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Purpose: It is important to understand how consumers (person with stroke/family member/carer) and health workers perceive stroke care services., Materials and Methods: Consumers and health workers from across New Zealand were surveyed on perceptions of stroke care, access barriers, and views on service centralisation. Quantitative data were summarised using descriptive statistics whilst thematic analysis was used for free-text answers., Results: Of 149 consumers and 79 health workers invited to complete a survey, 53 consumers (36.5%) and 41 health workers (51.8%) responded. Overall, 40/46 (87%) consumers rated stroke care as 'good/excellent' compared to 24/41 (58.6%) health workers. Approximately 72% of consumers preferred to transfer to a specialised hospital. We identified three major themes related to perceptions of stroke care: 1) 'variability in care by stage of treatment'; 2) 'impact of communication by health workers on care experience'; and 3) 'inadequate post-acute services for younger patients'. Four access barrier themes were identified: 1) 'geographic inequities'; 2) 'knowing what is available'; 3) 'knowledge about stroke and available services'; and 4) 'healthcare system factors'., Conclusions: Perceptions of stroke care differed between consumers and health workers, highlighting the importance of involving both in service co-design. Improving communication, post-hospital follow-up, and geographic equity are key areas for improvement.Implications for rehabilitationProvision of detailed information on stroke recovery and available services in the community is recommended.Improvements in the delivery of post-hospital stroke care are required to optimise stroke care, with options including routine phone follow up appointments and wider development of early supported discharge services.Stroke rehabilitation services should continue to be delivered 'close to home' to allow community integration.Telehealth is a likely enabler to allow specialist urban clinicians to support non-urban clinicians, as well as increasing the availability and access of community rehabilitation.

Background: Ethnic differences in post-stroke outcomes have been largely attributed to biological and socioeconomic characteristics resulting in differential risk factor profiles and stroke subtypes, but evidence is mixed., Aims: This study assessed ethnic differences in stroke outcome and service access in New Zealand (NZ) and explored underlying causes in addition to traditional risk factors., Methods: This national cohort study used routinely collected health and social data to compare post-stroke outcomes between NZ Europeans, Māori, Pacific Peoples, and Asians, adjusting for differences in baseline characteristics, socioeconomic deprivation, and stroke characteristics. First and principal stroke public hospital admissions during November 2017 to October 2018 were included (N = 6879). Post-stroke unfavorable outcome was defined as being dead, changing residence, or becoming unemployed., Results: In total, 5394 NZ Europeans, 762 Māori, 369 Pacific Peoples, and 354 Asians experienced a stroke during the study period. Median age was 65 years for Māori and Pacific Peoples, and 71 and 79 years for Asians and NZ Europeans, respectively. Compared with NZ Europeans, Māori were more likely to have an unfavorable outcome at all three time-points (odds ratio (OR) = 1.6 (95% confidence interval (CI) = 1.3-1.9); 1.4 (1.2-1.7); 1.4 (1.2-1.7), respectively). Māori had increased odds of death at all time-points (1.7 (1.3-2.1); 1.5 (1.2-1.9); 1.7 (1.3-2.1)), change in residence at 3 and 6 months (1.6 (1.3-2.1); 1.3 (1.1-1.7)), and unemployment at 6 and 12 months (1.5 (1.1-2.1); 1.5 (1.1-2.1)). There was evidence of differences in post-stroke secondary prevention medication by ethnicity., Conclusion: We found ethnic disparities in care and outcomes following stroke which were independent of traditional risk factors, suggesting they may be attributable to stroke service delivery rather than patient factors.

