Adherence to antithrombotic therapy guidelines and atrial fibrillation in a rural hospital: a clinical audit.

INTRODUCTION: Atrial fibrillation (AF) is a major risk factor for ischaemic stroke and a common presentation in general practice. Scoring systems to guide antithrombotic treatment have been available since 1996, with the CHA2DS2-VASC in current use; however, little is known about adherence to guidelines in rural general practice. The purpose of this study was to determine whether patients in a rural population and with documented history of AF are prescribed antithrombotic treatment according to recognised guidelines. METHODS: A retrospective cohort study of inpatients was performed at a rural country hospital in South Australia. All patients with an ICD-10 CM code at the time of discharge were selected from June 2008 to July 2013. This included both newly diagnosed AF as well cases with existing history of AF. RESULTS: Among the 59 patients studied, 77% of patients received appropriate anticoagulation according to CHADS2 score and 83% according to CHA2DS2-VASC score. CONCLUSIONS: This study confirms that the guidelines are routinely followed in clinical practice in this rural population.

Transient Ischaemic Attack Rarely Precedes Stroke in a Cohort with Low Proportions of Large Artery Atherosclerosis: A Population-Based Study.

BACKGROUND: Ischaemic stroke is reportedly preceded by transient ischaemic attack (TIA) in 15-30% of all cases. The risk of stroke following TIA is highest in the presence of unstable atherosclerotic plaques in large arteries. The recent population-based Adelaide Stroke Incidence Study describes a population with a low proportion (16%) of stroke attributable to large artery atherosclerosis (LAA). We hypothesized that this population-based ischaemic stroke cohort would have a lower rate of preceding TIA than previously reported. METHODS: This paper is a prospective ascertainment of all suspected TIAs and strokes in a 12-month period from 2009 to 2010. Ischaemic stroke pathogenesis was classified by the TOAST criteria. Details of preceding TIA events were scrutinised. RESULTS: In this 12-month period, 318 stroke events in 301 individuals were recorded. Of the total 258 ischaemic strokes, 16% (95% confidence interval [CI] 12-22) were from LAA. Of 258 ischaemic stroke patients, only 11 (4%; 95% CI 2-7) reported symptoms in the preceding 90 days consistent with TIA. Nine (82%) sought medical attention. The median ABCD2 score in this group was 4.5 (IQR: 3-7), and the median time of event prior to stroke was 20 days (IQR: 4-32). CONCLUSION: In our population-based cohort, rates of TIA preceding ischaemic stroke were much lower than previously reported, probably reflective of effective secondary prevention (active TIA clinics) and primary prevention (limiting LAA prevalence). In our population, further enhancements in TIA care will be of limited yield.

Excess stroke incidence in young Aboriginal people in South Australia: Pooled results from two population-based studies.

Background Retrospective data indicate increased stroke incidence in Aboriginal/Torres Strait Islander (Indigenous) Australians, possibly with poorer outcomes. We present the first prospective population-based stroke incidence study in Indigenous Australians. Methods We pooled data from ASCEND and SEARCH, two prospective "ideal" South Australian stroke incidence studies, ASCEND conducted in urban Northwestern Adelaide (2009-2010) and SEARCH in five South Australian rural centers (2009-2011). We calculated age-standardized incidence for Aboriginal and non-Aboriginal people. Results The study population comprised 261,403 inhabitants. Among 432 first-ever strokes, 13 were in Aboriginal people (median age 51 vs. 78 years for non-Aboriginal people, p < 0.001). Age-standardized stroke incidence per 100,000 in Aboriginal patients (116, 95% CI: 95-137) was nearly two-fold that of non-Aboriginal patients (67, 95% CI: 51-84). Age-stratified excess incidence in Aboriginal people was restricted to those aged < 55 years (incidence rate ratio (IRR) 3.5, 95% CI: 2-7), particularly for intracerebral hemorrhage (IRR: 16, 95% CI: 4-61). Conclusion The excess stroke incidence in Aboriginal South Australians appears substantial, especially in those aged <55 years. Further work is required to delineate and address disparities.

Am I getting an accurate picture: a tool to assess clinical handover in remote settings?

