J7ournal of Epidemiology and Community Health 1993; 47: 144-148

Patterns of acute stroke care in three districts ofsouthern England

C D A Wolfe, N A Taub, J Woodrow, E Richardson, F G Warburton, P G J Burney

AbstractObjective-To quantify the use ofhealth careservices by acutely ill stroke patients in threedistrict health authorities.Design-A follow up study of all patientsrecorded in population based registers whohad a first ever stroke in three district healthauthorities, with assessment following theonset and three months after the stroke.Setting-West Lambeth, Lewisham andNorth Southwark, and Tunbridge Wells Dis-trict Health Authorities in south eastEngland.Subjects-All first time stroke patients underthe age of 75 years who presented between15 August 1989 and 14 August 1990.Measurements and main results-Hospitaladmission rates, rates ofuse ofrehabilitationservices, and contact with medical prac-titioners together with assessment of dis-ability and handicap were determined. Atotal of 386 strokes were registered. Seventyeight per cent were treated in hospital andyounger and incontinent patients were signi-ficantly more likely to be admitted. Themedian stay was 21 days. Patients in WestLambeth, those paralysed, and those whostayed longer in hospital were more likely toreceive physiotherapy. Altogether 265patients were followed up, 117 having diedwithin three months ofthe stroke. During thethree months, 150 (57%) had seen a hospitalphysician and 181 (69%) their generalpractitioner, but 18 (7%) had seen neither.Sixty seven (26%) patients were moderatelyor severely disabled. Twenty seven per cent ofinpatients had received no inpatient physio-therapy and 67% of all patients no outpatientphysiotherapy during the three months.Conclusions-The hospital admission rateswere high, with long lengths of stay. Therewere significant differences in the amount ofrehabilitation received in each district. Thiswas low overall, especially for those notadmitted to hospital. As expected, patientsadmitted for long periods were the mostlikely to receive therapy. Before districtpolicies for admission and management ofstroke patients can be drawn up, increasedknowledge of which aspects of stroke man-agement are effective is needed. Policiesshould aim to provide planned, coordinatedcare between hospital and the community. Itis striking that many patients received noform of rehabilitation therapy.

Epidemiol Commzunity Health 1993; 47: 144-148

Stroke causes one in eight deaths in the UnitedKingdom and is one of the most common causesof severe handicap in adults.1 2 The prevalence ofstroke is approximately 6/1000, so that 1500residents in an average health district are strokesufferers.3 Between 40% and 75% of patients areadmitted to hospital4-7; 12% of physicians' bedsare occupied by stroke patients and the treatmentof cerebrovascular disease consumes 4% of theNational Health Service budget.8 9The King's Fund criticised hospital services for

stroke patients and also primary care and com-munity services for being haphazard, fragmented,and poorly tailored to patients' needs.8 Although adeclining mortality rate from stroke has beenobserved since the late 1950s, there is littleevidence that this is related to improvements inhospital care.'0 Randomised controlled trials ofspecialised stroke units have not shown anyimprovement in survival or disability when com-pared with standard hospital care." 12 An over-view of the few controlled trials suggests that goodorganisation of disability management does leadto a more rapid recovery of independence andmore rapid discharge from hospital without anymajor increase in the time allocated by thera-pists. 13

There seems to be no functional difference inoutcome between patients managed at home or inhospital, although patients with more severestrokes tend to be admitted to hospital, and thebenefits of hospital versus community care havenot been properly evaluated.'4 15 There is someevidence that early physiotherapy is beneficial tofunctional recovery, and Smith et al found a slightdose response relationship between the amount ofunspecified therapy given and the functionalrecovery in patients seen after hospital discharge.The study included only 11% of dischargedpatients, however, and the clinical importance ofthe difference is difficult to judge.'6

Public health physicians require information onthe burden of stroke in the community in order tonegotiate contracts related to local needs withprovider units. The Government's green paper,The Health of the Nation suggests that targets be setfor stroke, rehabilitation ofstroke survivors being akey area of interest.17 This paper reports on thecurrent use of services by residents under the ageof75 in three districts during the first three monthsafter a stroke, the time when patients could mostbenefit from health service interventions.

