 - 44 years

45 - 54 years

55 - 64 years

65 - 74 years

75 - 84 years

85+ years

Age group analysis 5,116,900 2,941,253 713,310 624,369 455,744 287,021 95,203% of total population 57.5% 13.9% 12.2% 8.9% 5.6% 1.9%% reduction in population groups 12.5% 27.0% 37.0% 66.8%


(ICD 10)

Inpatient admission & GRO mortality records with no previous history of CBV in the year to 31 March 2007

Total population

0 - 44 years

45 - 54 years

55 - 64 years

65 - 74 years

75 - 84 years

85+ years

SMR01 Database ISD 1,625 65 142 284 437 465 232GRO Mortality Records - Added to I63Total Cases 1,625 65 142 284 437 465 232Incidence 0.32 0.02 0.20 0.45 0.96 1.62 2.44

SMR01 Database ISD 782 46 75 103 184 231 143GRO Mortality Records - I61 127 7 10 19 23 40 28Total Cases 909 53 85 122 207 271 171Incidence 0.18 0.02 0.12 0.20 0.45 0.94 1.80

SMR01 Database ISD 416 36 24 66 93 136 61GRO Mortality Records - I62 50 1 1 3 8 14 23Total Cases 466 37 25 69 101 150 84Incidence 0.09 0.01 0.04 0.11 0.22 0.52 0.88

SMR01 Database ISD 3,440 129 240 475 830 1,143 623GRO Mortality Records - G45 7 1 6GRO Mortality Records - I63 95 0 3 6 10 25 51GRO Mortality Records - I69 554 1 0 8 38 195 312Total Cases 4,096 130 243 489 878 1,364 992Incidence 0.80 0.04 0.34 0.78 1.93 4.75 10.42

SMR01 Database ISD 2,432 59 129 271 548 831 594GRO Mortality Records - I64 900 2 7 16 72 316 487Total Cases 3,332 61 136 287 620 1,147 1,081Incidence 0.65 0.02 0.19 0.46 1.36 4.00 11.35

Events calculated from data collected Total population

0 - 44 years

45 - 54 years

55 - 64 years

65 - 74 years

75 - 84 years

85+ years

Incidence of TIA 0.32 0.02 0.20 0.45 0.96 1.62 2.44Incidence of Haemorrhagic Stroke 0.27 0.03 0.15 0.31 0.68 1.47 2.68Incidence of Cerebral Infarcts 1.45 0.06 0.53 1.24 3.29 8.75 21.77Incidence of First Ever Stroke 1.72 0.10 0.69 1.55 3.96 10.22 24.45Incidence of First Ever CBV Event 2.04 0.12 0.88 2.00 4.92 11.84 26.89

Predicted TIA's 1,625 65 142 284 437 465 232Predicted Haemorrhagic Strokes 1,375 90 110 191 308 421 255Predicted Ischaemic Strokes 7,428 191 379 776 1,498 2,511 2,073

% Haemorrhagic Stroke Deaths 12.9% 8.9% 10.0% 11.5% 10.1% 12.8% 20.0%% Ischaemic Stroke Deaths 20.9% 1.6% 2.6% 3.9% 8.0% 21.3% 41.0%

Number of TIA's Admitted 1,625 65 142 284 437 465 232Number of Haemorrhagic Admitted 1,198 82 99 169 277 367 204

5,879 188 369 746 1,378 1,975 1,223

Total Number of Admissions 8,702 335 610 1,199 2,092 2,807 1,659

G45 - Transient Ischaemic Attack

Number of Ischaemic Infarcts Admitted

I64 - Inconclusive

Stroke

Predicted number of first ever cerebrovascular events

% of first ever cerebrovascular events not admitted - death in the community

Number of patients admitted to Scottish hospitals in the year to 31 March 2007

I61 - Intracerebral Haemorrhage

I62 - Intracranial Haemorrhage

I63 - Cerebral Infarction

Source ISD19

54

Appendix 5.2 Survival rates for stroke and TIA after a first ever hospital admission for year ending 31 March 2007

Original admissions Total population

0 - 44 years

45 - 54 years

55 - 64 years

65 - 74 years

75 - 84 years

85+ years

Number of TIA's 1,625 65 142 284 437 465 232Number of haemorrhagic strokes 1,198 82 99 169 277 367 204Number of ischaemic strokes 5,879 188 369 746 1,378 1,975 1,223Total Admissions 8,702 335 610 1,199 2,092 2,807 1,659

TIA 1,600 65 140 282 435 456 222Survival rate 98.5% 100.0% 98.6% 99.3% 99.5% 98.1% 95.7%Haemorrhagic stroke 736 55 73 114 177 219 98Survival rate 61.4% 67.1% 73.7% 67.5% 63.9% 59.7% 48.0%Ischaemic strokes 4,918 177 344 705 1,227 1,635 830Survival rate 83.7% 94.1% 93.2% 94.5% 89.0% 82.8% 67.9%

Comparator Infarct Analysis - Known Deaths 961 11 25 41 151 340 393Comparator Infarct Analysis - Predicted Deaths 954 7 19 52 158 364 355




Outcome - Month 12 numbers survived




Source ISD19

55

Appendix 5.3 Re-admission rates for stroke and TIA after a first ever hospital admission for year ending 31 March 2007


(ICD 10)

Number of patients readmitted at 3, 6 & 12 months following a first ever hospitalisation for a CBV event

Total population

0 - 44 years

45 - 54 years

55 - 64 years

65 - 74 years

75 - 84 years

85+ years

SMR01 - Original admittance 1,625 65 142 284 437 465 232

SMR01 - Readmission at 3 months 133 3 6 16 35 54 19SMR01 - Readmission at 6 months 173 3 7 20 47 68 28SMR01 - Readmission at 12 months 240 7 10 23 63 94 43

