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Dear Dave
With reference to your editorial in the January issue, do we geriatricians really welcome the emphasis being placed on hyperacute management of stroke in specialist centres if this is likely to be competing for, and winning, limited resources? Just look at the facts and do the maths: 30% of stroke patients are over 80 and there is no tPA licence for this age group; virtually all of the 72,000 stroke admissions in England from the total 110,000 stroke population - the Department's own figures by the way - would be eligible for organised stroke care where the NNT to prevent one death is 33 and to enable a person to regain independence is 20; by way of contrast, the Department considers two levels of thrombolysis delivery at 4% - 2880 patients - and 9% - 6480 patients; the numerically challenged National Audit Office (NAO) suggested that 9900 people would be eligible for treatment, 9% of all strokes not just the 9% of those admitted to hospital producing savings of £16 million and allowing 1500 to recover fully. In addition, thrombolysis, contrary to the assertion in NAO report, does not reduce mortality unlike organised hospital stroke care that saves lives of both young and old patients; granted, both thrombolysis and stroke unit care can restore autonomy but with one third of 72,000 patients currently not being able to access organised stroke care there are considerable numbers of lives lost and people being left disabled - 727 and 1200 to be precise; this is ethically indefensible in 2007. Taking all of that into consideration, do we really welcome the emphasis being placed on hyperacute management of stroke in specialist centres for a minority of predominantly younger patients, or as geriatricians should we be campaigning harder both individually, and also as a Society, to ensure that valuable, limited health resources are spent wisely and well on organised stroke care in hospital and the community, for the majority of both younger and older patients?

Dr Nigel Dudley, St James's University Hospital

Editor’s reply:

Dear Nigel ,
Thanks very much for your recent comments on Hyperacute services for stroke as mentioned in my January column. Your points are very well made and as Stroke medicine becomes increasingly recognised as a separate speciality, it will be interesting to see how it fares in terms of resource allocation and its approach to patients with frailty and co morbidities. I totally agree that we should not squander the benefits we have achieved in organising Stroke care and fear that as financial pressures mount it will be the rehabilitation end of the pathway that will be squeezed.

Dave