The National Stroke Foundation’s recent rehabilitation services audit report confirms that only a small proportion of Australians receive evidence-based care.1 The gap between best evidence-based and actual care in many areas of stroke is staggering.

For example, only 44% of patients transferred to rehabilitation had been in a stroke unit. This mirrors the acute care services audit finding that many patients do not receive dedicated stroke unit care,2 despite overwhelming evidence of effectiveness.3 Only 7% of ischaemic stroke patients received thrombolysis treatment,2 yet for every 100 patients who receive it, there are up to 10 extra independent survivors.4 About 20% of stroke patients are discharged from hospital without medication (to lower cholesterol and blood pressure) to prevent recurrent stroke;2 however, for every 100 people treated with blood-pressure-lowering medication, three people are saved from death and/or disability from recurrent stroke and cardiovascular events.3 Over one-third of patients are put at risk of complications because their swallowing ability is not assessed before being given food, drink or oral medications.2 Despite the contribution of lifestyle risk factors to secondary stroke risk, almost half (47%) of patients do not receive lifestyle risk factor modification advice.1 Only 37% of patients are referred for community rehabilitation,1 although for every 100 people who receive it, six are saved from death and/or disability.3 For virtually every important quality indicator, outcomes are better if patients had been in a stroke unit, or in a hospital treating over 100 stroke patients per year.

Stroke has been a designated National Health Priority Area disease since 1996; yet federal budget funding has never been provided for the implementation of a comprehensive stroke strategy. The reasons for this are not clear. The broader disease category to which stroke belongs (cardiovascular disease) has received only a tiny proportion of program funding ($8.6 million) compared with other conditions ($2.5 billion for cancer, $1.6 billion for diabetes and $1.4 billion for mental health).5 This is despite the fact that that cardiovascular disease is Australia’s biggest killer (with ischaemic heart disease responsible for 15% of all deaths, and cerebrovascular disease for 8%6), and accounts for 18% of the overall burden of disease.7

Within cardiovascular disease, there is a large funding disparity between heart disease and stroke, with stroke losing out by far. The reasons for this are also unclear. Perhaps it is because stroke is wrongly assumed by many to only be a disease of the elderly, perhaps because lobbying and marketing attempts for heart disease have been more sustained and effective, or perhaps because the difference between the two is lost on most — many of the public think that stroke and heart attack are the same thing.

Mortality estimates for stroke grossly underestimate the burden of disease caused by the major acquired disability in many survivors.8 Stroke impairments can dramatically impact on function and reduce the psychosocial quality of life of people with stroke and their carers. Effects can last for decades, with an estimated yearly cost burden for stroke in Australia of $2 billion.9

We know about the evidence–practice gaps because current practice data are available from the National Stroke Foundation’s National Stroke Audit program (which includes an organisational audit of over 300 acute and rehabilitation hospitals and a clinical audit of the stroke care provided to over 14 000 patients in the past 4 years). We also know what care Australian stroke patients should be receiving — in acute care, during rehabilitation and after discharge. The Clinical guidelines for stroke management 2010 endorsed by the National Health and Medical Research Council clearly highlight effective interventions that reduce death and disability, and improve quality of life.3 However, the problems with stroke care are not limited to the care that commences on hospital arrival. Also staggering is the missed opportunity to prevent strokes in people with a transient ischaemic attack or minor stroke who do not present to hospital, where early intervention (within a week) can reduce the risk of an early recurrent stroke by 80%.10 Yet a coordinated rapid care model does not exist in Australia.

These evidence–practice gaps, and the variability in the quality of stroke care in Australia, are unacceptable and demonstrate fundamental deficiencies in the Australian health care system. These gaps are resulting in increased costs and greater burden of disability for individuals, their families, the health care system and society. Cost-effective changes in stroke care have been implemented in other countries with resultant reductions in morbidity and mortality.11 What will it take for Australia to have a funded national stroke care improvement strategy to ensure all Australians are able to access evidence-based stroke care? After all, we already have the solutions, what we need is government commitment and the relevant funding.