BACKGROUND: Good clinical handover is critical to safe medical care. Little research has investigated handover in rural settings. In a remote setting where nurses and medical students give telephone handover to an aeromedical retrieval service, we developed a tool by which the receiving clinician might assess the handover; and investigated factors impacting on the reliability and validity of that assessment. METHODS: Researchers consulted with clinicians to develop an assessment tool, based on the ISBAR handover framework, combining validity evidence and the existing literature. The tool was applied 'live' by receiving clinicians and from recorded handovers by academic assessors. The tool's performance was analysed using generalisability theory. Receiving clinicians and assessors provided feedback. RESULTS: Reliability for assessing a call was good (G = 0.73 with 4 assessments). The scale had a single factor structure with good internal consistency (Cronbach's alpha = 0.8). The group mean for the global score for nurses and students was 2.30 (SD 0.85) out of a maximum 3.0, with no difference between these sub-groups. CONCLUSIONS: We have developed and evaluated a tool to assess high-stakes handover in a remote setting. It showed good reliability and was easy for working clinicians to use. Further investigation and use is warranted beyond this setting.

Stroke Epidemiology in an Australian Rural Cohort (SEARCH).

Background Stroke rates in Australia and New Zealand have been declining since 1990 but all studies have been completed in large urban centers. Aim We report the first Australasian stroke incidence study in a rural population. Methods The authors applied the principle of complete ascertainment, used the WHO standard definition of stroke and classified ischemic stroke by the TOAST criteria. Data were collected from five rural centers defined by postcode of residence, over a 2-year period with 12 months of follow up of all cases. Results There were 217 strokes in 215 individuals in a population of 96,036 people, over 2 years, giving a crude attack rate of 113 per 100,000 per year. The 181 first-ever strokes (83% of total), standardized to the WHO world population, occurred at a rate of 50/100,000 (95% CI: 43-58). The 28-day fatality for first-ever strokes was 24% (95% CI: 18-31) and 77% (95% CI: 71-83) were classified as ischemic (140/181), 15% (95% CI: 10-21) intracerebral hemorrhage, 3% (95% CI: 1-6) due to subarachnoid hemorrhage and 5% (95% CI: 2-9) were unknown. A high proportion of first-ever ischemic strokes (44%) were cardioembolic, mostly (77%) due to atrial arrhythmias. Of the 38 with known atrial arrhythmias prior to stroke, only six (16%) were therapeutically anticoagulated. Conclusions This rural companion study of a recent Australian urban stroke incidence study confirms the downward trend of stroke incidence in Australia, and reiterates that inadequate anticoagulation of atrial arrhythmia remains a preventable cause of ischemic stroke.

Primary health care for Aboriginal women and children in the year after birth: findings from a population-based study in South Australia.

OBJECTIVE: To investigate the extent to which Aboriginal women access primary care for themselves and their infant in the year after childbirth. METHOD: Cross sectional population-based survey of women giving birth to Aboriginal babies in South Australia between July 2011 and June 2013. RESULTS: A total of 344 women took part in the study 4-9 months after giving birth. The majority had seen a primary health care practitioner since the birth: 86% had seen a Child and Family Health Service (CaFHS) nurse, 81% a general practitioner (GP), and 61% an Aboriginal health worker (AHW). Women living in remote areas were more likely to have seen primary care practitioners than women living in Adelaide (GP: OR 2.3, 95% CI 1.0-5.2; CaFHS: OR 2.4, 95% CI 1.0-5.8; AHW: OR 5.2, 95% CI 2.8-9.8). Around 16% of women with gestational diabetes and 10% with hypertension had not seen a GP since the birth, and 24% of women who had a low birthweight infant had not seen a CaFHS nurse. CONCLUSIONS: Despite high prevalence of maternal and infant morbidity, a sizeable minority of women did not access primary care practitioners postpartum. Implications for public health: Stronger efforts are needed to ensure Aboriginal women and families receive appropriate postnatal follow-up.

Determining the Number of Ischemic Strokes Potentially Eligible for Endovascular Thrombectomy: A Population-Based Study.

