The good news for New Zealand Europeans is that ischaemic stroke case fatality rates (CFR) are falling for them. In their study based on analysis of data from the hospital discharge coding National Minimum Dataset and the National Mortality Collection, Peter Sandiford and his colleagues have shown that age-sex standardised 30-day ischaemic stroke CFR for New Zealand Europeans fell from 13.4% in 2000-2004 to 10.7% in 2010-2014.1 This good news likely reflects the improvements in stroke care in general in New Zealand over the same period. There is overwhelming evidence that stroke unit care significantly reduces death and disability after stroke compared with generic medical care.2 Over the study period, there has been sustained effort to implement organised stroke unit care in New Zealand. A survey of stroke services in 2007 identified improvements in provision of organised acute inpatient stroke care since 2001, although gaps still remained.3 The effort to improve the standard and standardisation of stroke care throughout New Zealand continues through regional and national stroke networks, supported by the Ministry of Health.The news that despite these efforts, case fatality rates have not improved significantly in ethnic groups other than New Zealand European is bad news indeed. Sandifords study shows clearly that other ethnic groups in New Zealand have a higher ischaemic stroke CFR than do NZ Europeans and that this difference appears to be increasing. While CFR for M1ori was at least trending in the right direction over the last decade (down to 16.2% from 18.2%), this improvement was not statistically significant and the rate of any improvement is slower than for Europeans. The CFR for M1ori remains significantly worse in absolute terms than for other ethnicities.Not all the news for ethnic trends in stroke is bad. There are some positive signs of improvement in stroke outcomes from other sources, most notably the Auckland Regional Community Stroke (ARCOS) studies. Thirty-year trends in incidence and outcome of stroke in the Auckland region were published last year.4 Age-standardised stroke mortality rates, a measure which includes stroke incidence and case-fatality rates, have fallen significantly in the last 30 years across all ethnicities. The positive trend has continued in the most recent ARCOS study period: 2002-3 compared with 2011-12. But the ARCOS data do also show ethnic disparities within these improvements: the 30-year trend for age-standardised stroke incidence is reducing for New Zealand Europeans, but not in other ethnic groups in Auckland (New Zealand European change from 153/100,000/year in 1982 to 122 in 2012, M1ori 134 to 156, Pacific 147 to 197).4The age at stroke onset is increasing in most ethnic groupsa good thingbut age remains a glaring indication of the inequalities in stroke in New Zealand: average age at stroke onset in Auckland in 2012 was 75.3 years in New Zealand Europeans (up from 72.2 in 1982), compared with 59.6 in M1ori (56.7), 61.6 in Pacific (55.8) and 67.5 (down from 72.1) in Asian/other ethnic groups.One cannot avoid the conclusion that public health efforts to prevent stroke and in-hospital efforts to treat stroke once it has occurred are showing good benefit for the New Zealand European population, but they dont appear to be working nearly as well, if at all, for others.Why the disparities? As Sandiford and his colleagues discuss, the major possible explanations for disparity in CFR could be differences in severity of stroke at presentation, or that there are differences in access to acute hospital stroke services. If non-European New Zealanders present with more severe stroke, this is most likely due to reduced rate of presentation with milder stroke, rather than a major biological difference in stroke type. Failure to diagnose mild stroke is important as it results in a missed opportunity to implement appropriate treatments that might prevent a more severe stroke later. There is a need to increase public awareness of the signs of stroke and the associated need to seek medical attention. If there are differences in access to life-saving acute hospital services, then timeliness of access may be an important factor. If patients present to hospital later after stroke they miss the opportunity for acute stroke treatments, including stroke thrombolysis and thrombectomy. However, while stroke thrombolysis reduces disability, it hasnt been shown to reduce mortality, and thrombectomy wasnt available during the period studied. The other aspects of stroke unit care to avoid complications and provide early rehabilitation may be more important. Regardless, there is a need to increase public awareness of the signs of stroke and the associated need to seek medical attentionfast.This need to improve public awareness of stroke, its early signs, and the need to seek urgent medical attention, has been recognised by the Ministry of Health, which has funded a public awareness campaign using theFAST message (Face-Arm-Speech-Time), currently in progress nationally after an initial successful pilot in the Waikato. I hope that readers are indeed aware of this campaigns existence. But, studies like Sandifords that show the severity of ethnic differences in stroke outcome in New Zealand mean that more questions need to be asked and we need to be aware that signs of overall improvement do not mean that all are improving. What are the details of geographic and ethnic variation in stroke care access, and what are the barriers that we can target to overcome? Will theFAST campaign be effective in raising awareness of stroke for all New Zealanders, or some ethnicities more than others? We need to ask, and answer these questions then act on themfast.