MethodsStroke registers were set up to cover all theresidents of West Lambeth (WL), Lewisham andNorth Southwark (LNS) and Tunbridge Wells

Division ofCommunity Health,United Medical andDental Schools, StThomas's Campus,London SEI 7EHC D A WolfeN A TaubJ WoodrowE RichardsonF G WarburtonP G J Burney

Correspondence to:Dr C D A Wolfe

Accepted for publicationSeptember 1992

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Stroke care patterns in southern England

(TW) District Health Authorities in southernEngland.'8 Data were collected on the patients'gender, age, ethnic group, living conditions beforestroke, and activities of daily living and handicapscores before stroke. Information was collected ona standardised questionnaire from either thepatient, the hospital or general practitioner notes,health care workers, relatives, and coroners andpost mortem reports. The activities of daily livingwas assessed by the research assistant using theBarthel 20 point scale'9 20 and handicap using theRanking 6 point scale, with good agreementbetween observers.2123 The dates of stroke and ofhospital admission and discharge, the hospital,type ofhospital bed (medical, neurology, geriatric,intensive care, surgical), and any transfers todifferent types ofbed were recorded. The severityof the stroke at the time ofmaximum impairmentwithin the first 24 hours (coma, paralysis, speech,urinary or swallowing impairments), and the useof computed tomography were recorded.The number ofcontacts with rehabilitation staff

were recorded for the first three weeks after thestroke. Details of the number of contacts wereobtained from the rehabilitation departments inall units treating district residents. Only formalcontacts were recorded and not rehabilitationperformed on wards by other health care profes-sionals. No estimation of the length or content ofcontact was made as the study was not addressingthe effectiveness of the various components ofrehabilitation.The number of rehabilitation sessions received

in the first three weeks was compared between thelive, non-comatose patients (that is, those forwhom it would be most suitable) who wereadmitted to hospital and those who remained athome.The same details and a record of changes in

status were recorded at three months along withdata on the number of contacts with hospitalphysicians, general practitioners (in surgery ordomicillary), and with rehabilitation professionals(as inpatients and as outpatients). Details of anyillness other than the stroke were recorded.Information on whether blood pressure had beenmeasured and hypertension treated was obtainedfrom patients and from outpatient and generalpractitioner notes. The numbers of therapy ses-sions received by those live and non-comatosepatients during the three months are displayed forboth inpatients and outpatients. The analysis isbased on inpatient sessions while an inpatient andoutpatient sessions while an outpatient.

STATISTICAL METHODSNon-parametric methods were used to analysedata that were not normally distributed on lengthsof stay in hospital, numbers of visits to generalpractitioners, and rehabilitation sessions.The associations of various characteristics with

a patient's admission to hospital and with receiptof physiotherapy, occupational or speech therapy(non-comatose patients only) were estimated bymultiple logistic regression, after adjusting for age,ethnicity, and district of residence.24 Whenmodelling for the receipt ofrehabilitation services,the only additional variables considered were thelength of stay in hospital and the relevant severityindicators associated with the form of

rehabilitation (for example, speech/swallowingimpairment for speech therapy). When modellingfor admission to hospital, other variables wereselected by a backwards stepwise procedure withsignificance set at the 5% level. The variablesconsidered were gender, Rankin and Barthelscores before the stroke, whether living alonebefore the stroke, type of hospital bed, severityindicators, and the number of rehabilitation ses-sions. Patients who died on the day of their strokewere not included in these analyses. The unknownresponses were considered as a separate category,but these categories' contribution to the regressionare not interpreted. The categories ofthe variablesselected are displayed in the relevant tables.

ResultsA total of 386 first time strokes were registeredduring the study period.The mean age at the time of stroke was 64-2

years. Twenty five per cent of subjects lived alonebefore their stroke. Twenty eight patients (7%)were already in hospital at the time of their stroke(3 (3%) WL, 19 (11%) LNS, and 6 (6%) TW;variation between districts X2=5 9. p=005). Afurther 274 (71 %) patients were admitted tohospital and 83 (22%) were not admitted. Thirtytwo deaths (25% of all deaths) occurred on thesame day as the stroke.Two hundred and twenty six hospital admis-

sions (83%) were on the same day as the stroke,with no significance between districts. Youngerpatients and those with incontinence were morelikely to be admitted to hospital and there was noapparent difference in admission rates betweendistricts.

