Pathways to enhancing the quality of stroke care through national data monitoring systems for hospitals

In reply: We thank Nichols and colleagues for highlighting the heterogeneity of conditions underlying acute stroke, and the associated variability in risk factors, prognosis and management. The management of haemorrhagic forms of stroke, namely spontaneous intracerebral haemorrhage (ICH) and subarachnoid haemorrhage (SAH), has traditionally been focused on neurosurgical intervention to decompress the mass effect of the haematoma, relieve intracranial pressure, and reduce the risk of re-bleeding. The Australian Stroke Clinical Registry (AuSCR) and the National Stroke Foundation national audit include cases of ICH since care quality and outcomes may differ for patients with ICH compared with those with ischaemic stroke.1 Since few ICH cases require neurosurgery,2 evidence for better medical management of ICH is needed (eg, early intensive blood pressure lowering treatment).3 Therefore, ICH must continue to be part of national monitoring of stroke care. Current national monitoring excludes cases of SAH since it remains firmly a “neurosurgical” condition. A separate national SAH registry to monitor process of care may be warranted, given that epidemiological data show stable rates and outcomes for the disease over recent decades.4,5 Stroke is a complex disease for which continued efforts to monitor and improve care provide the best opportunity to improve outcomes.