Background: Although geographical differences in treatment and outcomes after stroke have been described, we lack evidence on differences in the costs of treatment between urban and nonurban regions. Additionally, it is unclear whether greater costs in one setting are justified given the outcomes achieved. We aimed to compare costs and quality-adjusted life years in people with stroke admitted to urban and nonurban hospitals in New Zealand., Methods: Observational study of patients with stroke admitted to the 28 New Zealand acute stroke hospitals (10 in urban areas) recruited between May and October 2018. Data were collected up to 12 months poststroke including treatments in hospital, inpatient rehabilitation, other health service utilization, aged residential care, productivity, and health-related quality of life. Costs in New Zealand dollars were estimated from a societal perspective and assigned to the initial hospital that patients presented to. Unit prices for 2018 were obtained from government and hospital sources. Multivariable regression analyses were conducted when assessing differences between groups., Results: Of 1510 patients (median age 78 years, 48% female), 607 presented to nonurban and 903 to urban hospitals. Mean hospital costs were greater in urban than nonurban hospitals ($13 191 versus $11 635, P =0.002), as were total costs to 12 months ($22 381 versus $17 217, P <0.001) and quality-adjusted life years to 12 months (0.54 versus 0.46, P <0.001). Differences in costs and quality-adjusted life years remained between groups after adjustment. Depending on the covariates included, costs per additional quality-adjusted life year in the urban hospitals compared to the nonurban hospitals ranged from $65 038 (unadjusted) to $136 125 (covariates: age, sex, prestroke disability, stroke type, severity, and ethnicity)., Conclusions: Better outcomes following initial presentation to urban hospitals were associated with greater costs compared to nonurban hospitals. These findings may inform greater targeted expenditure in some nonurban hospitals to improve access to treatment and optimize outcomes.

Background and Objectives: International evidence shows that patients treated at nonurban hospitals experience poorer access to key stroke interventions. Evidence for whether this results in poorer outcomes is conflicting and generally based on administrative or voluntary registry data. The aim of this study was to use prospective high-quality comprehensive nationwide patient-level data to investigate the association between hospital geography and outcomes of patients with stroke and access to best-practice stroke care in New Zealand., Methods: This is a prospective, multicenter, nationally representative observational study involving all 28 New Zealand acute stroke hospitals (18 nonurban) and affiliated rehabilitation and community services. Consecutive adults admitted to the hospital with acute stroke between May 1 and October 31, 2018, were captured. Outcomes included functional outcome (modified Rankin Scale [mRS] score shift analysis), functional independence (mRS score 0-2), quality of life (EuroQol 5-dimension, 3-level health-related quality of life questionnaire), stroke/vascular events, and death at 3, 6, and 12 months and proportion accessing thrombolysis, thrombectomy, stroke units, key investigations, secondary prevention, and inpatient/community rehabilitation. Results were adjusted for age, sex, ethnicity, stroke severity/type, comorbid conditions, baseline function, and differences in baseline characteristics., Results: Overall, 2,379 patients were eligible (mean [SD] age 75 [13.7] years; 51.2% male; 1,430 urban, 949 nonurban). Patients treated at nonurban hospitals were more likely to score in a higher mRS score category (greater disability) at 3 (adjusted odds ratio [aOR] 1.28, 95% CI 1.07-1.53), 6 (aOR 1.33, 95% CI 1.07-1.65), and 12 (aOR 1.31, 95% CI 1.06-1.62) months and were more likely to have died (aOR 1.57, 95% CI 1.17-2.12) or experienced recurrent stroke and vascular events at 12 months (aOR 1.94, 95% CI 1.14-3.29 and aOR 1.65, 95% CI 1.09-2.52). Fewer nonurban patients received recommended stroke interventions, including endovascular thrombectomy (aOR 0.25, 95% CI 0.13-0.49), acute stroke unit care (aOR 0.60, 95% CI 0.49-0.73), antiplatelet prescriptions (aOR 0.72, 95% CI 0.58-0.88), ≥60 minutes of daily physical therapy (aOR 0.55, 95% CI 0.40-0.77), and community rehabilitation (aOR 0.69, 95% CI 0.56-0.84)., Discussion: Patients managed at nonurban hospitals experience poorer stroke outcomes and reduced access to key stroke interventions across the entire care continuum. Efforts to improve access to high quality stroke care in nonurban hospitals should be a priority., (Copyright © 2022 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Neurology.)