Patients were admitted to 28 hospitals. Lengthsof stay in hospital varied from 1 to 264 days with amedian of 21 days and showed no significantdifference between the districts (Kruskal-Wallistest., p=0-10).Of the WL residents who suffered a stroke, 49

(50%) were admitted to the local district hospitaland 17 (17%) to neighbouring district hospitals.Ofthe LNS residents, 1 5 (64%) were admitted tothe two district hospitals and 20 (11 %) toneighbouring district hospitals. Of the TWpatients, 75 (69%) were admitted to the two localdistrict hospitals and 3 (3%) to neighbouringdistrict hospitals.

Overall, 239 (79%) of the hospital admissionswere to medical beds, 34 (11%) to geriatric, 12(4%) to intensive care, and 4 (1%) to neurologybeds.On the day of the stroke 77 (20%) patients were

in a coma. Of those who were conscious andsurvived the first day 298 (76%) had a paralysis orweakness, 226 (59%) had a speech impairment,103 (27%) a swallowing impairment, and 132(34%) were incontinent or had a urinary catheter.

Overall, 69% of patients admitted to hospitalreceived some physiotherapy in the first threeweeks and there was a significant differencebetween the districts (X15 5, p<0-001). Forthose patients who received physiotherapy themedian number ofsessions was 3 3 per week, witha significant difference between districts (Kruskal-Wallis test, p=0 002). There was no significantdifference between districts in the proportions of

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patients who received occupational or speechtherapy; the median number of sessions for thesepatients were 1-7 and 1 session per weekrespectively.

Eleven of 57 (19%) patients not admitted tohospital received physiotherapy and had a medianof two sessions per week during the first threeweeks. Four per cent received occupational ther-apy and none received speech therapy during thisperiod.

ASSESSMENT THREE MONTHS AFTER STROKE

Two hundred and sixty five patients were assessedthree months after their stroke. Altogether 117had died and three were lost to follow up (two hadmoved abroad). Forty two (16%) were still inhospital and there was no significant differencebetween the districts (X2=2-3, p>0-1). One hun-dred and seventy seven patients (67%) were livingwith another person, 39 (15%) were living alone,

Table I Rankin handicap score measured three months after stroke in the three healthdistricts

West Lewisham & TunbridgeHanidicap Score Lambeth N Southwark Wells All 3

Functionally 0,1,2 36 (570/.) 76 (61%S,) 54 (74%) 166 (64%)independentModerate

Severe

4 patients were not assess

3 10 (16%o) 21 (17%Yo) 12 (16%) 43 (16%>){4 14 (22%YO) 18 (14%) 4 (5%) 36 (14%M)15 3 (5%Xo) 10 (8%X)) 3 (4'%)) 16 (6%)

sed

Table II Barthel disability score measured three months after stroke in the three healthdistricts

West Lewishani & IunbridgeDisability Score Lanmbeth N Southwark Wells All 3

None 20 33 (52%) 56 (45%,,) 49 (67'S>) 138 (531%)Mild 15-19 12 (19%/,) 29 (23%/,) 15 (21%X,) 56 (21%S,)Moderate/Severe 0-14 18 (29%) 40 (32'S,) 9 (12%X)) 67 (26'%,)

4 patients were not assessed

Table III Inpatient and outpatient rehabilitation therapy rates during the first threemonths (sessions per week), for patients who survived the day of stroke without being in

coma

Mediansessionsper week

Total No. % for those Kruskal-no. of with with x2 receiving Wallispatients therapy therapy, p value therapy p value

