Abstract
Background
International research has shown that patients treated at non-urban hospitals and those
from ethnic minority groups experience poorer access to best practice stroke care interventions.
Much of this previous research has focussed on access to acute stroke care, with fewer studies
investigating access to post-acute care. Evidence has shown that ethnic minority groups have
poorer post-stroke outcomes compared to Europeans, however, it is less clear whether patients
treated at non-urban hospitals also experience worse outcomes. In New Zealand there has been
limited research on either of these topics, however, departures from best practice care have
previously been accepted for smaller, non-urban hospitals. Over the past decade, there has been
a lot of work undertaken to improve stroke care in New Zealand, however, it remains unknown
whether best practice stroke care access is equitable and outcomes equal for all patients.
Aims
The aims of this research were to investigate whether hospital location (urban/non-urban)
or ethnicity have an impact on access to best practice stroke care or patient outcomes in New
Zealand. In addition, the research aimed to gain an understanding of consumer (patient,
carer/family member) and health worker perspectives of stroke care in New Zealand and
identify barriers to accessing best practice care.
Methods
This programme of research consisted of four interconnected studies beginning with an
online survey investigating stroke service provision in New Zealand stroke hospitals (n=28),
with a particular focus on urban/non-urban differences in care delivery. Two prospective
studies, run concurrently, involved 2,379 patients admitted to hospital with stroke between May
and October 2018. Data on stroke interventions provided across the care continuum, up to three
months following admission, were collected. Outcomes were captured at three months, and for
a sub-set of patients at six and 12 months. An online mixed methods survey was conducted to
explore consumer [patient (n=41), carer/family member (n=12)] and health worker (n=41)
perspectives of stroke care, and barriers to accessing best practice stroke care in New Zealand.
Results
Patients treated at non-urban hospitals had poorer access to a number of components of
best practice stroke care and had poorer outcomes across several domains, including functional
outcome, mortality and vascular and stroke recurrence, up to 12 months post stroke. By
ethnicity, many components of best practice stroke care were accessed equally, and for some
components there was enhanced provision. Of concern, the provision of cultural care for Māori
and Pacific patients was found to be sub-optimal. Despite generally equal access to stroke care,
non-Europeans had poorer functional outcomes at three, six and 12 months, and Māori
specifically were more likely to have a poor functional outcome at three and 12 months and
were more likely to have died by 12 months. Ethnicity was not identified by consumers as a
barrier to accessing care, whereas ‘geographic inequities’ was one of the access barrier themes
identified. Consumers generally rated stroke care in New Zealand higher than health workers,
but both groups agreed that there was variability in care by stage of treatment, with
improvements required particularly post discharge.
Discussion
Patients treated at non-urban hospitals had reduced access to key stroke interventions
across the entire care continuum, and this was associated with poorer outcomes up to 12 months
post stroke. Non-Europeans had equal access to many components of best practice stroke care,
however, despite this, had poorer outcomes compared to Europeans. This points to inequitable
access for non-Europeans to best practice stroke care and suggests that enhanced provision of
care is required to achieve truly equitable access and equal outcomes. Perceptions of stroke
care differed between consumers and health workers. Post-discharge follow-up and geographic
equity were identified as key areas for improvement, with telehealth a likely strong enabler.