Aim: The aim of this study was to explore the perspectives of people with stroke and their whānau on barriers to accessing best practice care across Aotearoa, and to brainstorm potential solutions., Method: We conducted ten focus groups nationwide and completed a thematic analysis., Results: Analysis of the data collected from the focus groups identified five themes: (1) inconsistencies in stroke care; (2) importance of effective communication; (3) the role of whānau support; (4) the need for more person rather than stroke centred processes; and (5) experienced inequities. Participants also identified potential solutions., Conclusion: Key recommendations include the need for improved access to stroke unit care for rural residents, improved post-discharge support and care coordination involving the whānau, improved communication across the patient journey, and a concerted effort to improve culturally safe care. Next step is to implement and monitor these recommendations., Competing Interests: The study was funded by the Health Research Council of New Zealand (HRC 17/037). Some of the authors receive other grant funding, but none that relates to this study, and report no competing interests.

Background: Stroke systems of care differ between larger urban and smaller rural settings and it is unclear to what extent this may impact on patient outcomes. Ethnicity influences stroke risk factors and care delivery as well as patient outcomes in nonstroke settings. Little is known about the impact of ethnicity on poststroke care, especially in Māori and Pacific populations., Objective: Our goal is to describe the protocol for the Reducing Ethnic and Geographic Inequities to Optimise New Zealand Stroke Care (REGIONS Care) study., Methods: This large, nationwide observational study assesses the impact of rurality and ethnicity on best practice stroke care access and outcomes involving all 28 New Zealand hospitals caring for stroke patients, by capturing every stroke patient admitted to hospital during the 2017-2018 study period. In addition, it explores current access barriers through consumer focus groups and consumer, carer, clinician, manager, and policy-maker surveys. It also assesses the economic impact of care provided at different types of hospitals and to patients of different ethnicities and explores the cost-efficacy of individual interventions and care bundles. Finally, it compares manual data collection to routine health administrative data and explores the feasibility of developing outcome models using only administrative data and the cost-efficacy of using additional manually collected registry data. Regarding sample size estimates, in Part 1, Study A, 2400 participants are needed to identify a 10% difference between up to four geographic subgroups at 90% power with an α value of .05 and 10% to 20% loss to follow-up. In Part 1, Study B, a sample of 7645 participants was expected to include an estimated 850 Māori and 419 Pacific patients and to provide over 90% and over 80% power, respectively. Regarding Part 2, 50% of the patient or carer surveys, 40 provider surveys, and 10 focus groups were needed to achieve saturation of themes. The main outcome is the modified Rankin Scale (mRS) score at 3 months. Secondary outcomes include mRS scores; EQ-5D-3L (5-dimension, 3-level EuroQol questionnaire) scores; stroke recurrence; vascular events; death; readmission at 3, 6, and 12 months; cost of care; and themes around access barriers., Results: The study is underway, with national and institutional ethics approvals in place. A total of 2379 patients have been recruited for Part 1, Study A; 6837 patients have been recruited for Part 1, Study B; 10 focus groups have been conducted and 70 surveys have been completed in Part 2. Data collection has essentially been completed, including follow-up assessment; however, primary and secondary analyses, data linkage, data validation, and health economics analysis are still underway., Conclusions: The methods of this study may provide the basis for future epidemiological studies that will guide care improvements in other countries and populations., International Registered Report Identifier (irrid): DERR1-10.2196/25374., (©Annemarei Ranta, Stephanie Thompson, Matire Louise Ngarongoa Harwood, Dominique Ann-Michele Cadilhac, Peter Alan Barber, Alan John Davis, John Henry Gommans, John Newton Fink, Harry Karel McNaughton, Hayley Denison, Marine Corbin, Valery Feigin, Virginia Abernethy, William Levack, Jeroen Douwes, Jacqueline Girvan, Andrew Wilson. Originally published in JMIR Research Protocols (http://www.researchprotocols.org), 12.01.2021.)