While an inpatient:Physio: all 3WLLNSTW

OT: all 3WLLNSTW

Speech: all 3WLLNSTW

While ani outpatientPhysio: all 3WLLNSTW

OT: all 3WI,LNSTW

Speech: all 3WLLNSTW

251 182 7358 53 91122 87 7171 42 59

251 139 5558 36 62122 70 5771 33 46

185 95 5136 21 5893 51 5556 23 41

234 78 3359 17 29106 41 3969 20 29

234 28 1259 10 17106 10 969 8 12

I X2=16 8

J p<0-OOl

lX22=3 5p>O l

XlX=3-5p>0.1

t X2=2.5I P>O I

p>O l

160 25 1630 4 13

80 12 1 5 p>=0.16

5o 9 18>-

3-53-44-13 0

1 51-51.91 7

091-41 30-8

070 60-70 6

0-40 80 30 9

0 40 50 60 3

p=0 008

p>OI

p=002

IP>OI

I p=0 03

jp>O-

OT=occupational therapy; physio=phsyiotherapy; speech=speech therapyData for speech therapy apply only to patients with speech and/or swallowing impairmentWL=West Lambeth; LNS=Lewisham and North Sotithwark; TW=Tunbridge Wells

and 5 (2%) were in residential care. Of thoseinitially living alone 36 (54%) were still alone and18 (27%) were still in hospital with no significantdistrict difference (X2=0 8, p>0-1).One hundred and eleven (42%) patients had

received medical care for a condition other thanthe stroke but only 17 (6%) had been admitted tohospital for that condition. One hundred and fifty(57%) patients had seen a physician orgeriatrician-with 97 as outpatients, 51 asinpatients, and only two as a domiciliary visit. Ofthe 83 patients not admitted to hospital at the timeoftheir stroke 54 were alive at three months, and ofthese 20 (37%) had seen a physician as anoutpatient. Thirty four (13%) of the patients whosurvived to follow up were neither admitted tohospital nor seen by a hospital doctor, 18 (7%)were followed up by neither a GP nor a hospitaldoctor.The Rankin and Barthel scores at three months

are given in tables I and II. One hundred and thirtyfive patients (53%) had no change in their Barthelscore compared with the assessment of their statusbefore the stroke, 59 (23%) had a worsening of 1to 5 points, and 49 (19%) a worsening of 6 to 15points. Overall, 76 (30%) had no change in theRankin score; 54 (21 %) showed a worsening of 1

point, 47 (18%) 2 points, 36 (14%) 3 points, 25(10%) 4 points, and 11 (4%) 5 points, with 8 (3%)having an improvement in their handicap score.

Seventy three per cent of patients had receivedsome inpatient physiotherapy during the threemonths and there was a highly significant variationbetween the districts. The rate for physiotherapyas an outpatient was only 33%, with no apparentdifference between the districts (table III).

Patients in West Lambeth, paralysed patients,and those with longer lengths of stay in hospitalwere more likely to receive physiotherapy (tableIV). Patients with longer lengths of stay and thosewho were paralysed but not incontinent were morelikely to receive occupational therapy. Speechtherapy was more likely to be received by long staypatients and those with a speech impairment.

Overall, 181 patients (69%) had seen their GPsince the stroke (WL 65%, LNS 63%, and TW82%) and there was a significant differencebetween districts (X2=8-0, p=0 02). The meannumber of surgery visits was 1-3 during threemonths, with a significant difference betweendistricts (WL 1-5, LNS 0-9, TW 1-7, Kruskal-Wallis test, H=19-3, p<0-001).

Fifty eight pateints (89%) in WL, 98 (78%) inLNS, and 62 (86%) in TW had their bloodpressure recorded during the first three months,with no variation between districts (o=47,p=0-09). Overall, 127 (48%) patients were diag-nosed as hypertensive and 125 (98%) of thesewere on antihypertensive treatment.At three months, 75 (28%) patients still had a

speech impairment, and of these 10 had no otherimpairment, 18 (7%) had a swallowingimpairment, 26 (10%) were incontinent or cath-eterised, and two patients were still in semi-comabut had not had a recurrence of stroke. Onehundred and eighty one patients (68%) were

paralysed or had a weakness. There was no signifi-cant difference between districts for any of thesemeasures of severity.