% Readmission at 12 months 14.8% 10.8% 7.0% 8.1% 14.4% 20.2% 18.5%

SMR01 - Original admittance 782 46 75 103 184 231 143






SMR01 - Original admittance 3,440 129 240 475 830 1,143 623






Readmission summary for cerebral infarcts at 12 months

Total population

0 - 44 years

45 - 54 years

55 - 64 years

65 - 74 years

75 - 84 years

85+ years

Transient Ischaemic Attack 14.8% 10.8% 7.0% 8.1% 14.4% 20.2% 18.5%Haemorrhagic stroke (I61 & I62) 10.9% 11.0% 9.1% 12.4% 13.7% 9.5% 9.3%Ischaemic stroke (I63 & I64) 15.0% 14.9% 15.7% 15.5% 16.5% 15.3% 12.3%

388 15 32 59 102 122 58409 11 19 48 100 155 77Comparator Infarct Analysis - Predicted Readmissions



I64 - Inconclusive

Stroke

Comparator Infarct Analysis - Known ReadmissionsReadmission summary for infarcts at 3 months



Source ISD19

56

Appendix 5.4 Prior admission of patients who had a first ever admittance for stroke or TIA for year ending 31 March 2007

Stroke

Classifications (ICD 10)

Prior admissions identified for conditions likely to be contra indicated for thrombolysis & carotid surgery

Total population

0 - 44 years

45 - 54 years

55 - 64 years

65 - 74 years

75 - 84 years

85+ years


SMR01 - Liver Complications 12 1 1 2 3 5 0SMR01 - Type 1 Diabetes 35 0 5 8 15 5 2SMR01 - Type 2 Diabetes 206 4 12 30 68 71 21

% Total Complications Admitted 15.6% 7.7% 12.7% 14.1% 19.7% 17.4% 9.9%







SMR01 - Original admittance 3,440 129 240 475 830 1,143 623






Complications summary by CBV event Total population

0 - 44 years

45 - 54 years

55 - 64 years

65 - 74 years

75 - 84 years

85+ years

Transient Ischaemic Attack 15.6% 7.7% 12.7% 14.1% 19.7% 17.4% 9.9%Haemorrhagic Stroke 13.4% 9.8% 27.3% 18.3% 13.0% 13.4% 4.4%Cerebral Infarcts 17.6% 11.2% 18.2% 19.4% 23.4% 17.6% 10.9%

Complications summary by intervention Total population

0 - 44 years

45 - 54 years

55 - 64 years

65 - 74 years

75 - 84 years

85+ years

Contraindicated for Thrombolysis 3.8% 5.3% 6.2% 6.2% 5.8% 2.5% 1.3%Possible contraindications for carotid surgery 13.6% 5.9% 11.0% 12.5% 17.1% 15.1% 9.5%

I64 - Inconclusive

Stroke





Source ISD19

57

Appendix 5.5 Incidence of stroke and TIA resulting in a first ever hospital admission by NHS board for year ending 31 March 2007

Stroke Event 0 - 44 years

45 - 54 years

55 - 64 years

65 - 74 years

75 - 84 years

85+ years

Total population

G45 Transient Ischaemic Attack 65 142 284 437 465 232 1,625Total ICH 90 110 191 308 421 255 1,375Total Infarcts 191 379 776 1,498 2,511 2,073 7,428Total Number of Stokes 281 489 967 1,806 2,932 2,328 8,803Total CBV Events 346 631 1,251 2,243 3,397 2,560 10,428

Stoke Event 0 - 44 years

45 - 54 years

55 - 64 years

65 - 74 years

75 - 84 years

85+ years

Total population

G45 Transient Ischaemic Attack 0.02 0.20 0.45 0.96 1.62 2.44 0.32Total ICH 0.03 0.15 0.31 0.68 1.47 2.68 0.27Total Infarcts 0.06 0.53 1.24 3.29 8.75 21.77 1.45Total Number of Stokes 0.10 0.69 1.55 3.96 10.22 24.45 1.72Total CBV Events 0.12 0.88 2.00 4.92 11.84 26.89 2.04

Population Ranking Health Board 0 - 44

years45 - 54 years

55 - 64 years

65 - 74 years

75 - 84 years

85+ years

Total population

Comparator Scotland 0.10 0.69 1.55 3.96 10.22 24.45 1.721 Greater Glasgow & Clyde 0.12 0.90 1.76 4.46 10.05 25.52 1.752 Lothian 0.06 0.58 1.58 3.50 10.20 23.92 1.523 Lanarkshire 0.09 0.78 1.68 4.32 10.72 27.06 1.684 Grampian 0.11 0.70 1.20 3.66 9.76 24.63 1.615 Tayside 0.12 0.50 1.76 4.07 10.04 23.59 1.966 Ayr 0.12 0.60 1.88 3.58 11.35 25.14 1.95

Population Ranking Health Board 0 - 44

years45 - 54 years

55 - 64 years

65 - 74 years

75 - 84 years

85+ years

Total population

Comparator Scotland 0.10 0.69 1.55 3.96 10.22 24.45 1.727 Fife 0.08 0.57 1.28 4.27 10.63 21.49 1.718 Highlands 0.07 0.55 1.27 3.86 9.84 22.97 1.789 Forth Valley 0.10 0.74 1.41 3.79 10.43 24.22 1.6310 Dumfries 0.07 0.42 1.63 3.64 10.27 23.12 1.9911 Borders 0.09 0.74 1.15 3.83 8.74 27.04 1.9012 Islands 0.08 0.30 0.73 2.54 8.89 20.79 1.46

