- Email: [email protected]
Transient ischaemic attacks: unstable, treatable, neglected
Comment
Thus follow-up trials of longer duration are required to confirm that the effects of pitrakinra are not just restricted to alterations in the kinetics of the late-phase response. Issues concerning efficacy in patients with more severe asthma, and the potential for genuine disease modification with longer-term treatment, especially in children, also remain to be addressed. These latest findings with pitrakinra are exciting and novel, and will breathe new life into the debate surrounding the role of the Th2 cytokine cascade in asthma pathogenesis and how best to design drugs to attenuate their effects.
2 3
4
5
6 7
8
9
*Patrick G Holt, Peter D Sly Telethon Institute for Child Health Research, Subiaco, WA 6008, Australia [email protected] We declare that we have no conflict of interest. 1
Asher MI, Montefort S, Bjorksten B, et al. Worldwide time trends in the prevalence of symptoms of asthma, allergic rhinoconjunctivitis, and eczema in childhood: ISAAC Phases One and Three repeat multicountry crosssectional surveys. Lancet 2006; 368: 733–43.
10 11
12
Busse WW, Lemanske RF. Asthma. N Engl J Med 2001; 344: 350–62. Johnston SL, Pattemore PK, Sanderson G, et al. The relationship between upper respiratory infections and hospital admissions for asthma: a time-trend analysis. Am J Respir Crit Care Med 1996; 154: 654–60. Kusel MMH, de Klerk NH, Kebadze T, et al. Early-life respiratory viral infections, atopic sensitization and risk of subsequent development of persistent asthma. J Allergy Clin Immunol 2007; 119: 1105–10. Murray CS, Poletti G, Kebadze T, et al. Study of modifiable risk factors for asthma exacerbations: virus infection and allergen exposure increase the risk of asthma hospital admissions in children. Thorax 2006; 61: 376–82. Bischoff SC. Role of mast cells in allergic and non-allergic immune responses: comparison of human and murine data. Nat Rev Immunol 2007; 7: 93–104. Wenzel S, Wilbraham D, Fuller R, Burmeister Getz E, Longphre M. Effect of an interleukin-4 variant on late phase response to allergen challenge in asthmatic patients: results of two phase 2a studies. Lancet 2007; 370: 1422–31. Ali FR, Oldfield WL, Higashi N, Larche M, Kay AB. Late asthmatic reactions induced by inhalation of allergen-derived T cell peptides. Am J Respir Crit Care Med 2004; 169: 20–26. Holgate S. The inflammation-repair cycle in asthma: the pivotal role of the airway epithelium. Clin Exp Allergy 1998; 28 (suppl 5): 97–103. Holt PG, Sly PD, Martinez FD, et al. Drug development strategies for asthma: in search of a new paradigm. Nat Immunol 2004; 5: 695–98. Hart PH, Bonder CS, Balogh J, Dickensheets HL, Donnelly RP, Finlay-Jones JJ. Differential responses of human monocytes and macrophages to IL-4 and IL-13. J Leukoc Biol 1999; 66: 575–78. O’Byrne PM, Inman MD, Adelroth E. Reassessing the Th2 cytokine basis of asthma. Trends Pharmacol Sci 2004; 25: 244–48.