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Table IV Multiple logistic regression model to predict which patients receivephysiotherapy within three months of their stroke in the three health districts

No r Odds ratio 95% CI p valueAge (y) 54 30 22 1 00 p>0 1

55-64 65 43 2 22 0 61 to 80565-69 65 51 3 43 0.95 to 12 4170-74 86 66 2-65 0-77 to 9 04

District: WL 56 51 1 00 p<0001LNS 120 89 0 09 0-02 to 0 35TW 70 42 0-07 0.02 to 0-29

Ethnic group: White 203 148 1 00 p>0 1Black 42 33 0-96 0 34 to 2 68Not known 1 1

Length of inpatient stay(weeks): 0-2 110 60 1 00 p<0001

3-5 45 37 4 66 1-72 to 12 646-11 59 54 10-74 3 50 to 32-9512+ 32 31 58-26 5-13 to 662.1

Paralysis: No 12 4 1 00 p<0001Yes 229 177 9-36 1 88 to 46-54Not known 5 1 -

WL=West Lambeth; LNS=Lewisham and North Southwark; TW=Tunbridge WellsNo=total number of patients in categoryr=number of these who receive physiotherapyRestricted to those admitted to hospital, live and not initially comatose

DiscussionHealth services for patients who have suffered a

stroke cost an average district health authority an

estimated three million pounds per annum.8 Thisestimate is considered conservative as long termand respite care are not included in these costs.Despite the magnitude of the problem there seemto be deficiencies in the provision ofservices to thisgroup of patients which both the purchasers andproviders of health care should consider whendrawing up contract specifications.8 9 There hasbeen no comprehensive audit of stroke servicesundertaken in the United Kingdom and this studyexamines stroke service provision in the acutephase of the illness in residents aged under 75years, a group which is the focus of thegovernment's targets for stroke. 17 For a conditionthat consumes a considerable proportion ofhealthservice resources there has been little evaluation ofthe effectiveness of the services provided fortreating it.

This was a large study, encompassing a popula-tion of over 600 000 district residents. Toencourage registration of strokes, several sources

of notification were used and feedback to healthcare professionals was on a regular basis. We havealready estimated the incidence and case fatality ofstroke in the under 75s in these districts'8 but thispaper is concerned with the utilisation of healthservices in these groups. We are confident that thecase ascertainment methods used provide us withan accurate picture in the three health districts.The hospital admission rate of 78% is higher

than that previously quoted,5 7which may reflect a

lack of community based rehabilitation andnursing services in the districts under study.Admission to hospital is often for social andnursing reasons,7 consequently hospital may notbe the most appropriate place for these patients. Aquarter of all patients were living alone before theirstroke, however, and this may be a good reason foradmission. There seems to be no difference inadmission rates between rural TW and the innercity districts but younger patients and those whowere incontinent as a result of their stroke were

more likely to be admitted. The appropriateness ofthese admissions was not assessed independentlyin this study. In a World Health Organisationstudy5 similar hospital admission rates within thefirst 24 hours of a stroke were reported and a

similar proportion of strokes occurred to patientswhile in hospital but in this study LNS hadsignificantly more strokes occurring in postopera-tive cardiac patients.The median length of stay in hospital of three

weeks is twice that reported in Bristol andrepresents a considerable proportion of physi-cians' bed days for a condition where the appro-priateness of admission is questioned for manypatients.6 Local district general hospitals managedonly between 50% and 70% of their residents andin future purchasers of stroke services should beseeking comprehensive district provision to allowfor continuity of care between hospital and thecommunity, although this may be unrealistic ininner city districts.A detailed clinical audit of the medical process

was not carried out in the three districts as districtsand units had not developed agreed standards ofcare or a stroke policy with which the results couldbe compared. These data do, however, provide abaseline for audit. Subsequent to these resultshaving been brought to the attention of localhealth care professionals, standards and objectivesin two of the districts have been formulated.25There is some evidence that early rehabilitation

is beneficial to functional recovery, although mostof the functional gains experienced by strokepatients are probably attributable to spontaneousrecovery. Rehabilitation may, however, result inincreased independence in the performance ofactivities of daily living for patients who haveintermediate levels of functional ability.'5 16 Theanalysis of rehabilitation received, restricted tothose patients eligible to receive it, illustratesmajor deficiencies and some significant variationbetween districts in the provision ofthese services,especially for patients in the community. Thirtyone per cent ofpatients received no physiotherapyin the first three weeks. This may be because of alack of services, poor communication, a beliefthattherapy has no effect on functional outcome, orbecause there was no clinical indication. Thoseoutpatients who received physiotherapy received amedian of less than one session per week andlonger stay inpatients were the most likely toreceive therapy.There was significant variation between dis-