Health Board Analysis of Contribution to First Ever Stroke Incidence

Health Board Analysis of Contribution to First Ever Stroke Incidence

Age Analysis of First Ever in a lifetime Stroke - Number of Cases

Age Analysis of First Ever in a lifetime Stroke - Incidence per 1000 of the Population

Source ISD19

58

Appendix 5.6 Predicted mortality for patients with first admission of ischaemic stroke for year ending 31 March 2007

Original Admissions Total population

0 - 44 years

45 - 54 years

55 - 64 years

65 - 74 years

75 - 84 years

85+ years



Clinically Identifiable Subtypes of Cerebral Infarction

Total population

0 - 44 years

45 - 54 years

55 - 64 years

65 - 74 years

75 - 84 years

85+ years






Total population

0 - 44 years

45 - 54 years

55 - 64 years

65 - 74 years

75 - 84 years

85+ years

LACI - Lacunar Infarcts 4% 2% 2% 2% 4% 4% 8%TACI - Total Anterior Circulation Infarcts 50% 25% 25% 25% 25% 60% 65%PACI - Partial Anterior Circulation Infarcts 11% 5% 5% 5% 11% 11% 22%POCI - Posterior Circulation Infracts 14% 7% 7% 7% 14% 14% 21%Application of OCSP Mortality Rate at 6 Months - Applied in Scotland in the First 30 Days of AdmissionLACI - Lacunar Infarcts 62 0 2 3 13 19 24TACI - Total Anterior Circulation Infarcts 484 2 8 25 49 202 199PACI - Partial Anterior Circulation Infarcts 214 5 6 12 50 74 67POCI - Posterior Circulation Infracts 195 0 3 12 46 69 64

Predicted No of Deaths in the First Month 954 7 19 52 158 364 355Known No of Deaths in the First Month 961 11 25 41 151 340 393

Number of Infarction Subtypes Survived at 1 Month

Total population

0 - 44 years

45 - 54 years

55 - 64 years

65 - 74 years

75 - 84 years

85+ years

LACI - Lacunar Infarcts 1,322 6 101 165 314 455 282TACI - Total Anterior Circulation Infarcts 491 5 23 76 147 134 107PACI - Partial Anterior Circulation Infarcts 1,671 91 112 223 408 598 239POCI - Posterior Circulation Infracts 1,150 6 41 155 281 426 242Application of OSCP Recurrent Stroke Rates LACI - Lacunar Infarcts 2% 1% 1% 1% 2% 2% 2%TACI - Total Anterior Circulation Infarcts 4% 2% 2% 2% 4% 4% 4%PACI - Partial Anterior Circulation Infarcts 14% 11% 12% 13% 14% 15% 16%POCI - Posterior Circulation Infracts 11% 8% 9% 10% 11% 12% 12%Predicted Number of Patients to be readmitted as a result of Recurrent StrokeLACI - Lacunar Infarcts 24 0 1 2 6 9 6TACI - Total Anterior Circulation Infarcts 18 0 0 2 6 5 4PACI - Partial Anterior Circulation Infarcts 237 10 13 29 57 90 38POCI - Posterior Circulation Infracts 131 0 4 16 31 51 29Predicted Readmissions at 3 Months 409 11 19 48 100 155 77Known Readmissions at 3 Months 388 15 32 59 102 122 58

Predictive Outcome Model (Adapted from OCSP 1986) - Identifying the Four Subtypes of Infarction

Predictive Outcome Model (Adapted from OCSP 1986) - 30 Day Mortality

Predictive Outcome Model (Adapted from OCSP 1986) - Recurrent Strokes Readmitted in the First 3 Months

59

Appendix 5.7 Predicted mortality and disability for patients with first admission of ischaemic stroke for year ending 31 March 2007

Original Admissions Total population

0 - 44 years

45 - 54 years

55 - 64 years

65 - 74 years

75 - 84 years

85+ years




Total population

0 - 44 years

45 - 54 years

55 - 64 years

65 - 74 years

75 - 84 years

85+ years






Total population

0 - 44 years

45 - 54 years

55 - 64 years

65 - 74 years

75 - 84 years

85+ years



LACI - Lacunar Infarcts 61% 78% 78% 68% 61% 61% 52%TACI - Total Anterior Circulation Infarcts 5% 45% 35% 25% 5% 0% 0%PACI - Partial Anterior Circulation Infarcts 55% 75% 75% 70% 59% 49% 38%POCI - Posterior Circulation Infracts 61% 83% 83% 78% 61% 61% 49%Total Allocation between Infarct Groups 100% 100% 100% 100% 100% 100% 100%

Number of Infarction Subtypes having an mRS of between 0 and 2

Total population

0 - 44 years

45 - 54 years

55 - 64 years

65 - 74 years

75 - 84 years

85+ years

LACI - Lacunar Infarcts 846 5 80 114 199 289 159TACI - Total Anterior Circulation Infarcts 48 3 11 25 10 0 0PACI - Partial Anterior Circulation Infarcts 1,041 72 89 165 270 329 116POCI - Posterior Circulation Infracts 823 5 37 130 199 302 150Total Allocation between Infarct Groups 2,758 85 216 434 678 920 425

Number of Infarction Subtypes having an mRS of between 3 and 5

Total population

0 - 44 years

45 - 54 years

55 - 64 years

65 - 74 years

75 - 84 years

85+ years

LACI - Lacunar Infarcts 475 1 21 50 114 166 122TACI - Total Anterior Circulation Infarcts 443 2 12 51 137 134 107PACI - Partial Anterior Circulation Infarcts 630 19 24 59 137 269 122POCI - Posterior Circulation Infracts 327 1 4 25 82 124 92Total Allocation between Infarct Groups 1,875 23 61 185 471 693 444