Transient ischaemic attacks: unstable, treatable, neglected Published Online October 9, 2007 DOI:10.1016/S01406736(07)61449-4 See Articles page 1432 See Lancet Neurol 2007; 6: 953–60
1398
Stroke affects 15 million people worldwide every year, and is the leading cause of acquired disability.1 Unfortunately, despite ample evidence that thrombolytics improve outcome after an acute ischaemic stroke, very few patients receive this treatment.2 In view of these dismal statistics, high priority should be accorded to stroke prevention. Results from several randomised trials have shown that the risk of ischaemic stroke in high-risk individuals can be significantly reduced by strategies such as blood-pressure lowering, statin therapy, antithrombotic drugs, and carotid endarterectomy.3 About 30–40% of patients with ischaemic stroke have had an earlier transient ischaemic attack (TIA) or minor stroke.4 Recent studies suggest that, after a TIA, the 90-day risk of a subsequent stroke is as high as 10·5%, and almost half these strokes could occur within the first 2 days.5 In today’s Lancet, Peter Rothwell and colleagues present the results of the Early use of Existing Preventive Strategies for Stroke (EXPRESS) study.6 The investigators compared the usual UK practice of delayed assessment and treatment of patients with TIA or a minor stroke (phase 1) with a revised protocol of prompt assessment and introduction of therapy within 24 h of the event (phase 2). Their find-
ings show that rapid assessment and early treatment after a TIA results in a much lower 90-day risk of recurrent stroke (10·3% in phase 1 vs 2·1% in phase 2, p=0·0001). There are, however, a few issues that need attention. In the referrals to the study clinic, the number of strokes after a TIA (16 in phase 1 vs one in phase 2) or after minor stroke (17 vs five) was low, and the results therefore require cautious interpretation. Furthermore, the investigators used a short course of dual antithrombotics (clopidogrel and aspirin). In the MATCH trial,7 long-term dual therapy in patients with ischaemic stroke and TIA did not offer any additional benefits than did clopidogrel alone, but in fact increased the risk of life-threatening haemorrhage at 18 months. However, there is preliminary evidence that dual therapy might have a better risk-benefit ratio in selected patients8 or if started early after a TIA.9 In EXPRESS, the risk of haemorrhagic complications in patients on dual therapy was low in the 30-day follow-up.6 Additionally there was no attempt to separate patients with high-risk TIAs (age ≥60 years, motor symptoms, speech impairment, presence of vascular risk factors, and symptom duration of more than 60 min) in whom the risk of subsequent stroke is especially high.5 Demonstration of www.thelancet.com Vol 370 October 20, 2007
reduction of recurrent events in this high-risk group would have been of added interest. Whether high-risk TIAs were represented equally in both study groups is unclear. In another study (SOS-TIA)10 just published in The Lancet Neurology, the investigators used a similar approach of urgent assessment of patients with suspected TIA and introduction of early stroke-prevention treatment in patients with confirmed or possible TIA. Results showed a 3-month stroke rate of 1·24%, versus an expected rate of 5·96% derived from risk scores (ABCD²).11 Lastly, both EXPRESS and SOS-TIA investigators used a cocktail of stroke-prevention therapies with encouraging results, but which individual therapy was most effective in lowering early risk of stroke remains uncertain. For the use of stroke-prevention therapies (antiplatelet drugs, lipid-lowering agents, and antihypertensives) in this population of patients, we suggest clinicians follow current consensus statements.12 From the results of EXPRESS and SOS-TIA, it is evident that after a TIA or minor stroke the key to successful lowering of the risk of early stroke lies in prompt assessment and early treatment by stroke specialists in a dedicated clinic. These clinics could also have other advantages. In SOS-TIA, about 22% of patients with suspected TIA had a diagnosis other than TIA or minor stroke. These patients are not at high risk of early stroke. Because of the scarcity of available health resources, identification of these TIA mimics is essential because these patients do not need urgent neurovascular imaging and costly therapies that could also have potentially serious adverse effects. In EXPRESS, the time to carotid surgery in patients with symptomatic stenosis was shorter in the early intervention group than in the delayed assessment group. There is good evidence that in patients with TIA and minor stroke the benefit of carotid endarterectomy declines rapidly with delay in surgery beyond 2 weeks of symptom onset.13 What next? We believe that the results of EXPRESS— which show a substantial reduction in 90-day risk of recurrent strokes of more than 50%—are very important and should promote renewed attention to urgent care of patients with TIAs and minor strokes. We also believe that there is a pressing need to complete proposed larger randomised trials (eg, Fast Assessment of Stroke and Transient Ischemic Attack to Prevent Early Recurrence [FASTER] and Clopidogrel in Acute Stroke and Transient Ischemic Attack [CASTIA]). We hope that these trials www.thelancet.com Vol 370 October 20, 2007