tricts in the use of physiotherapy. In the districtwhich during the study period started to haveweekly multidisciplinary meetings to plan strokecare, over 90% received some physiotherapy.There were no district differences for occupationaland speech therapy but the overall proportion ofpatients who received sessions was low in com-parison with the prevalence of disability. Theseresults are not surprising when the low staffinglevels in the rehabilitation departments involved inthe study, especially in the community, are con-sidered.The data display very low rehabiliation rates

compared with the Bristol study of 1984 in whichan average of 46 minutes therapy a day wererecorded over the first six months of therapy, butneither study included the therapy learnt andpractised by the patients on their own.'5 With amedian of one session per week of physiotherapyrecorded in this study, the government's sug-gestion that targets be set for the rehabilitation ofstroke patients should be developed further. The

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effectiveness of the rehabilitation provided shouldbe evaluated, however, alongside the developmentof these targets. The study did not explore howappropriately rehabilitation therapy was distri-buted but concurs with previous studies showingthat therapy is more intense for those with themore severe strokes'4 and that research is requiredto determine which components of rehabilitationare effective, and at what intensity.A planned discharge from hospital with com-

munity care after expensive, long lengths of stay inhospital is considered an important part of goodstroke care.8 Patients were followed up in hospitaloutpatient clinics in only 55% of cases. Only 69%had seen their GP since their stroke, with asignificantly higher proportion being seen by theirGP in rural TW. As 7% of patients saw neither aGP nor a hospital doctor after discharge fromhospital or after diagnosis at home, targets couldbe set to address this issue of continuity of care andbe audited both in hospital and in primary care.The levels of impairment and handicap at three

months were similar to those in otherstudies.24 27 30 The level of speech impairmentwas higher than previously quoted but this studydid not undertake a detailed neurological assess-ment of the speech impairment. Of more impor-tance are the resultant levels of disability andhandicap, which are similar to those in Britishstudies, 27 2830 with 45'S, of patients being eithermoderately or severely disabled after their stroke.These data illustrate the need for support servicesfor this group of patients.These data illustrate the pattern of care for

stroke in those aged under 75 years in a populationof 620 000. There is a high admission rate tohospital with long lengths of stay but with noplanned, coordinated follow up in the community.The King's Fund has advocated the evaluation ofdifferent forms of care for stroke patients toovercome the haphazard, fragmented, and poorlytailored services. This report supports the need toassess different packages of care and to developtargets for stroke management and rehabilitation.

We wish to thank the Chest Heart and Stroke Associa-tion and the Department of Health for funding. We aremost grateful to all those who notified the register ofcases, especially those in the community. Our thanks toAna Childs for typing the manuscript.

Office of Population Censuses and Surveys. Mortalitystatistics cause. Englanid and Wales. London: HMSO, 1991(Series DH2, No 17).

2 MartinJ, White A, Meltzer H. Office of Population Censusesand Surveys. Disabled adults: services transport andemtiploymnenzt ((Report 4) Disabilityin Great Britaini). London:HMSO, 1989.

3 Kurtze JF. The current neurologic burden of illness andinjury in the United States. Neurology 1982; 32: 1207-14.

4 Brocklehurst C, Andrews K, Morris P, Richards BR,Laycock PJ. Why admit stroke patients to hospital? Age andAgeintg 1978; 7: 100-8.

5 Aho K, Harmsen P, Hatomo S, Marquardsen J, Smirnov VE,Strasser T. Cerebrovascular disease in the community:results of a WHO collaborative study. Bull WHO 1980; 8(i):113-30.

6 Wade DT, Langton Hewer R. Hospital admission for acutestroke: who, for how long, and to what effect? _7 EpidemiolComnmrunity Health 1985; 39: 347-52.

7 Bamford J, Sandercock P, Warlow C, Gray M. Why arepatients with acute stroke admitted to hospital? BMJ 1986;1: 1369-72.