Dependency RatioTotal

population0 - 44 years

45 - 54 years

55 - 64 years

65 - 74 years

75 - 84 years

85+ years

Totals for Scotland 40% 21% 22% 30% 41% 43% 51%

Predictive Outcome Model (Adapted from OCSP 1986) - Age Related Ratio between Dependency & Independency

Application of OCSP Disability Rates at 30 Days - mRS of between 0 and 2

Predictive Outcome Model (Adapted from OCSP 1986) - Identifying Disability in the Four Subtypes of Infarction

Predictive Outcome Model (Adapted from OCSP 1986) - Death & Disability Rates at 30 Days

Predictive Outcome Model (Adapted from OCSP 1986) - Allocation Split of Dependence at 30 Days

Mortality Rate Detailed in Infarct Analysis & Readmission

Application of OCSP Disability Rates at 30 Days - mRS of between 3 and 5

60

Appendix 6.1 Estimated first hospital admissions for stroke or TIA

Population statistics mid year estimate provided by GRO as at 30 June 2007

Total population

0 - 44 years

45 - 54 years

55 - 64 years

65 - 74 years

75 - 84 years

85+ years

Age group analysis 5,144,200 2,938,670 728,462 631,455 457,382 289,941 98,290% of total population 57.1% 14.2% 12.3% 8.9% 5.6% 1.9%% reduction in population groups 13.3% 27.6% 36.6% 66.1%

Incidence of stroke that has resulted in a first ever hospital admission


(ICD 10)

Information from data collected in 3 year incidence studies for Scotland

Total population

0 - 44 years

45 - 54 years

55 - 64 years

65 - 74 years

75 - 84 years

85+ years

Incidence calculated for 2006 0.30 0.03 0.20 0.47 0.83 1.47 2.61Incidence calculated for 2007 0.32 0.02 0.20 0.45 0.96 1.62 2.44Incidence calculated for 2008 0.31 0.02 0.23 0.48 0.87 1.52 2.30Average Incidence for Period 0.31 0.02 0.21 0.47 0.89 1.54 2.45Incidence calculated for 2006 0.18 0.02 0.12 0.24 0.42 1.02 1.61Incidence calculated for 2007 0.18 0.02 0.12 0.20 0.45 0.94 1.80Incidence calculated for 2008 0.17 0.02 0.13 0.20 0.43 0.87 1.49Average Incidence for Period 0.18 0.02 0.12 0.21 0.43 0.95 1.63Incidence calculated for 2006 0.08 0.01 0.05 0.11 0.22 0.44 0.73Incidence calculated for 2007 0.09 0.01 0.04 0.11 0.22 0.52 0.88Incidence calculated for 2008 0.09 0.01 0.05 0.11 0.25 0.46 0.84Average Incidence for Period 0.09 0.01 0.04 0.11 0.23 0.48 0.82Incidence calculated for 2006 0.84 0.05 0.35 0.88 2.19 4.97 10.54Incidence calculated for 2007 0.80 0.04 0.34 0.78 1.93 4.75 10.42Incidence calculated for 2008 0.75 0.05 0.31 0.75 1.80 4.22 9.84Average Incidence for Period 0.80 0.05 0.33 0.80 1.97 4.65 10.26Incidence calculated for 2006 0.68 0.02 0.18 0.55 1.37 4.37 11.95Incidence calculated for 2007 0.65 0.02 0.19 0.46 1.36 4.00 11.35Incidence calculated for 2008 0.66 0.02 0.22 0.53 1.36 3.93 10.84Average Incidence for Period 0.66 0.02 0.20 0.51 1.36 4.10 11.38

Prevalence of first every CBV event that has resulted in outright mortality with no hospital admission record


Information from data collected in 3 year incidence studies for Scotland - GRO Mortality Records

Total population

0 - 44 years

45 - 54 years

55 - 64 years

65 - 74 years

75 - 84 years

85+ years

Prevalence calculated for 2006 13.6% 7.4% 15.8% 11.7% 11.7% 15.8% 15.6%Prevalence calculated for 2007 12.9% 8.9% 10.0% 11.5% 10.1% 12.8% 20.0%Prevalence calculated for 2008 12.2% 8.7% 19.7% 12.2% 8.3% 11.4% 16.2%Average Prevalence for Period 12.9% 8.3% 15.2% 11.8% 10.0% 13.3% 17.2%Prevalence calculated for 2006 21.4% 3.0% 2.7% 5.3% 10.2% 22.2% 41.3%Prevalence calculated for 2007 20.9% 1.6% 2.6% 3.9% 8.0% 21.3% 41.0%Prevalence calculated for 2008 20.7% 1.9% 1.8% 4.4% 10.2% 20.8% 40.2%Average Prevalence for Period 21.0% 2.2% 2.4% 4.5% 9.5% 21.4% 40.8%

Events calculated from data collected on the probability of a first ever hospital admission

Total population

0 - 44 years

45 - 54 years

55 - 64 years

65 - 74 years

75 - 84 years

85+ years

Incidence of TIA 0.31 0.02 0.21 0.47 0.89 1.54 2.45Incidence of Haemorrhagic Stroke 0.27 0.03 0.17 0.32 0.67 1.42 2.45Incidence of Ischaemic Stroke 1.46 0.07 0.53 1.32 3.33 8.75 21.64Incidence of first ever admisson - stroke 1.73 0.10 0.70 1.64 4.00 10.17 24.09Incidence of first ever admission - CBV 2.04 0.13 0.91 2.11 4.89 11.70 26.54