Science Photo Library
Comment
False-colour angiogram of carotid artery stenosis
will confirm and complement the findings presented by Rothwell and colleagues, and revolutionise the way we manage cerebrovascular disease. Patients with TIAs and minor strokes are not disabled. If the risk of a disabling stroke can be substantially reduced in this population, we strongly recommend that patients should receive the same urgent attention as is provided for those with acute coronary syndromes. Naeem Dean, *Ashfaq Shuaib Royal Alexandra Hospital, Edmonton, AB, Canada (ND); and Department of Medicine, University of Alberta, Edmonton, AB, Canada T6B2B7 (AS) [email protected] We declare that we have no conflict of interest. 1 2
3 4
5 6
Mackay J, Mensah G. Atlas of heart disease and stroke. Geneva: World Health Organization, 2004. Heuschmann PU, Kolominsky-Rabas PL, Roether J, et al. Predictors of in-hospital mortality in patients with acute ischemic stroke treated with thrombolytic therapy. JAMA 2004; 292: 1831–38. Hackam DG, Spence JD. Combining multiple approaches for the secondary prevention of vascular events after stroke. Stroke 2007; 38: 1881–85. Rothwell PM, Buchan A, Johnston SC. Recent advances in management of transient ischaemic attacks and minor ischaemic stroke. Lancet Neurol 2006; 5: 323–31. Johnston SC, Gress DR, Browner WS, Sidnet S. Short term prognosis after emergency department diagnosis of TIA. JAMA 2000; 284: 2901–06. Rothwell PM, Giles MF, Chandratheva A, on behalf of the Early use of Existing Preventive Strategies for Stroke (EXPRESS) study. Effect of urgent treatment of transient ischaemic attack and minor stroke on early recurrent stroke (EXPRESS study): a prospective population-based sequential comparison. Lancet 2007; published online Oct 9. DOI:10.1016/S0140-6736(07)61448-2.
1399
Comment
7
8
9
Diener HC, Bogousslavsky J, Brass LM, et al. Aspirin and clopidogrel compared with clopidogrel alone after recent ischaemic stroke or transient ischaemic attack in high risk patients (MATCH): randomised double-blind, placebo controlled trial. Lancet 2004; 364: 331–37. Markus HS, Droste DW, Kaps M, et al. Dual antiplatelets therapy with clopidogrel and aspirin in symptomatic carotid stenosis evaluated using Doppler embolic signal detection: the Clopidogrel and Aspirin for Reduction of Emboli in Symptomatic Carotid Stenosis (CARESS) trial. Circulation 2005; 111: 2233–40. Kennedy J, Ryckborst KJJ, Demchuk AM, on behalf of FASTER investigators. The Fast Assessment of Stroke and Transient ischemic attack to prevent Early Recurrence (FASTER) trial—results of the pilot phase. Cerebrovasc Dis 2007; 23 (suppl 2): 56.
10
11
12
13
Lavallée PC, Meseguer E, Abboud H, et al. A transient ischaemic attack clinic with round-the-clock access (SOS-TIA): feasibility and effects. Lancet Neurol 2007; published online Oct 9. DOI:10.1016/S1474-4422(07)70248-X. Johnston SC, Rothwell PM, Nguyen-Huynh MN, et al. Validation and refinement of scores to predict very early stroke risk after transient ischaemic attack. Lancet 2007; 369: 283–92. Sacco RL, Adams R, Albers G, et al. Guidelines for prevention of stroke in patients with ischaemic stroke or transient ischaemic attack: a statement for health care professionals from American Heart Association/American Stroke Association Council on Stroke. Stroke 2006; 37: 577–617. Rothwell PM, Eliasziw M, Gutnikov SA, et al. Sex difference in the effect of time from symptoms to surgery on benefit from carotid endarterectomy for transient ischaemic attack and nondisabling stroke. Stroke 2004; 35: 2855–61.
What next for the NHS? See Editorial page 1393
The provision of good-quality health care is the goal of all clinicians. So the focus of our interim report on the UK National Health Service (NHS), Our NHS, our future,1 had to be on improving the quality of care the people of England receive from their health service (panel). Patients, NHS staff, and the public identified four dimensions of good-quality care (fairness, responsiveness, safety, and effectiveness) and assessed the potential for improvement. Our final report will be released in June, 2008. Fairness is a great strength of NHS care. The Commonwealth Fund placed the UK first for equity in a comparison of six health-care systems.2 While 47 million US citizens do not have health insurance, the NHS is free at the point of need.3 The NHS might lead the way, but we can still improve. For instance, inequality in infant mortality has widened in recent years. In 2003–05, infant mortality was 18% higher in the routine and manual working classes than in the total population, whereas in 1997–99 it was 13% above average.4 At the same time, the areas with the greatest need have fewest doctors per head. So Oldham has half the number of primary clinicians compared with Northumberland.