8 King's Fund Consensus statement. The treatment of stroke.BMJ 1988; 297: 126-8.

9 Office of Health Economics. Stroke. London: Office ofHealth Economics, 1988 Series No 89.

10 Gillum RF, Gromez-Martin 0, Kottbe E, Jacobs DR et al.Acute stroke in a metropolitan area. 1970 and 1980. TheMinnesota Heart Study. Journal of Chronic Diseases 1985;38: 891-8.

11 Garraway WM, Akhtar AJ, Hockey L, Prescott RJ.Management of acute stroke in the elderly: follow-up of acontrolled trial. BMJ 1980; 281: 827-9.

12 Stevens RS, Ambler NR, Warren MD. A randomizedcontrolled trial of a stroke rehabilitation ward. Age andAgeinlg 1984; 13: 65-75.

13 Ebrahim S. Clinical epidemniology of stroke. Oxford: OxfordUniversity Press, 1990.

14 Wade DT, Langton Hewer R, Skilbeck CE, Bainton D,Burns Cox C. Controlled trial of a home care service foracute stroke patients. Lancet 1985; ii: 323-6.

15 Wade DT, Skilbeck CE, Langton Hewer R, Wood VA.Therapy after stroke: amounts, determinants and effects.Initeniational Rehabilitation Medicine 1984; 6: 105-110.

16 Smith DS, Goldenberg E, Ashburn A. Remedial therapyafter stroke: a randomized controlled trial. BMJ 1981; 282:517 -20.

17 Secretary of State for Health. The health of the nation: aconisultative docunment/for healthin Eniglanid. London: HMSO,1991. (Cmnd 1523)

18 Wolfe CDA, Taub NA, Woodrow J, Richardson E,Warburton FG, Burney PGJ. Does inicidence, severity orcase-fatality of stroke vary in Southern England.7 EipidemiolConmmnunity, Health 1993; 47: 139-143.

19 Mahoney Fl, Barthel DW. Functional evaluation. TheBarthel index. Marylanid State Medical J7ournal 1965; 14:61-5.

20 Collins C, Wade DT, DavisS, Horne V. The Barthel ADLindex: a reliability study. International Disabilities Studies1968; 10: 61-3.

21 Rankin R. Cerebral vascular accidents in patients over 60. IIPrognosis. Scott Med_3 1957; 2: 200-5.

22 van Swieton JC, Koudstaal PJ, Visser MC, Schouten HJA,van Gijn J. Interobserver agreement for the assessment ofhandicap in stroke patients. Stroke 1988; 19: 604-7.

23 Wolfe CDA, Taub NA, Woodrow EJ, Bumey PGJ.Assessment of scales of disability and handicap for strokepatients. Stroke 1991; 22: 1242-4.

24 Dixon WJ, BMDP Statistical software manual. Volume 2.Berkeley: University of California Press, 1990; 739-806.

25 Wcst Lambeth Health Authority Stroke Steering Group.Setting district stroke standards and objectives. I Roy CollPhysicians Lond 1992; 26: 172-6.

26 Brocklehurst JC, Andrews K, Richards B, Laycock P. Howmuch physical therapy for patients with a stroke? BMY 1978;1: 1307-10.

27 Malmgren R, BamfordJ, Warlow C, SandercockP, SlatteryJ. Projecting the number of patients with first evcr strokesand patients newly handicapped by stroke in England andWales. BAM 1989; 298: 656-60.

28 Wade DT. Langton Hewer R. Functional abilities afterstroke: measurement, natural history and prognosis. YNeurol Neurosuirg Psychiatry 1987; 50: 177-82.

29 Wade DT, Langton Hewer R, David RM, Enderby PM.Aphasia after stroke: natural history and associated deficits.Y Neurol Neurosurg Psychiatry 1986; 49: 11-16.

30 Bamford J, Sandercock P, Dennis M, Burn J, Warlow C. Aprospective study of acute cerebrovascular disease in thecommunity. The Oxfordshire Community StrokeProject- 1981-86. 2. Incidence, case fatality rates andoverall outcome at one year of cerebral infarction, primaryintracerebral and subarachnoid haemorrhage. 7 NeurolNeurosurg Psychiatry 1990; 53: 16-22.

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