The good news for New Zealand Europeans is that ischaemic stroke case fatality rates (CFR) are falling for them. In their study based on analysis of data from the hospital discharge coding National Minimum Dataset and the National Mortality Collection, Peter Sandiford and his colleagues have shown that age-sex standardised 30-day ischaemic stroke CFR for New Zealand Europeans fell from 13.4% in 2000-2004 to 10.7% in 2010-2014.1 This good news likely reflects the improvements in stroke care in general in New Zealand over the same period. There is overwhelming evidence that stroke unit care significantly reduces death and disability after stroke compared with generic medical care.2 Over the study period, there has been sustained effort to implement organised stroke unit care in New Zealand. A survey of stroke services in 2007 identified improvements in provision of organised acute inpatient stroke care since 2001, although gaps still remained.3 The effort to improve the standard and standardisation of stroke care throughout New Zealand continues through regional and national stroke networks, supported by the Ministry of Health.The news that despite these efforts, case fatality rates have not improved significantly in ethnic groups other than New Zealand European is bad news indeed. Sandifords study shows clearly that other ethnic groups in New Zealand have a higher ischaemic stroke CFR than do NZ Europeans and that this difference appears to be increasing. While CFR for M1ori was at least trending in the right direction over the last decade (down to 16.2% from 18.2%), this improvement was not statistically significant and the rate of any improvement is slower than for Europeans. The CFR for M1ori remains significantly worse in absolute terms than for other ethnicities.Not all the news for ethnic trends in stroke is bad. There are some positive signs of improvement in stroke outcomes from other sources, most notably the Auckland Regional Community Stroke (ARCOS) studies. Thirty-year trends in incidence and outcome of stroke in the Auckland region were published last year.4 Age-standardised stroke mortality rates, a measure which includes stroke incidence and case-fatality rates, have fallen significantly in the last 30 years across all ethnicities. The positive trend has continued in the most recent ARCOS study period: 2002-3 compared with 2011-12. But the ARCOS data do also show ethnic disparities within these improvements: the 30-year trend for age-standardised stroke incidence is reducing for New Zealand Europeans, but not in other ethnic groups in Auckland (New Zealand European change from 153/100,000/year in 1982 to 122 in 2012, M1ori 134 to 156, Pacific 147 to 197).4The age at stroke onset is increasing in most ethnic groupsa good thingbut age remains a glaring indication of the inequalities in stroke in New Zealand: average age at stroke onset in Auckland in 2012 was 75.3 years in New Zealand Europeans (up from 72.2 in 1982), compared with 59.6 in M1ori (56.7), 61.6 in Pacific (55.8) and 67.5 (down from 72.1) in Asian/other ethnic groups.One cannot avoid the conclusion that public health efforts to prevent stroke and in-hospital efforts to treat stroke once it has occurred are showing good benefit for the New Zealand European population, but they dont appear to be working nearly as well, if at all, for others.Why the disparities? As Sandiford and his colleagues discuss, the major possible explanations for disparity in CFR could be differences in severity of stroke at presentation, or that there are differences in access to acute hospital stroke services. If non-European New Zealanders present with more severe stroke, this is most likely due to reduced rate of presentation with milder stroke, rather than a major biological difference in stroke type. Failure to diagnose mild stroke is important as it results in a missed opportunity to implement appropriate treatments that might prevent a more severe stroke later. There is a need to increase public awareness of the signs of stroke and the associated need to seek medical attention. If there are differences in access to life-saving acute hospital services, then timeliness of access may be an important factor. If patients present to hospital later after stroke they miss the opportunity for acute stroke treatments, including stroke thrombolysis and thrombectomy. However, while stroke thrombolysis reduces disability, it hasnt been shown to reduce mortality, and thrombectomy wasnt available during the period studied. The other aspects of stroke unit care to avoid complications and provide early rehabilitation may be more important. Regardless, there is a need to increase public awareness of the signs of stroke and the associated need to seek medical attentionfast.This need to improve public awareness of stroke, its early signs, and the need to seek urgent medical attention, has been recognised by the Ministry of Health, which has funded a public awareness campaign using theFAST message (Face-Arm-Speech-Time), currently in progress nationally after an initial successful pilot in the Waikato. I hope that readers are indeed aware of this campaigns existence. But, studies like Sandifords that show the severity of ethnic differences in stroke outcome in New Zealand mean that more questions need to be asked and we need to be aware that signs of overall improvement do not mean that all are improving. What are the details of geographic and ethnic variation in stroke care access, and what are the barriers that we can target to overcome? Will theFAST campaign be effective in raising awareness of stroke for all New Zealanders, or some ethnicities more than others? We need to ask, and answer these questions then act on themfast.