Measurement of quality of stroke care with national electronic health records: a cohort during and after the COVID-19 pandemic

ObjectivesTo evaluate the value of linked electronic health records (EHRs) for measuring stroke care quality in England before and after the COVID-19 pandemic, focusing on metrics not routinely captured: stroke incidence, dispensing of secondary prevention medications, and a proxy of disability--time spent at home after stroke ("home-time"). DesignProspective cohort study using national linked datasets. SettingEngland-wide health data linkage including the Sentinel Stroke National Audit Programme (SSNAP), primary and secondary care, dispensed medications, and mortality records, accessed via NHS Englands Secure Data Environment. Participants425,675 adults with a first stroke between 1 January 2020 and 31 December 2023; data were available for 304,210 in primary care, 279,825 in hospital admissions, 220,470 in SSNAP, and 59,465 in death records. Main outcome measuresAnnual stroke incidence; first-year medication dispensing rates for antiplatelets, anticoagulants, antihypertensives, and lipid-lowering agents; and home-time at 180 days post-stroke. ResultsStroke ascertainment was highest when combining all sources, with 10.8% of non-fatal ischaemic strokes recorded exclusively in primary care and 19.4% of fatal strokes identified solely through death records. Standardised annual stroke incidence rose from 227.6 [95% CI 226.1, 229.0] to 244.8 [95% CI 243.4, 246.3] per 100,000 over the study period including the COVID-19 pandemic. During the COVID-19 lockdown, non-fatal stroke recordings decreased while stroke-related deaths rose, indicating that recording quality was sensitive to shifts in healthcare-seeking behavior during the pandemic. Among people with ischaemic stroke, 89.1% received an antiplatelet or anticoagulant, 44.5% an antihypertensive, and 80.5% a lipid-lowering therapy. For haemorrhagic stroke, these proportions were, for anticoagulants 13.5%, antiplatelets 13.2%, antihypertensives 46.6%, and lipid lowering 41.1%. Medication dispensing for stroke prevention declined with increasing age and comorbidity but varied little by ethnicity, region, or pandemic period. Mean home-time within 180 days of stroke was 166.6 [95% CI 166.4, 166] days, decreasing with greater age (141.4 days for 90 years or older [95% CI 140.7, 142.1]), deprivation (166.4 [95% CI 166.1, 166.6] for most deprived quintile), and stroke severity (137.4 days for NIHSS score on arrival over 22 [95% CI 135.8, 139.1]), and increasing with years from the COVID-19 pandemic 2023 169.3 days [95% CI 169.0, 169.5] vs. 2020 164.4 days [95% CI 164.4 [164.1, 164.7]). ConclusionsStandardised stroke incidence increased significantly over the study period, highlighting a growing public health burden that persisted despite disruptions due to the pandemic. While secondary prevention coverage for antiplatelets and lipids was high, the suboptimal dispensing of antihypertensives, particularly in older and comorbid populations, signals a critical target for clinical optimisation. Home-time represents a sensitive, person-centered outcome that exposes disparities linked to socioeconomic deprivation and clinical severity that can be used to enhance routine stroke audits. These findings justify the expansion of linked EHR infrastructure and the modernisation of governance frameworks to enable the longitudinal evaluation of care quality beyond the COVID-19 era. Strengths and Limitations of this StudyO_LIThis study utilises a whole-population linkage of national audit (SSNAP), primary care (GDPPR), hospital (HES), and mortality (ONS) records, which maximises case ascertainment compared to routine audits. C_LIO_LIThe use of NHS Business Services Authority (NHSBSA) medication dispensing data potentially provides a more accurate proxy for medication adherence than primary care prescribing records alone. C_LIO_LIThe inclusion of primary care records enables capture of patients not admitted to hospital or managed in ambulatory settings, while linkage with hospital records allows longitudinal measurement of home-time following stroke. C_LIO_LIPotential misclassification of stroke subtypes and first-ever versus recurrent stroke events remains a risk due to the varying PPV of ICD-10 and SNOMED-CT concepts in electronic health records from different healthcare settings. C_LIO_LIThe analysis is unable to account for medications prescribed in the private sector or clinical factors not captured in routine electronic health records, such as specific reasons for contraindications, prior tolerance, or eligibility to secondary prevention. C_LI