Predicted TIA's 1,612 73 152 295 406 446 241Predicted Haemorrhagic Strokes 1,378 96 121 204 305 412 241Predicted Ischaemic Strokes 7,605 199 386 832 1,525 2,536 2,127

% Haemorrhagic Stroke Deaths 12.9% 8.3% 15.2% 11.8% 10.0% 13.3% 17.2%% Ischaemic Stroke Deaths 21.0% 2.2% 2.4% 4.5% 9.5% 21.4% 40.8%

Number of TIA's 1,612 73 152 295 406 446 241Number of Haemorrhagic 1,201 88 103 180 274 357 199Number of Ischaemic Infarcts 5,997 194 377 794 1,380 1,992 1,259

Number of First Ever Admissions 8,811 355 632 1,269 2,061 2,795 1,699




I64 - Inconclusive

Stroke

Predicted number of cerebrovasclar events likely to lead to a first hospital admission

Prevalance of cerebrovascular events that will not be admitted - death in the community

Number of CBV events due for a first ever admission to Scottish hospitals in the year to 31 March 2009

Haemorrhagic Stroke

Community Mortality

Ischaemic Stroke Community Mortality


Source ISD19

61

Appendix 6.2 Estimated survival rates for patients following a first admission to hospital for stroke or TIA

Predicted first ever hospital admissions as a result of stroke or CBV event

Total population

0 - 44 years

45 - 54 years

55 - 64 years

65 - 74 years

75 - 84 years

85+ years

Number of FES - TIA's 1,612 73 152 295 406 446 241Number of FES - Haemorrhagic 1,201 88 103 180 274 357 199Number of FES - Infarcts 5,997 194 377 794 1,380 1,992 1,259Total Admissions 8,811 355 632 1,269 2,061 2,795 1,699


Average survial rates following a first ever admisson for stroke or TIA outcome at 1 month

Total population

0 - 44 years

45 - 54 years

55 - 64 years

65 - 74 years

75 - 84 years

85+ years

Survival rates in 2006 99.9% 98.8% 100.0% 100.0% 100.0% 100.0% 100.0%Survival rates in 2007 98.5% 100.0% 98.6% 99.3% 99.5% 98.1% 95.7%Survival rates in 2008 98.3% 100.0% 100.0% 99.0% 98.0% 98.4% 96.0%Average contribution for period 98.9% 99.6% 99.5% 99.4% 99.2% 98.8% 97.2%Survival rates in 2006 64.3% 79.5% 70.3% 73.5% 68.5% 57.8% 50.3%Survival rates in 2007 61.4% 67.1% 73.7% 67.5% 63.9% 59.7% 48.0%Survival rates in 2008 65.0% 86.3% 63.7% 74.6% 65.6% 61.2% 52.1%Average contribution for period 63.6% 77.6% 69.3% 71.9% 66.0% 59.6% 50.1%Survival rates in 2006 84.0% 95.8% 94.2% 94.2% 89.5% 81.1% 70.3%Survival rates in 2007 83.7% 94.1% 93.2% 94.5% 89.0% 82.8% 67.9%Survival rates in 2008 83.5% 95.1% 94.7% 93.3% 88.3% 80.9% 70.7%Average contribution for period 83.7% 95.0% 94.0% 94.0% 88.9% 81.6% 69.6%

Predicted number of first ever admissons as a result of stroke or TIA event likely to survive at 1 month

Total population

0 - 44 years

45 - 54 years

55 - 64 years

65 - 74 years

75 - 84 years

85+ years

Number of FES - TIA's 1,595 72 151 293 403 441 234Number of FES - Haemorrhagic 762 69 71 129 181 213 100Number of FES - Infarcts 5,015 185 354 747 1,228 1,625 877Total numbers survived at 1 month 7,372 326 577 1,169 1,811 2,278 1,211Number of FES - TIA's 18 0 1 2 3 5 7Number of FES - Haemorrhagic 439 20 32 51 93 144 99Number of FES - Infarcts 982 10 22 48 153 367 383Total mortality at 1 month 1,439 30 55 100 249 516 489

Total rate of mortality at 1 month 16.3% 8.4% 8.7% 7.9% 12.1% 18.5% 28.8%


Average survial rates following a first ever admisson for stroke or TIA outcome at 1 year

Total population

0 - 44 years

45 - 54 years

55 - 64 years

65 - 74 years

75 - 84 years

85+ years

Survival rates in 2006 89.8% 98.8% 96.4% 96.5% 93.1% 87.9% 73.0%Survival rates in 2007 89.7% 100.0% 97.9% 97.2% 92.7% 86.7% 73.3%Survival rates in 2008 92.5% 100.0% 98.2% 97.7% 95.0% 88.5% 82.3%Average contribution for period 90.7% 99.6% 97.5% 97.1% 93.6% 87.7% 76.2%Survival rates in 2006 52.2% 77.3% 67.3% 62.4% 57.6% 42.2% 32.4%Survival rates in 2007 49.3% 64.6% 69.7% 60.4% 54.2% 43.6% 27.9%Survival rates in 2008 54.1% 77.9% 54.9% 68.8% 56.6% 47.8% 36.5%Average contribution for period 51.9% 73.3% 64.0% 63.9% 56.1% 44.5% 32.3%Survival rates in 2006 68.2% 92.2% 91.7% 87.5% 78.4% 63.3% 40.2%Survival rates in 2007 68.4% 90.4% 88.9% 87.5% 78.1% 64.6% 42.6%Survival rates in 2008 70.9% 93.6% 92.1% 87.6% 80.0% 65.1% 49.1%Average contribution for period 69.2% 92.1% 90.9% 87.5% 78.9% 64.3% 44.0%