Panel: Our NHS, our future • NHS should be focused on improvement of quality of care • In four dimensions of quality care—fairness, responsiveness, safety, and effectiveness—NHS is not currently performing as well as it could • Initial solutions include improving access to general practices, reducing health-care associated infections, and championing of innovation • Future proposals will mainly be developed locally with some national focus on overarching issues
1400
This imbalance needs to be addressed—as Bierman argues, equity needs to be central to how we measure performance, to how we assess the quality of care.5 If the NHS cannot rest on its laurels with regard to fairness, improving responsiveness is an even bigger challenge. No one would suggest that the NHS is a world leader in patient-centred, personalised, and convenient care. Yet the NHS could be if we listen to what people want. When we asked over a thousand people at events across England as part of the review, most wanted general practices to be open in the evenings or on Saturdays, or both. More than half the population want to die at home, but less than a fifth of deaths take place there.6 The NHS should respond to these desires when possible, so we are increasing the options available locally to encourage more flexible opening hours for general practices and end-of-life care will be one of the topics to get detailed consideration by clinicians in working groups across England. Some people may quibble that responsiveness is not a priority, but no one would dispute that goodquality care is safe care. Do no harm is a central tenet of clinicians and was identified as one of the Tavistock Principles for ethical health care.7 However, the current incidence of health-care associated infections means that sometimes we are harming the very patients we seek to cure. Although only 1% of Staphylococcus aureus infections in Denmark are meticillin-resistant, the proportion in the UK is 44%.8 The announcement in our interim report of bacteriological screening of elective and emergency admissions for meticillin-resistant S aureus infections should help to tackle health-care associated infections, but there also needs to be a local focus on cleanliness across the NHS. www.thelancet.com Vol 370 October 20, 2007
Thus follow-up trials of longer duration are required to confirm that the effects of pitrakinra are not just restricted to alterations in the kinetics of the late-phase response. Issues concerning efficacy in patients with more severe asthma, and the potential for genuine disease modification with longer-term treatment, especially in children, also remain to be addressed. These latest findings with pitrakinra are exciting and novel, and will breathe new life into the debate surrounding the role of the Th2 cytokine cascade in asthma pathogenesis and how best to design drugs to attenuate their effects.
2 3
4
5
6 7
8
9
*Patrick G Holt, Peter D Sly Telethon Institute for Child Health Research, Subiaco, WA 6008, Australia [email protected] We declare that we have no conflict of interest. 1
Asher MI, Montefort S, Bjorksten B, et al. Worldwide time trends in the prevalence of symptoms of asthma, allergic rhinoconjunctivitis, and eczema in childhood: ISAAC Phases One and Three repeat multicountry crosssectional surveys. Lancet 2006; 368: 733–43.