BACKGROUND AND PURPOSE: Endovascular thrombectomy (ET) is standard-of-care for ischemic stroke patients with large vessel occlusion, but estimates of potentially eligible patients from population-based studies have not been published. Such data are urgently needed to rationally plan hyperacute services. Retrospective analysis determined the incidence of ET-eligible ischemic strokes in a comprehensive population-based stroke study (Adelaide, Australia 2009-2010). METHODS: Stroke patients were stratified via a prespecified eligibility algorithm derived from recent ET trials comprising stroke subtype, pathogenesis, severity, premorbid modified Rankin Score, presentation delay, large vessel occlusion, and target mismatch penumbra. Recognizing centers may interpret recent ET trials either loosely or rigidly; 2 eligibility algorithms were applied: restrictive (key criteria modified Rankin Scale score 0-1, presentation delay <3.5 hours, and target mismatch penumbra) and permissive (modified Rankin Scale score 0-3 and presentation delay <5 hours). RESULTS: In a population of 148 027 people, 318 strokes occurred in the 1-year study period (crude attack rate 215 [192-240] per 100 000 person-years). The number of ischemic strokes eligible by restrictive criteria was 17/258 (7%; 95% confidence intervals 4%-10%) and by permissive criteria, an additional 16 were identified, total 33/258 (13%; 95% confidence intervals 9%-18%). Two of 17 patients (and 6/33 permissive patients) had thrombolysis contraindications. Using the restrictive algorithm, there were 11 (95% confidence intervals 4-18) potential ET cases per 100 000 person-years or 22 (95% confidence intervals 13-31) using the permissive algorithm. CONCLUSIONS: In this cohort, ≈7% of ischemic strokes were potentially eligible for ET (13% with permissive criteria). In similar populations, the permissive criteria predict that ≤22 strokes per 100 000 person-years may be eligible for ET.

Use of cannabis during pregnancy and birth outcomes in an Aboriginal birth cohort: a cross-sectional, population-based study.

OBJECTIVES: Indigenous women continue to experience rates of stillbirth, preterm birth and low birth weight, two to three times higher than other women in high-income countries. The reasons for disparities are complex and multifactorial. We aimed to assess the extent to which adverse birth outcomes are associated with maternal cannabis use and exposure to stressful events and social health issues during pregnancy. DESIGN/SETTING: Cross-sectional, population-based survey of women giving birth to Aboriginal babies in South Australia, July 2011-June 2013. Data include: maternal cannabis use, exposure to stressful events/social health issues, infant birth weight and gestation. PARTICIPANTS: 344 eligible women with a mean age of 25 years (range 15-43 years), enrolled in the study. Participants were representative in relation to maternal age, infant birth weight and gestation. RESULTS: 1 in 5 women (20.5%) used cannabis during pregnancy, and 52% smoked cigarettes. Compared with mothers not using cannabis or cigarettes, mothers using cannabis had babies on average 565 g lighter (95% CI -762 to -367), and were more likely to have infants with a low birth weight (OR=6.5, 95% CI 3.0 to 14.3), and small for gestational age (OR=3.8, 95% CI 1.9 to 7.6). Controlling for education and other social characteristics, including stressful events/social health issues did not alter the conclusion that mothers using cannabis experience a higher risk of negative birth outcomes (adjusted OR for odds of low birth weight 3.9, 95% CI 1.4 to 11.2). CONCLUSIONS: The findings provide a compelling case for stronger efforts to address the clustering of risk for adverse outcomes in Aboriginal and Torres Strait Islander communities, and point to the need for antenatal care to address broader social determinants of adverse perinatal outcomes. Integrated responses--collaboratively developed with Aboriginal communities and organisations--that focus on constellations of risk factors, and a holistic approach to addressing social determinants of adverse birth outcomes, are required.

Translating a health service intervention into a rural setting: lessons learned.

BACKGROUND: Limited research exists on the process of applying knowledge translation (KT) methodology to a rural-based population health intervention. METHODS: This study reports on the implementation and translational stages of a previously described Co-creating KT (Co-KT) framework in the rural town of Port Lincoln, South Australia (population: 14,000). The Co-KT framework involves five steps: (i) collecting local data; (ii) building stakeholder relationships; (iii) designing an evidence-based intervention incorporating local knowledge; (iv) implementation and evaluation of the intervention; and (v) translating the research into policy and practice. Barriers and enablers to the overall Co-KT implementation process were identified. Our intervention focused on musculoskeletal (MSK) conditions. RESULTS: Although the Co-KT framework was valuable in engaging with the community, translating the final intervention into daily clinical practice was prevented by a lack of an accessible policy or financial framework to anchor the appropriate intervention, a lack of continued engagement with stakeholders, access problems to general practitioners (GPs) and Allied Health Professionals; and the paucity of referrals from GPs to Allied Health Professionals. Consequently, while many aspects of the intervention were successful, including the improvement of both function and pain in study participants, the full implementation of the Co-KT framework was not possible. DISCUSSION: This study implemented and evaluated a Co-KT framework for a population with MSK conditions, linking locally generated health care system knowledge with academic input. Further policy, health system changes, and on-the-ground support are needed to overcome the identified implementation challenges in order to create sustainable and effective system change.