Predicted number of first ever admissons as a result of stroke or TIA event likely to survive at 1 year

Total population

0 - 44 years

45 - 54 years

55 - 64 years

65 - 74 years

75 - 84 years

85+ years

Number of FES - TIA's 1,462 72 148 286 380 391 183Number of FES - Haemorrhagic 622 65 66 115 154 159 64Number of FES - Infarcts 4,140 179 343 695 1,088 1,281 554Total numbers survived at 1 year 6,224 316 557 1,096 1,622 1,831 801Number of FES - TIA's 151 0 4 8 26 55 57Number of FES - Haemorrhagic 579 24 37 65 120 198 135Number of FES - Infarcts 1,857 15 34 99 292 711 706Total mortality at 1 year 2,587 39 75 172 438 964 898

Total rate of mortality at 1 year 29.4% 11.1% 11.9% 13.6% 21.3% 34.5% 52.8%

Haemorrhagic Stroke

Ischaemic Stroke


Haemorrhagic Stroke

Ischaemic Stroke


62

Appendix 6.3 Estimated re-admission rates for patients following a first admission to hospital for stroke or TIA


Total population

0 - 44 years

45 - 54 years

55 - 64 years

65 - 74 years

75 - 84 years

85+ years

Number of FES - TIA's 1,612 73 152 295 406 446 241Number of FES - Haemorrhagic 1,201 88 103 180 274 357 199Number of FES - Infarcts 5,997 194 377 794 1,380 1,992 1,259Total Admissions 8,811 355 632 1,269 2,061 2,795 1,699Incidence of First Ever Stroke with No Previous Admission History b/fwd from Incidence Summary


Annual readmission rates calculated from first ever stroke presentations

Total population

0 - 44 years

45 - 54 years

55 - 64 years

65 - 74 years

75 - 84 years

85+ years

Readmission rate for 2005 15.9% 15.4% 15.2% 17.8% 13.8% 16.5% 16.7%Readmission rate for 2006 16.3% 3.6% 15.2% 15.3% 16.1% 18.3% 19.4%Readmission rate for 2007 14.8% 10.8% 7.0% 8.1% 14.4% 20.2% 18.5%Average readmission rate - current year 15.6% 9.9% 12.5% 13.7% 14.8% 18.4% 18.2%Readmission rate for 2005 10.6% 19.0% 13.6% 13.2% 11.4% 8.9% 4.2%Readmission rate for 2006 11.8% 15.9% 14.9% 15.3% 8.9% 10.3% 11.2%Readmission rate for 2007 10.9% 11.0% 9.1% 12.4% 13.7% 9.5% 9.3%Average readmission rate - current year 11.1% 15.3% 12.5% 13.7% 11.4% 9.6% 8.2%Readmission rate for 2005 16.3% 19.1% 20.6% 18.0% 17.4% 16.5% 11.8%Readmission rate for 2006 15.8% 19.3% 17.2% 15.9% 18.1% 15.3% 12.7%Readmission rate for 2007 15.0% 14.9% 15.7% 15.5% 16.5% 15.3% 12.3%Average readmission rate - current year 15.7% 17.8% 17.8% 16.5% 17.3% 15.7% 12.3%

Predicted Additional Admissions from Recurrent Stroke in the Current Year

Total population

0 - 44 years

45 - 54 years

55 - 64 years

65 - 74 years

75 - 84 years

85+ years

Number of FES - TIA's 252 7 19 41 60 82 44Number of FES - Haemorrhagic 133 13 13 25 31 34 16Number of FES - Infarcts 940 35 67 131 239 313 155Total Admissions 1,325 55 99 196 330 429 215


Annual readmission rates calculated from total admissions & first ever stroke presentations

First ever event

Recurrent events

Total events

Total actual admissions

Recurrent event from

a prior year

% Additional recurrence

Readmission rate for 2005 1,557 247 1,804 2,040 236 15.2%Readmission rate for 2006 1,545 252 1,797 2,011 214 13.9%Readmission rate for 2007 1,625 240 1,865 2,061 196 12.1%Average readmission from prior years 1,576 246 1,822 2,037 215 13.7%Readmission rate for 2005 1,185 126 1,311 1,544 233 19.7%Readmission rate for 2006 1,165 137 1,302 1,498 196 16.8%Readmission rate for 2007 1,198 131 1,329 1,561 232 19.4%Average readmission from prior years 1,183 131 1,314 1,534 220 18.6%Readmission rate for 2005 6,334 1,033 7,367 8,706 1,339 21.1%Readmission rate for 2006 6,112 965 7,077 8,339 1,262 20.6%Readmission rate for 2007 5,879 881 6,760 8,198 1,438 24.5%Average readmission from prior years 6,108 960 7,068 8,414 1,346 22.1%

Average readmission rates for stroke and TIA from prior years

Total population

0 - 44 years

45 - 54 years

55 - 64 years

65 - 74 years

75 - 84 years

85+ years

Transient Ischaemic Attack 13.7% 8.7% 10.9% 12.0% 12.9% 16.1% 15.9%Haemorrhagic Stroke 18.6% 25.6% 21.0% 22.9% 19.1% 16.0% 13.8%Ischaemic Stroke 22.1% 25.0% 25.1% 23.2% 24.4% 22.1% 17.3%

Predicted additional admissions from recurrent stroke from prior years

Total population

0 - 44 years

45 - 54 years

55 - 64 years

65 - 74 years

75 - 84 years

85+ years

Number of FES - TIA's 220 6 17 35 52 72 38Number of FES - Haemorrhagic 222 23 22 41 52 57 27Number of FES - Infarcts 1,321 49 95 184 336 440 217Total Admissions 1,763 78 134 260 440 569 282

