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

Objectives: To 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”). Design Prospective cohort study using national linked datasets. Setting England-wide health data linkage including the Sentinel Stroke National Audit Programme (SSNAP), primary and secondary care, dispensed medications, and mortality records, accessed via NHS England’s Secure Data Environment. Participants 425,675 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 measures Annual stroke incidence; first-year medication dispensing rates for antiplatelets, anticoagulants, antihypertensives, and lipid-lowering agents (with a one-month washout period); and home-time at 180 days post-stroke. Results Stroke 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 behaviour 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]). Conclusions Standardised stroke incidence increased significantly over the study period, highlighting a growing public health burden that persisted despite disruptions due to the pandemic although it should be noted that variation in case ascertainment and stroke coding practices was observed. While secondary prevention coverage for antiplatelets and lipids was high, lower rates of dispensing of antihypertensives, particularly in older and comorbid populations, potentially signal a critical target for clinical optimisation. Home-time represents a sensitive, person-centred 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.