10 11
12
Busse WW, Lemanske RF. Asthma. N Engl J Med 2001; 344: 350–62. Johnston SL, Pattemore PK, Sanderson G, et al. The relationship between upper respiratory infections and hospital admissions for asthma: a time-trend analysis. Am J Respir Crit Care Med 1996; 154: 654–60. Kusel MMH, de Klerk NH, Kebadze T, et al. Early-life respiratory viral infections, atopic sensitization and risk of subsequent development of persistent asthma. J Allergy Clin Immunol 2007; 119: 1105–10. Murray CS, Poletti G, Kebadze T, et al. Study of modifiable risk factors for asthma exacerbations: virus infection and allergen exposure increase the risk of asthma hospital admissions in children. Thorax 2006; 61: 376–82. Bischoff SC. Role of mast cells in allergic and non-allergic immune responses: comparison of human and murine data. Nat Rev Immunol 2007; 7: 93–104. Wenzel S, Wilbraham D, Fuller R, Burmeister Getz E, Longphre M. Effect of an interleukin-4 variant on late phase response to allergen challenge in asthmatic patients: results of two phase 2a studies. Lancet 2007; 370: 1422–31. Ali FR, Oldfield WL, Higashi N, Larche M, Kay AB. Late asthmatic reactions induced by inhalation of allergen-derived T cell peptides. Am J Respir Crit Care Med 2004; 169: 20–26. Holgate S. The inflammation-repair cycle in asthma: the pivotal role of the airway epithelium. Clin Exp Allergy 1998; 28 (suppl 5): 97–103. Holt PG, Sly PD, Martinez FD, et al. Drug development strategies for asthma: in search of a new paradigm. Nat Immunol 2004; 5: 695–98. Hart PH, Bonder CS, Balogh J, Dickensheets HL, Donnelly RP, Finlay-Jones JJ. Differential responses of human monocytes and macrophages to IL-4 and IL-13. J Leukoc Biol 1999; 66: 575–78. O’Byrne PM, Inman MD, Adelroth E. Reassessing the Th2 cytokine basis of asthma. Trends Pharmacol Sci 2004; 25: 244–48.
Transient ischaemic attacks: unstable, treatable, neglected Published Online October 9, 2007 DOI:10.1016/S01406736(07)61449-4 See Articles page 1432 See Lancet Neurol 2007; 6: 953–60
1398
Stroke affects 15 million people worldwide every year, and is the leading cause of acquired disability.1 Unfortunately, despite ample evidence that thrombolytics improve outcome after an acute ischaemic stroke, very few patients receive this treatment.2 In view of these dismal statistics, high priority should be accorded to stroke prevention. Results from several randomised trials have shown that the risk of ischaemic stroke in high-risk individuals can be significantly reduced by strategies such as blood-pressure lowering, statin therapy, antithrombotic drugs, and carotid endarterectomy.3 About 30–40% of patients with ischaemic stroke have had an earlier transient ischaemic attack (TIA) or minor stroke.4 Recent studies suggest that, after a TIA, the 90-day risk of a subsequent stroke is as high as 10·5%, and almost half these strokes could occur within the first 2 days.5 In today’s Lancet, Peter Rothwell and colleagues present the results of the Early use of Existing Preventive Strategies for Stroke (EXPRESS) study.6 The investigators compared the usual UK practice of delayed assessment and treatment of patients with TIA or a minor stroke (phase 1) with a revised protocol of prompt assessment and introduction of therapy within 24 h of the event (phase 2). Their find-
ings show that rapid assessment and early treatment after a TIA results in a much lower 90-day risk of recurrent stroke (10·3% in phase 1 vs 2·1% in phase 2, p=0·0001). There are, however, a few issues that need attention. In the referrals to the study clinic, the number of strokes after a TIA (16 in phase 1 vs one in phase 2) or after minor stroke (17 vs five) was low, and the results therefore require cautious interpretation. Furthermore, the investigators used a short course of dual antithrombotics (clopidogrel and aspirin). In the MATCH trial,7 long-term dual therapy in patients with ischaemic stroke and TIA did not offer any additional benefits than did clopidogrel alone, but in fact increased the risk of life-threatening haemorrhage at 18 months. However, there is preliminary evidence that dual therapy might have a better risk-benefit ratio in selected patients8 or if started early after a TIA.9 In EXPRESS, the risk of haemorrhagic complications in patients on dual therapy was low in the 30-day follow-up.6 Additionally there was no attempt to separate patients with high-risk TIAs (age ≥60 years, motor symptoms, speech impairment, presence of vascular risk factors, and symptom duration of more than 60 min) in whom the risk of subsequent stroke is especially high.5 Demonstration of www.thelancet.com Vol 370 October 20, 2007