Ischaemic Stroke


Haemorrhagic Stroke

Ischaemic Stroke


Haemorrhagic Stroke

63

Appendix 6.4 Estimated prior admission rates for patients later admitted for stroke or TIA for the first time


Total population

0 - 44 years

45 - 54 years

55 - 64 years

65 - 74 years

75 - 84 years

85+ years

Number of FES - TIA's 1,612 73 152 295 406 446 241Number of FES - Haemorrhagic 1,201 88 103 180 274 357 199Number of FES - Infarcts 5,997 194 377 794 1,380 1,992 1,259Total Admissions 8,811 355 632 1,269 2,061 2,795 1,699Incidence of First Ever Stroke with No Previous Admission History b/fwd from Incidence Summary


Annual Complication Rates by CBV Event Calculated from First Ever Stroke

Presentations

Total population

0 - 44 years

45 - 54 years

55 - 64 years

65 - 74 years

75 - 84 years

85+ years

Complications arising in 2006 13.8% 3.6% 8.7% 15.3% 19.3% 14.8% 8.0%Complications arising in 2007 15.6% 7.7% 12.7% 14.1% 19.7% 17.4% 9.9%Complications arising in 2008 16.1% 8.6% 11.3% 16.9% 20.8% 14.9% 15.0%Average Contribution 15.2% 6.6% 10.9% 15.4% 19.9% 15.7% 11.0%



Predicted number of admissions included in First Ever Stroke likely to have

complications

Total population

0 - 44 years

45 - 54 years

55 - 64 years

65 - 74 years

75 - 84 years

85+ years

Number of FES - TIA's 244 5 17 46 81 70 26Number of FES - Haemorrhagic 174 6 21 35 46 52 14Number of FES - Infarcts 1,030 28 69 143 320 342 128Number of Admissions 1,449 39 107 223 447 464 169% of Total Admissions 16.4% 10.9% 16.9% 17.6% 21.7% 16.6% 9.9%

InterventionAnnual Complication Rates by

Anticipated Intervention Calculated from FES Presentations

Total population

0 - 44 years

45 - 54 years

55 - 64 years

65 - 74 years

75 - 84 years

85+ years

Contraindication Rate in 2006 3.5% 10.9% 6.9% 3.6% 4.7% 2.8% 1.0%Contraindication Rate in 2007 3.8% 5.3% 6.2% 6.2% 5.8% 2.5% 1.3%Contraindication Rate in 2008 3.7% 4.9% 8.9% 4.0% 5.8% 3.0% 0.7%Average Rate of Contraindication 3.7% 7.1% 7.4% 4.6% 5.4% 2.8% 1.0%

Contraindication Rate in 2006 12.9% 6.9% 9.8% 13.3% 16.2% 14.2% 8.3%Contraindication Rate in 2007 13.6% 5.9% 11.0% 12.5% 17.1% 15.1% 9.5%Contraindication Rate in 2008 13.2% 5.8% 8.4% 12.8% 18.5% 13.4% 10.0%Average Rate of Contraindication 13.2% 6.2% 9.7% 12.9% 17.3% 14.2% 9.3%

Thrombolysis Ischaemic Stroke

Only

Carotid Surgery TIA and

Ischaemic Stroke Only


Haemorrhagic Stroke

Ischaemic Stroke

Source ISD19

64

Appendix 6.5 Estimated admission rates for patients who have attended a neurovascular outpatient clinic

Predicted Admissions to Scottish Hospitals in the Year to 31st March 2009

Total population

0 - 44 years

45 - 54 years

55 - 64 years

65 - 74 years

75 - 84 years

85+ years

Number of FES - TIA's 1,612 73 152 295 406 446 241Number of Recurrent TIA's CY 252 7 19 41 60 82 44Number of Recurrent TIA's PY 220 6 17 35 52 72 38Total number of TIA Admitted 2,085 86 188 370 518 600 323Number of FES - Haemorrhagic 1,201 88 103 180 274 357 199Number of Recurrent Heamorrhagic CY 133 13 13 25 31 34 16Number of Recurrent Heamorrhagic PY 222 23 22 41 52 57 27Total number of Haemorrhagic Strokes 1,556 125 138 245 358 448 243Number of FES - Infarcts 5,997 194 377 794 1,380 1,992 1,259Number of Recurrent Infarcts CY 940 35 67 131 239 313 155Number of Recurrent Infarcts PY 1,321 49 95 184 336 440 217Total number of Infarcts Admitted 8,258 278 539 1,109 1,955 2,745 1,631

Total Admissions 11,898 488 865 1,725 2,831 3,793 2,196

Predicted Outpatients Attending Neurovascular Clinics

Total population

0 - 44 years

45 - 54 years

55 - 64 years

65 - 74 years

75 - 84 years

85+ years

Number of Ischaemic Events Admitted 10,343 364 727 1,480 2,473 3,345 1,954

93% Outpatient Attendance from SSCAS 9,598 338 675 1,373 2,295 3,104 1,81311% RAO & Transient Monocular Blindness 1,075 38 76 154 257 348 20329% Non Cerebrovascular Events 2,822 99 198 404 675 913 53359% TIA and Minor Stroke Attendances 5,701 201 401 816 1,363 1,844 1,077

Independency Analysis of Ischaemic Strokes & CBV Events mRS < = 2

Total population

0 - 44 years

45 - 54 years

55 - 64 years

65 - 74 years

75 - 84 years

85+ years

Independency Ratio First Ever Stroke 60% 79% 78% 70% 59% 57% 49%25% Independency Ratio Recurrent Stroke 45% 59% 59% 53% 44% 43% 37%