Frailty and health service use in rural South Australia.

BACKGROUND: Frailty is a common geriatric condition, well known to contribute to morbidity and mortality. What is not yet well articulated in the literature is the health service use of frail older people in rural areas. This study investigated the impact of frailty on health service use in rural South Australia. METHODS: This secondary cross-sectional analysis included people aged ≥ 65 years from the LINKIN health census in Port Lincoln. Frailty was classified using a Frailty Index (FI) score ≥ 0.25. Health service use was determined by patient questionnaire. All regression analyses controlled for age, gender and education level. RESULTS: 1501 people [mean (SD) age=75.9 (7.9)] years were included. Frailty prevalence was 25%, with this prevalence higher in females (29%) than in males (21%). Compared with their non-frail peers, frail adults were more likely to have consulted health providers, including: general practitioners (GPs) (odds ratio (OR), 95% confidence interval (CI=2.09, 1.24-3.53); physiotherapists (OR, CI=2.42, 1.80-3.25); mental health providers (OR, CI=2.88, 1.42-5.85); community nurses (OR, CI=2.57, 1.73-3.82); and dieticians (OR, CI=2.77, 1.77-4.48). They were also more likely to have visited a health professional prior to a problem occurring (OR, CI=1.51, 1.08-2.11), travelled to the city for a specialist appointment (OR, CI=1.53, 1.11-2.11), and to have been hospitalised in the previous 12 months (OR, CI=2.39, 1.74-3.29). CONCLUSION: Frail older adults were more likely to use several health services, yet often had unmet needs in their health care.

Heat-health behaviours of older people in two Australian states.

AIM: A major heatwave occurred in Australia in early 2009 with considerable and varied health impacts in South Australia (SA) and Victoria. The aim of this study was to investigate the heat-adaptive behaviours of older people in these states. METHODS: A computer-assisted telephone survey of 1000 residents of SA and Victoria aged 65 years or older was conducted at the end of summer 2010-2011. RESULTS: The majority of respondents reported undertaking heat-adaptive behaviours. In SA, there was a significantly higher proportion of households with air conditioning compared to Victoria, and a higher recall of heat-health messages. In both states, self-reported morbidity during heatwaves was higher in women, persons with poorer health and those with cardiovascular conditions. CONCLUSION: An increase in global temperatures in conjunction with an ageing population is a concern for public health. Our findings suggest acclimatisation to hot weather may influence behaviours and health outcomes in older people.

Early career location of University of Adelaide rural cohort medical students.

INTRODUCTION: In 2001 the Australian Government Department of Health began what is now the Rural Clinical Training and Support (RCTS) program which funds rural background selection and rural clinical education in an attempt to increase the rural medical workforce. At the University of Adelaide, students of the 6-year undergraduate medical program have the opportunity to complete the whole of their fifth year of clinical studies at one of eight rural locations. This study seeks to track the early career movements of these graduates in order to determine the program's rural medical workforce impact. METHODS: The retrospective study involved graduates who had studied a rural fifth year between 2003 and 2010 inclusive. Only domestic students were included in the study. One hundred and twenty four out of a possible 127 participants were contacted by email and asked to complete a 28-question online survey using SurveyMonkey. The survey included questions regarding career choices since graduation and experiences during the RCTS program. Quantitative data was analysed using descriptive statistics and qualitative data underwent thematic analysis. RESULTS: The survey response rate was 58.2% with 74 useable responses. Respondents described the career choices they had made since graduation, including the stage they were at in their training, the speciality they had chosen and their location during each year. Data showed that between 2009 and 2012 between 20.8% and 34.1% of respondents were located in a rural area (Australian Standard Geographical Classification - Remoteness Areas 2-5). More than half of respondents have spent time in a rural area since graduation and 85.1% of respondents indicated they had intentions to work in a rural area in the future. In saying this, 8 years post-graduation is not long enough to assess the rural work force outcome. Graduates move frequently between practice locations even at 8 years post-graduation; only five respondents had completed postgraduate training. The RCTS program is important in the progression from medical school to rural practice, including the initial decision to take part in it. The interest of some respondents who were practising in rural areas in 2012, and were initially 'very interested' in rural practice, either 'slightly' or 'significantly increased'. CONCLUSIONS: These results show that the RCTS program can supplement an initial interest in rural medicine.