reduction of recurrent events in this high-risk group would have been of added interest. Whether high-risk TIAs were represented equally in both study groups is unclear. In another study (SOS-TIA)10 just published in The Lancet Neurology, the investigators used a similar approach of urgent assessment of patients with suspected TIA and introduction of early stroke-prevention treatment in patients with confirmed or possible TIA. Results showed a 3-month stroke rate of 1·24%, versus an expected rate of 5·96% derived from risk scores (ABCD²).11 Lastly, both EXPRESS and SOS-TIA investigators used a cocktail of stroke-prevention therapies with encouraging results, but which individual therapy was most effective in lowering early risk of stroke remains uncertain. For the use of stroke-prevention therapies (antiplatelet drugs, lipid-lowering agents, and antihypertensives) in this population of patients, we suggest clinicians follow current consensus statements.12 From the results of EXPRESS and SOS-TIA, it is evident that after a TIA or minor stroke the key to successful lowering of the risk of early stroke lies in prompt assessment and early treatment by stroke specialists in a dedicated clinic. These clinics could also have other advantages. In SOS-TIA, about 22% of patients with suspected TIA had a diagnosis other than TIA or minor stroke. These patients are not at high risk of early stroke. Because of the scarcity of available health resources, identification of these TIA mimics is essential because these patients do not need urgent neurovascular imaging and costly therapies that could also have potentially serious adverse effects. In EXPRESS, the time to carotid surgery in patients with symptomatic stenosis was shorter in the early intervention group than in the delayed assessment group. There is good evidence that in patients with TIA and minor stroke the benefit of carotid endarterectomy declines rapidly with delay in surgery beyond 2 weeks of symptom onset.13 What next? We believe that the results of EXPRESS— which show a substantial reduction in 90-day risk of recurrent strokes of more than 50%—are very important and should promote renewed attention to urgent care of patients with TIAs and minor strokes. We also believe that there is a pressing need to complete proposed larger randomised trials (eg, Fast Assessment of Stroke and Transient Ischemic Attack to Prevent Early Recurrence [FASTER] and Clopidogrel in Acute Stroke and Transient Ischemic Attack [CASTIA]). We hope that these trials www.thelancet.com Vol 370 October 20, 2007
Science Photo Library
Comment
False-colour angiogram of carotid artery stenosis
will confirm and complement the findings presented by Rothwell and colleagues, and revolutionise the way we manage cerebrovascular disease. Patients with TIAs and minor strokes are not disabled. If the risk of a disabling stroke can be substantially reduced in this population, we strongly recommend that patients should receive the same urgent attention as is provided for those with acute coronary syndromes. Naeem Dean, *Ashfaq Shuaib Royal Alexandra Hospital, Edmonton, AB, Canada (ND); and Department of Medicine, University of Alberta, Edmonton, AB, Canada T6B2B7 (AS) [email protected] We declare that we have no conflict of interest. 1 2
3 4
5 6
Mackay J, Mensah G. Atlas of heart disease and stroke. Geneva: World Health Organization, 2004. Heuschmann PU, Kolominsky-Rabas PL, Roether J, et al. Predictors of in-hospital mortality in patients with acute ischemic stroke treated with thrombolytic therapy. JAMA 2004; 292: 1831–38. Hackam DG, Spence JD. Combining multiple approaches for the secondary prevention of vascular events after stroke. Stroke 2007; 38: 1881–85. Rothwell PM, Buchan A, Johnston SC. Recent advances in management of transient ischaemic attacks and minor ischaemic stroke. Lancet Neurol 2006; 5: 323–31. Johnston SC, Gress DR, Browner WS, Sidnet S. Short term prognosis after emergency department diagnosis of TIA. JAMA 2000; 284: 2901–06. Rothwell PM, Giles MF, Chandratheva A, on behalf of the Early use of Existing Preventive Strategies for Stroke (EXPRESS) study. Effect of urgent treatment of transient ischaemic attack and minor stroke on early recurrent stroke (EXPRESS study): a prospective population-based sequential comparison. Lancet 2007; published online Oct 9. DOI:10.1016/S0140-6736(07)61448-2.
1399
Comment
7
8
9
Diener HC, Bogousslavsky J, Brass LM, et al. Aspirin and clopidogrel compared with clopidogrel alone after recent ischaemic stroke or transient ischaemic attack in high risk patients (MATCH): randomised double-blind, placebo controlled trial. Lancet 2004; 364: 331–37. Markus HS, Droste DW, Kaps M, et al. Dual antiplatelets therapy with clopidogrel and aspirin in symptomatic carotid stenosis evaluated using Doppler embolic signal detection: the Clopidogrel and Aspirin for Reduction of Emboli in Symptomatic Carotid Stenosis (CARESS) trial. Circulation 2005; 111: 2233–40. Kennedy J, Ryckborst KJJ, Demchuk AM, on behalf of FASTER investigators. The Fast Assessment of Stroke and Transient ischemic attack to prevent Early Recurrence (FASTER) trial—results of the pilot phase. Cerebrovasc Dis 2007; 23 (suppl 2): 56.