No of TIA's Admitted 2,085 86 188 370 518 600 323No of FES - Infarcts Admitted 3,572 153 294 557 815 1,137 616No of Recurrent Strokes Admitted 1,024 49 95 166 255 322 136No of Neurovascular OP Attendees 5,701 201 401 816 1,363 1,844 1,077

Total number of patients who subject to further investigation may be suitable for Carotid Surgery without complications

12,382 489 978 1,909 2,951 3,903 2,152

Dependency Analysis of Ischaemic Strokes mRS 3 - 5

Total population

0 - 44 years

45 - 54 years

55 - 64 years

65 - 74 years

75 - 84 years

85+ years

Dependency Ratio First Ever Stroke 40% 21% 22% 30% 41% 43% 51%Dependency Ratio Recurrent Stroke 55% 41% 41% 47% 56% 57% 63%

No of FES - Infarcts Admitted 2,425 41 82 237 566 855 643No of Recurrent Strokes Admitted 1,237 34 67 149 321 431 235

Total number of patients who subject to further investigation may be suitable for Thrombolysis assuming that they arrive on time without complications

3,662 75 150 386 886 1,286 879

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73

Appendix 7.9 Costs by function for hospitals in NHS Greater Glasgow and Clyde

Hospital NameSouthern General

Victoria Infirmary

Glasgow Royal

InfirmaryWestern Infirmary Stobhill

Royal Alexandra Hospital

Inverclyde Royal

HospitalVale of Leven

Principal LocationSouth

GlasgowSouth

GlasgowNorth

GlasgowNorth

GlasgowNorth

GlasgowPaisley

RenfrewGreenock Inverclyde

Alexandria Dumbarton

Hospital Classification Code A2 A2 A1 A1 A2 A2 A2 A3

Southern General

Victoria Infirmary

Glasgow Royal



Inverclyde Royal


Accident & Emergency 24 Hour Coverage Yes No Yes Yes Yes Yes Yes NoCT Scanning Facilities Yes Yes Yes Yes Yes Yes Yes YesMRI Scanning Facilities Yes Yes Yes Yes Yes Yes Yes NoUltrasound Scanning Facilities Yes Yes Yes Yes Yes Yes Yes YesCurrent Discharges for Carotid Endarterectomy Yes No Yes Yes No No No NoCurrently Delivering Thrombolytic Therapy Yes No No Yes No No No No

Ranking out of 6 6 3 5 6 4 4 4 2Estimated Number of Additional Hospital Transfers 0 3 1 0 2 2 2 4

Southern General

Victoria Infirmary

Glasgow Royal



Inverclyde Royal


Acute Stroke Unit Available Yes No Yes Yes Yes Yes Yes NoRehabilitation Stroke Unit Available Yes Yes No No Yes Yes Yes YesIf No Rehabilitation Unit are patients transferred Elsewhere n/a n/a Yes Yes n/a n/a n/a n/aNeurovascular Clinic Available Yes Yes Yes Yes Yes Yes Yes No

Costs of Patient Transport: SAS Greater Glasgow & Clyde

Health Board Total

Southern General

Victoria Infirmary

Glasgow Royal



Inverclyde Royal


Accident & Emergency - Cost per Incident 163 163 163 163 163 163 163 163 163Patient Transport Service - Cost per Journey 18 18 18 18 18 18 18 18 18Ambulance Car Service - Cost per Journey 16 16 16 16 16 16 16 16 16Patient Air Transport Service - Cost per Mission 3,009 3,009 3,009 3,009 3,009 3,009 3,009 3,009 3,009

Costs associated with an initial diagnosis of Stroke in Greater Glasgow & Clyde

Health Board Total

Southern General

Victoria Infirmary

Glasgow Royal



Inverclyde Royal


Accident & Emergency - Consultant Clinic Costs 83 84 75 80 77 78 89 85 83CT Scanning - Cost Per Scan Event 119 140 77 111 125 126 132 108 87MRI Scanning - Cost Per Scan Event 232 252 169 201 230 204 239 195 157Ultrasound Scanning - Cost Per Scan Event 56 66 36 52 64 61 62 51 41

Inpatient costs per day in Greater Glasgow & Clyde excluding surgery and overheads

Health Board Total

Southern General

Victoria Infirmary

Glasgow Royal



Inverclyde Royal


Inpatient Costs per Day - General Medicine 233 280 281 181 207 264 235 201 215

Consultant outpatient costs per event in Greater Glasgow & Clyde

Health Board Total

Southern General

Victoria Infirmary

Glasgow Royal



Inverclyde Royal


Consultant Outpatients - General Medicine 122 172 152 128 141 105 108 117 115Consultant Outpatients - General Surgery 182 127 125 96 110 70 98 103 93Consultant Outpatients - Vascular Surgery 115 125 0 102 118 0 0 0 0

Surgical intervention costs for inpatients and outpatients in Greater Glasgow & Clyde

Health Board Total

Southern General

Victoria Infirmary

Glasgow Royal



Inverclyde Royal


Daycase Surgery - General Surgery 751 928 840 720 755 680 581 730 773Inpatient Surgery - Cost Per Day's Stay 382 310 273 217 242 310 260 311 1,130Theatre Costs - Per Hour 1,463 1,079 1,356 1,071 1,257 1,375 1,477 1,570 2,516

Hospitals in Greater Glasgow & Clyde with a CT Scanner for first level diagnosis for the exclusion of haemorrhagic stroke

Current general service provision in the hospitals of Greater Glasgow & Clyde in relation to stroke pathway

Current service provision for stroke in Greater Glasgow & Clyde

Source: NHS Quality Improvement Scotland

management of patients with stroke or tia: assessment - sign

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