Risk factors, health effects and behaviour in older people during extreme heat: a survey in South Australia.

Older people had a high incidence of hospitalisation during the 2009 heat wave in South Australia. We sought to explore resilience, behaviours, health risk factors and health outcomes during recent heat waves for a representative sample of independently living residents. A telephone survey of 499 people aged 65 years and over was conducted, and included both metropolitan and rural residences. A variety of adaptive strategies were reported, with 75% maintaining regular appointments and activities during the heat. However, 74% took medication for chronic disease and 25% assessed their health status to be fair to poor. In a multivariate model, factors associated with heat health outcomes included medication for mental health, heart failure, diabetes or respiratory health, reporting a reduced health status, use of mobility aids and being female. Compared with younger participants, those over 75 had more check-up calls and visits by family, friends and neighbours. However, confidence to call on support was associated with indicators of social isolation. The study indicates that older people are generally resilient, but interventions addressing multi-morbidity and medication interactions and social isolation should be developed.

Extreme heat and health: perspectives from health service providers in rural and remote communities in South Australia.

Among the challenges for rural communities and health services in Australia, climate change and increasing extreme heat are emerging as additional stressors. Effective public health responses to extreme heat require an understanding of the impact on health and well-being, and the risk or protective factors within communities. This study draws on lived experiences to explore these issues in eleven rural and remote communities across South Australia, framing these within a socio-ecological model. Semi-structured interviews with health service providers (n = 13), and a thematic analysis of these data, has identified particular challenges for rural communities and their health services during extreme heat. The findings draw attention to the social impacts of extreme heat in rural communities, the protective factors (independence, social support, education, community safety), and challenges for adaptation (vulnerabilities, infrastructure, community demographics, housing and local industries). With temperatures increasing across South Australia, there is a need for local planning and low-cost strategies to address heat-exacerbating factors in rural communities, to minimise the impact of extreme heat in the future.

A study protocol for applying the co-creating knowledge translation framework to a population health study.

BACKGROUND: Population health research can generate significant outcomes for communities, while Knowledge Translation (KT) aims to expressly maximize the outcomes of knowledge producing activity. Yet the two approaches are seldom explicitly combined as part of the research process. A population health study in Port Lincoln, South Australia offered the opportunity to develop and apply the co-KT Framework to the entire research process. This is a new framework to facilitate knowledge formation collaboratively between researchers and communities throughout a research to intervention implementation process. DESIGN: This study employs a five step framework (the co-KT Framework) that is formulated from engaged scholarship and action research principles. By following the steps a knowledge base will be cumulatively co-created with the study population that is useful to the research aims. Step 1 is the initiating of contact between the researcher and the study contexts, and the framing of the research issue, achieved through a systematic data collection tool. Step 2 refines the research issue and the knowledge base by building into it context specific details and conducting knowledge exchange events. Step 3 involves interpreting and analysing the knowledge base, and integrating evidence to inform intervention development. In Step 4 the intervention will be piloted and evaluated. Step 5 is the completion of the research process where outcomes for improvement will be instituted as regular practice with the facilitation of the community.In summary, the model uses an iterative knowledge construction mechanism that is complemented by external evidence to design interventions to address health priorities within the community. DISCUSSION: This is a systematic approach that operationalises the translational cycle using a framework for KT practice. It begins with the local context as its foundation for knowledge creation and ends with the development of contextually applicable interventions. It will be of interest to those involved in KT research, participatory action research, population health research and health care systems studies. The co-KT Framework is a method for embedding the principles of KT into all stages of a community-based research process, in which research questions are framed by emergent data from each previous stage.

Aboriginal Families Study: a population-based study keeping community and policy goals in mind right from the start.