10
11
12
13
Lavallée PC, Meseguer E, Abboud H, et al. A transient ischaemic attack clinic with round-the-clock access (SOS-TIA): feasibility and effects. Lancet Neurol 2007; published online Oct 9. DOI:10.1016/S1474-4422(07)70248-X. Johnston SC, Rothwell PM, Nguyen-Huynh MN, et al. Validation and refinement of scores to predict very early stroke risk after transient ischaemic attack. Lancet 2007; 369: 283–92. Sacco RL, Adams R, Albers G, et al. Guidelines for prevention of stroke in patients with ischaemic stroke or transient ischaemic attack: a statement for health care professionals from American Heart Association/American Stroke Association Council on Stroke. Stroke 2006; 37: 577–617. Rothwell PM, Eliasziw M, Gutnikov SA, et al. Sex difference in the effect of time from symptoms to surgery on benefit from carotid endarterectomy for transient ischaemic attack and nondisabling stroke. Stroke 2004; 35: 2855–61.
What next for the NHS? See Editorial page 1393
The provision of good-quality health care is the goal of all clinicians. So the focus of our interim report on the UK National Health Service (NHS), Our NHS, our future,1 had to be on improving the quality of care the people of England receive from their health service (panel). Patients, NHS staff, and the public identified four dimensions of good-quality care (fairness, responsiveness, safety, and effectiveness) and assessed the potential for improvement. Our final report will be released in June, 2008. Fairness is a great strength of NHS care. The Commonwealth Fund placed the UK first for equity in a comparison of six health-care systems.2 While 47 million US citizens do not have health insurance, the NHS is free at the point of need.3 The NHS might lead the way, but we can still improve. For instance, inequality in infant mortality has widened in recent years. In 2003–05, infant mortality was 18% higher in the routine and manual working classes than in the total population, whereas in 1997–99 it was 13% above average.4 At the same time, the areas with the greatest need have fewest doctors per head. So Oldham has half the number of primary clinicians compared with Northumberland.
Panel: Our NHS, our future • NHS should be focused on improvement of quality of care • In four dimensions of quality care—fairness, responsiveness, safety, and effectiveness—NHS is not currently performing as well as it could • Initial solutions include improving access to general practices, reducing health-care associated infections, and championing of innovation • Future proposals will mainly be developed locally with some national focus on overarching issues
1400
This imbalance needs to be addressed—as Bierman argues, equity needs to be central to how we measure performance, to how we assess the quality of care.5 If the NHS cannot rest on its laurels with regard to fairness, improving responsiveness is an even bigger challenge. No one would suggest that the NHS is a world leader in patient-centred, personalised, and convenient care. Yet the NHS could be if we listen to what people want. When we asked over a thousand people at events across England as part of the review, most wanted general practices to be open in the evenings or on Saturdays, or both. More than half the population want to die at home, but less than a fifth of deaths take place there.6 The NHS should respond to these desires when possible, so we are increasing the options available locally to encourage more flexible opening hours for general practices and end-of-life care will be one of the topics to get detailed consideration by clinicians in working groups across England. Some people may quibble that responsiveness is not a priority, but no one would dispute that goodquality care is safe care. Do no harm is a central tenet of clinicians and was identified as one of the Tavistock Principles for ethical health care.7 However, the current incidence of health-care associated infections means that sometimes we are harming the very patients we seek to cure. Although only 1% of Staphylococcus aureus infections in Denmark are meticillin-resistant, the proportion in the UK is 44%.8 The announcement in our interim report of bacteriological screening of elective and emergency admissions for meticillin-resistant S aureus infections should help to tackle health-care associated infections, but there also needs to be a local focus on cleanliness across the NHS. www.thelancet.com Vol 370 October 20, 2007