Aim: To describe stroke services currently offered in New Zealand hospitals and compare service provision in urban and non-urban settings., Method: An online questionnaire was sent to stroke lead clinicians at all New Zealand District Health Boards (DHBs). Questions covered number and location of stroke inpatients, stroke service configuration, use of guidelines/protocols, staffing mix, access to staff education, and culture appropriate care., Results: There were responses from all 20 DHBs. Differences between urban and non-urban hospitals included: access to acute stroke units (55.6% non-urban vs 100% urban; p=0.013), stroke clinical nurse specialists (50% vs 90%; p=0.034), stroke clot retrieval (38.9% vs 80%; p=0.037) and Pacific support services (55.6% vs 100%; p=0.030). There were also differences in carer training (66.7% non-urban vs 100% urban; p=0.039) and goal-specific rehabilitation plans in the community (61.1% vs 100%; p=0.023). Access to TIA services, stroke rehabilitation units, early supported discharge, psychologists, continuing staff education, and culturally responsive stroke care were suboptimal irrespective of hospital location., Conclusion: Hospital location is associated with differences in stroke services provision across New Zealand and ongoing work is required to optimise consistent access to best practice care. These results, in conjunction with an ongoing (REGIONS Care) study, will be used to determine whether this affects patient outcomes., Competing Interests: Prof. Cadilhac is the Data Custodian for the Australian Stroke Clinical Registry.

Background: Rural communities throughout the United States are eager to recruit and retain family physicians. This study examined factors that may contribute to a medical student's decision to consider rural family medicine practice using the Community Apgar Questionnaire (CAQ)., Methods: Third- and fourth-year medical students from 10 medical schools responded to a survey of 62 identified factors deemed to be present when assessing the strengths and challenges of recruiting family physicians to rural communities. Participants could also respond to six demographic questions. Factors were ranked based on importance to respondents and were compared using demographic information., Results: A total of 282 MS-3 and MS-4 students interested in family medicine from 10 US medical schools completed the survey (response rate 19.5%). Forty percent of participants anticipate practicing in a rural setting, followed by 31% for suburban and 29% for urban. The top three factors participants considered when anticipating a rural practice setting were spousal satisfaction, call frequency, and competition/collegiality. Additional differences were found across CAQ factors by future practice setting, gender, and location where the student was raised., Conclusions: Medical schools, rural preceptors, and rural communities may wish to consider highly rated factors found in the CAQ in the effort to increase the recruitment of family physicians interested in rural practice.

Background: Evidence is conflicting as to whether the bioavailability of food folates is influenced by the extent of their conjugation., Objective: The objective was to compare the bioavailability of 3 representative food folate sources with various degrees of glutamylation-ie, egg yolk, spinach, and yeast, whose polyglutamyl folate content measured 0%, 50%, and 100%, respectively., Design: In a randomized crossover trial, 13 male subjects, after a prestudy folate saturation procedure, received in random order either placebo or 500 mug total folate, which was provided as concentrated freeze-dried extract removed from the normal food matrix of egg yolk, spinach, or yeast. Blood samples (n = 10) were collected before and up to 10 h after treatments, which were administered at weekly intervals., Results: A significant increase from baseline plasma folate concentrations was observed by 0.5 h after treatment with egg yolk folate or spinach folate and by 1 h after treatment with yeast folate, and the concentrations remained significantly elevated for 3-5 h; no plasma folate response was observed after placebo treatment. The overall responses, calculated as plasma folate area under the curve (AUC) for egg yolk, spinach, and yeast folate, were 122.6 +/- 23.6, 136.2 +/- 21.4, and 102.5 +/- 21.1 nmol . h/L, respectively. No significant differences in AUC were seen between monoglutamyl (egg yolk) folate and either of the polyglutamate-containing folates examined., Conclusion: These results suggest that the ratio of monoglutamate to polyglutamate in natural folates is not a factor that limits the extent of intestinal absorption of food folate.

The psychiatric and ambulatory course of 21 older chronic schizophrenic patients who sustained hip fractures was studied prospectively, and their walking ability after the fractures was compared to that of 25 nonpsychiatric hip fracture patients. Although the schizophrenic patients were younger when the hip fractures occurred, their recuperation and ambulatory outcome were significantly worse. The psychiatric course was assessed with a standardized rating scale that was administered 6 months and 1 year after the fractures and compared to similar ratings done before the fractures. Significant mental deterioration was found at 6 months after the fractures, with no further changes later.