BACKGROUND: Australian Aboriginal and Torres Strait Islander women are between two to five times more likely to die in childbirth than non-Aboriginal women, and two to three times more likely to have a low birthweight infant. Babies with a low birthweight are more likely to have chronic health problems in adult life. Currently, there is limited research evidence regarding effective interventions to inform new initiatives to strengthen antenatal care for Aboriginal families. METHOD/DESIGN: The Aboriginal Families Study is a cross sectional population-based study investigating the views and experiences of Aboriginal and non-Aboriginal women having an Aboriginal baby in the state of South Australia over a 2-year period. The primary aims are to compare the experiences and views of women attending standard models of antenatal care with those accessing care via Aboriginal Family Birthing Program services which include Aboriginal Maternal Infant Care (AMIC) Workers as members of the clinical team; to assess factors associated with early and continuing engagement with antenatal care; and to use the information to inform strengthening of services for Aboriginal families. Women living in urban, regional and remote areas of South Australia have been invited to take part in the study by completing a structured interview or, if preferred, a self-administered questionnaire, when their baby is between 4-12 months old. DISCUSSION: Having a baby is an important life event in all families and in all cultures. How supported women feel during pregnancy, how women and families are welcomed by services, how safe they feel coming in to hospitals to give birth, and what happens to families during a hospital stay and in the early months after the birth of a new baby are important social determinants of maternal, newborn and child health outcomes. The Aboriginal Families Study builds on consultation with Aboriginal communities across South Australia. The project has been implemented with guidance from an Aboriginal Advisory Group keeping community and policy goals in mind right from the start. The results of the study will provide a unique resource to inform quality improvement and strengthening of services for Aboriginal families.

Knowledge translation within a population health study: how do you do it?

BACKGROUND: Despite the considerable and growing body of knowledge translation (KT) literature, there are few methodologies sufficiently detailed to guide an integrated KT research approach for a population health study. This paper argues for a clearly articulated collaborative KT approach to be embedded within the research design from the outset. DISCUSSION: Population health studies are complex in their own right, and strategies to engage the local community in adopting new interventions are often fraught with considerable challenges. In order to maximise the impact of population health research, more explicit KT strategies need to be developed from the outset. We present four propositions, arising from our work in developing a KT framework for a population health study. These cover the need for an explicit theory-informed conceptual framework; formalizing collaborative approaches within the design; making explicit the roles of both the stakeholders and the researchers; and clarifying what counts as evidence. From our deliberations on these propositions, our own co-creating (co-KT) Framework emerged in which KT is defined as both a theoretical and practical framework for actioning the intent of researchers and communities to co-create, refine, implement and evaluate the impact of new knowledge that is sensitive to the context (values, norms and tacit knowledge) where it is generated and used. The co-KT Framework has five steps. These include initial contact and framing the issue; refining and testing knowledge; interpreting, contextualising and adapting knowledge to the local context; implementing and evaluating; and finally, the embedding and translating of new knowledge into practice. SUMMARY: Although descriptions of how to incorporate KT into research designs are increasing, current theoretical and operational frameworks do not generally span a holistic process from knowledge co-creation to knowledge application and implementation within one project. Population health studies may have greater health impact when KT is incorporated early and explicitly into the research design. This, we argue, will require that particular attention be paid to collaborative approaches, stakeholder identification and engagement, the nature and sources of evidence used, and the role of the research team working with the local study community.

Adelaide stroke incidence study: declining stroke rates but many preventable cardioembolic strokes.

BACKGROUND AND PURPOSE: Stroke incidence rates are in flux worldwide because of evolving risk factor prevalence, risk factor control, and population aging. Adelaide Stroke Incidence Study was performed to determine the incidence of strokes and stroke subtypes in a relatively elderly population of 148 000 people in the Western suburbs of Adelaide. METHODS: All suspected strokes were identified and assessed in a 12-month period from 2009 to 2010. Standard definitions for stroke and stroke fatality were used. Ischemic stroke pathogenesis was classified by the Trial of ORG 10172 in Acute Stroke Treatment criteria. RESULTS: There were 318 stroke events recorded in 301 individuals; 238 (75%) were first-in-lifetime events. Crude incidence rates for first-ever strokes were 161 per 100 000 per year overall (95% confidence interval [CI], 141-183), 176 for men (95% CI, 147-201), and 146 for women (95% CI, 120-176). Adjusted to the world population rates were 76 overall (95% CI, 59-94), 91 for men (95% CI, 73-112), and 61 for women (95% CI, 47-78). The 28-day case fatality rate for first-ever stroke was 19% (95% CI, 14-24); the majority were ischemic (84% [95% CI, 78-88]). Intracerebral hemorrhage comprised 11% (8-16), subarachnoid hemorrhage 3% (1-6), and 3% (1-6) were undetermined. Of the 258 ischemic strokes, 42% (95% CI, 36-49) were of cardioembolic pathogenesis. Atrial fibrillation accounted for 36% of all ischemic strokes, of which 85% were inadequately anticoagulated. CONCLUSIONS: Stroke incidence in Adelaide has not increased compared with previous Australian studies, despite the aging population. Cardioembolic strokes are becoming a higher proportion of all ischemic strokes.