Stroke Presentation and Hospital Management Comparison of Neighboring Healthcare Systems With Differing Health Policies Vivienne L.S. Crawford, PhD; John G. Dinsmore, BSc; Robert W. Stout, DSc; Claire Donnellan, PhD; Desmond O’Neill, MD; Hannah McGee, PhD Background and Purpose—Acute stroke care is shaped by healthcare policies. Differing policies in similar populations allow for assessment of policy impact on health and healthcare outcomes. The purpose of this study was to compare stroke presentation and hospital care in two adjacent healthcare systems with differing healthcare policies. Methods—Interviews and chart review of consecutive acute stroke admissions in Northern Ireland (n=103) and the Republic of Ireland (n=100). Results—Marked regional contrasts were evident for key aspects of hospital care. Northern Ireland performed significantly better on 15 of 16 quality of care (Sentinel Audit) items. Delivery on standards was significantly better in Northern Ireland for early assessment (Northern Ireland 72%; Republic of Ireland 54%, P0.01), multidisciplinary review (Northern Ireland 69%; Republic of Ireland 31%, P0.001), medications review (Northern Ireland 54%; Republic of Ireland 19%, P0.001), and for discharge-rehabilitation planning (Northern Ireland 83%; Republic of Ireland 8%, P0.001). Preadmission prescription of advised cardiovascular medications was similar between regions for antihypertensives and anticoagulants but significantly higher in Northern Ireland for antiplatelets (Northern Ireland 65%; Republic of Ireland 38%, P=0.001) and lipid-regulating medication (Northern Ireland 44%; Republic of Ireland 26%; P=0.006). Prescribing levels increased in both regions and all medication categories by discharge but with significantly lower levels in Northern Ireland for antihypertensives (Northern Ireland 60%; Republic of Ireland 75%, P=0.025). Northern Ireland patients were more functionally dependent (mean Barthel Index 10.5 versus 12.7 [Republic of Ireland], P=0.013) and less aphasic (mean Frenchay Aphasia Screening Test 17.8 versus 16.8 [Republic of Ireland], P=0.022). Conclusions—In similar neighboring acute stroke populations, differing healthcare policies were associated with significant differences in processes of patient care. Policy reform is an important tool in ensuring optimal stroke care delivery. (Stroke. 2009;40:2143-2148.) Key Words: healthcare policy  medication profile  stroke management H ealth management strategies for stroke can significantly influence early detection and short- and long-term outcomes. Comparison within and across systems allows for benchmarking and continuing quality improvement, for in- stance, the UK Sentinel Audit of Stroke. 1 Current evidence suggests major variations between Western European coun- tries in outcome after acute stroke, 2 with the United Kingdom and Ireland scoring poorly in comparison to other Euro- pean countries. Whereas there are marked variations be- tween European countries in acute stroke facilities avail- able, 3 there is little focus on the impact of primary and other care systems on presentation with stroke, prevention strategies, and outcome. The present study compared stroke patients in the Republic of Ireland and Northern Ireland. Northern Ireland has a population of 1.7 million 4 and the Republic of Ireland has 4.2 million inhabitants 5 ; both have an estimated 230 strokes per 100 000 people annually. These 2 systems on 1 island have differing health policies, service structures, and funding arrangements. Northern Ire- land has universal free healthcare coverage, with free primary care physician and hospital healthcare to all. For those aged 65 years and over, medications are free. Private health insurance is unusual in Northern Ireland (10% in 2005). 6 The Republic of Ireland has a mix of public and private healthcare coverage. Approximately 26% of the population is eligible Received December 15, 2008; accepted December 23, 2008. From the School of Medicine, Dentistry, and Biomedical Sciences (V.LS.C., J.G.D., R.W.S.), Queen’s University Belfast, Northern Ireland, UK; the Division of Population Health Sciences (H.M.), Royal College of Surgeons in Ireland, Dublin; and Medical Gerontology (C.D., D.O.), Trinity Centre for Health Sciences, Adelaide and Meath Hospital, Ireland. Correspondence to Dr Vivienne Crawford, School of Medicine, Dentistry, and Biomedical Sciences, Queen’s University Belfast, Whitla Medical Building, 97 Lisburn Road, Belfast, BT9 7BL, Northern Ireland. E-mail v.crawford@qub.ac.uk © 2009 American Heart Association, Inc. Stroke is available at http://stroke.ahajournals.org DOI: 10.1161/STROKEAHA.108.545376 2143 by guest on July 25, 2015 http://stroke.ahajournals.org/ Downloaded from