Title: Stroke Sentinel Audit Programme: Investigating and Evaluating Stroke Therapy (SSNAPIEST)
Funder: Department of Health and Social Care

Abstract: BACKGROUND: Stroke is the UK’s greatest cause of severe adult disability. Physical, occupational and speech therapy (known collectively as ‘the stroke therapies’) are a cornerstone to effective stroke care but many patients receive sub-optimal amounts of therapy and little is known about cost-effectiveness. AIMS AND OBJECTIVES: We want to improve this situation. To do so, we need to understand WHY insufficient therapy is provided. We plan an in-depth analysis of data from the national stroke register to investigate the effectiveness of UK stroke therapies by • Identifying different therapy pathways • quantifying variation in therapy provision and the contributing organisational and patient related factors • Relating variation of therapy to care quality, outcome, and cost to identify the most clinically and cost-effective stroke therapy pathways • Explore optimal resource use for each pathway from the NHS perspective focusing on direct costs. Secondarily, we will identify patient sub-groups (defined by patient and stroke related characteristics), examine the therapy they receive and the association with functional recovery to inform future development of stratified stroke therapy pathways DATA SOURCE: The Sentinel Stroke National Audit Programme (SSNAP) database which records stroke related problems, recovery and treatment received for 95% of all stroke patients admitted in England and Wales. PARTICIPANTS: adult candidates for stroke therapy using in-patient or community stroke services. STATISTICAL ANALYSIS: Descriptive statistics will identify therapy pathways and quantify variation in therapy provision. Mixed effect regression modelling will account for patient-related factors influencing therapy provision. The regression models will be extended by linking them with SSNAP’s organisational data to determine the organisational factors influencing therapy provision. This process will be repeated for the factors influencing the quality of therapy (using data from the processes of care). Then all (patient, organisation and therapy related) factors will be modelled to explore their contribution to patient- and service-related outcomes. The processes of care, patient and organisational factors and outcomes are detailed in the ‘detailed project plan’. For the secondary aim: we will tabulate the co-morbidity of stroke related physical and psychological impairments and other patient characteristics using standard regression methods to identify how stroke characteristics relate to therapy input and outcomes HEALTH ECONOMIC ANALYSIS: The cost of each therapy pathway will be ascertained from NHS and Personal Social Services Research Unit costs resource utilization data linked with Hospital Episode Statistics data. Defined pathways will be compared with incremental cost effective ratios estimated in terms of cost per improved mortality, reduced length of stay. The cost/ effect optimal model will be derived from the cost effectiveness modelling using standard dominance strategies. NHS cost savings will be estimated by attributing cost of improved outcomes to the cost of ‘standard’ stroke care. The impact of patient characteristics and organisational features will be modelled using econometric modelling techniques allowing us to separate effects for each therapy pathway. We will assess the impact of different resource use on efficiency of outcomes using data envelopment analysis or stochastic frontier modelling

Lay abstract: BACKGROUND: Stroke is the UK’s greatest cause of adult disability. Therapy (physical, occupational and speech therapy) is an important aspect of stroke care that helps stroke patients regain movement, communication and ‘thinking’ skills so they can look after themselves and return to important activities. We know therapy is effective but in the UK, most patients receive sub-optimal amounts of therapy1 AIMS: We want to improve this situation. So we need to understand WHY insufficient therapy is provided. In the UK, we have a unique opportunity using data from the Sentinel Stroke National Audit Programme (SSNAP). SSNAP is a national stroke register that audits care from admission to 6 month follow-up, involving all acute stroke services in England and Wales (95% of all stroke admissions, ~80,000 per year) and ~250 community services SSNAP regularly publishes detailed information describing the following for hospital and community services1: stroke therapy provision; processes of care; how services are organised; outcomes from the patients’ and organisations’ point of view. However it only describes what happens. It does not explain HOW these factors are inter-linked; WHY therapy does not happen; how much therapy services COST, nor which are the MOST EFFECTIVE ways to organise them. We will work this out. A challenge for stroke therapy is that stroke can cause many types of difficulties, disabilities and potential to recover. These factors affect which therapy best suits each individual. Recently the idea of ‘stratified health care’ has emerged, based on the recognition that treatment works best when it is closely tailored to individuals’ needs. As a secondary aim, we wish to apply this principle to stroke therapy. We will use SSNAP data to investigate how disabilities occur together (or ‘cluster’) and, for particular groups, whether these are associated with different levels of therapy and recovery. This information will help to develop specific treatments and pathways for patient sub-group in the future. As the treatments will more accurately suit individual patients, we can expect them to be more effective, enabling greater recovery and less long-term support from health and social care services, resulting in cost savings to an overburdened health system. DESIGN: We will analyse the most up-to-date, relevant SSNAP data available to us; a huge ‘data-set involving ~160,000 patient records. The managers of the SSNAP programme will use established methods to identify the relevant data for ‘candidates for therapy’. These are stroke survivors who are in-patient for at least 3 days, conscious; not receiving end-of life care, and disabled by the stroke. We will then use sophisticated statistical and health economics techniques to answer the study objectives. PATIENT AND PUBLIC INVOLVEMENT: We have an established partnership with the PPI panel at the Manchester’s Stroke Research Centre. They recognise stroke therapy as a priority and consider the questions important and appropriate. They will collaborate throughout the project, have contributed to this plain English summary and will contribute to the detailed analysis plan, interpretation of results and material to publicise the findings to stroke survivors

Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: STROKE