Do stroke units save lives?

Stroke rehabilitation outcome variation in Veterans Affairs rehabilitation units: accounting for case-mix

OBJECTIVE

To assess variation in stroke outcomes and create a case-mix adjustment model for stroke rehabilitation in Veterans Affairs Medical Centers.

DESIGN

Observational

SETTING AND PATIENTS

Within Veteran's Health Administration hospitals, there are 63 acute rehabilitation bedservice units that care for approximately 2,000 stroke patients annually.

MAIN OUTCOME MEASURES

Functional gain in FIM points, length of stay (LOS), LOS efficiency (FIM gain/LOS).

RESULTS

Significant variation in average patient functional gain, LOS, and LOS efficiency was observed among the 37 highest-volume rehabilitation units. Using analysis of covariance, a model was developed that adjusted functional gain and LOS (logged LOS) unit means using 10 potential covariates identified in a literature review and in pilot studies. Four and six covariates, respectively, were retained in the final models for FIM gain and LOS. The R2 for FIM gain and LOS accounted for by rehabilitation unit alone increased from .07 to .31 (FIM gain) and from .13 to .34 (logLOS) with the addition of the significant covariates to each model.

CONCLUSIONS

As much as 24% of the variation in two important stroke rehabilitation outcomes is attributable to largely immutable patient and system characteristics (eg, patient function on admission, age, days since stroke onset, year of discharge, marital status, and referral source). Hence, controlling for case-mix is critical for accurate comparison of unit outcomes. Further, the variation in LOS efficiency between VA rehabilitation units suggests a large potential for cost and resource utilization savings system-wide.

Effect of nimodipine on memory after cerebral infarction

OBJECTIVES

Epidemiological studies indicate widespread memory impairment in patients with stroke in the early post-ictal stage. Nimodipine may have psychopharmacological properties and may improve memory. We conducted a single-blind randomized controlled trial to determine whether nimodipine given 7-14 days after cerebral infarction improved memory.

MATERIAL AND METHODS

One hundred patients with acute cerebral infarction were consecutively enrolled between D7 to D14. After stratification, patients were randomized to receive oral nimodipine 90 mg daily for 12 weeks, or no drug. Independent assessors administered Mini-Mental State Examination (MMSE) and Fuld Object-Memory Evaluation (FOME) at baseline, 6 weeks, and 12 weeks.

RESULTS

Patients receiving nimodipine showed greater improvement in FOME mean scores at 12 weeks (P=0.0334), and also in FOME score change across time (P=0.0283). Patients with severe disability who received nimodipine also showed greater MMSE score change across time (P=0.0495).

CONCLUSION

Nimodipine given 7-14 days after cerebral infarction for 3 months results in memory improvement.

Stroke unit treatment improves long-term quality of life: a randomized controlled trial

BACKGROUND AND PURPOSE

We have previously shown that treatment of acute stroke patients in the combined acute and rehabilitation stroke unit in our hospital improves survival and functional outcome compared with treatment in general wards. The primary aim of the present trial was to examine whether the treatment in our stroke unit had an effect on different aspects of quality of life (QoL) for stroke patients 5 years after the onset of stroke.

METHODS

In a randomized controlled trial, 110 patients with symptoms and signs of an acute stroke were allocated to the stroke unit and 110 to general wards. No significant differences existed in baseline characteristics between the two groups. The patients alive after 5 years were assessed by the Nottingham Health Profile (NHP) and the Frenchay Activities Index (FAI), which were the scales used as primary outcome measures for QoL. As secondary outcome measures we used a global score for the NHP and a simple visual analogue scale (VAS).

RESULTS

After 5 years, 45 of the patients treated in the stroke unit and 32 of those treated in general wards were alive. All surviving patients were assessed by the FAI. Thirty-seven (82.2%) of the stroke unit patients and 25 (78.1%) of the general wards patients were assessed by the NHP; 38 (84.4%) and 28 (87.5%), respectively, were assessed by the VAS. Patients treated in the stroke unit had a higher score on the FAI (P=0.0142). Assessment with the NHP showed better results in the stroke unit group for the dimensions of energy (P=0.0323), physical mobility (P=0.0415), emotional reactions (P=0.0290), social isolation (P=0.0089), and sleep (P=0.0436), although there was no difference in pain (P=0.3186). The global NHP score and VAS score also showed significantly better results in the stroke unit group (NHP, P<0.01; VAS, P<0.001). Patients who were independent in activities of daily living had significantly better QoL assessed by these scales than patients who were dependent.

CONCLUSIONS

Our study shows for the first time that stroke unit care improves different aspects of long-term QoL for stroke patients.

Complications of acute ischaemic stroke

Neurological, cardiac, and systemic complications during the first days to weeks after ischaemic stroke can cause substantial morbidity and mortality. The reported 30-day case fatality rate for cerebral infarction varies between 10 and 17%. The incidence and effects of the various complications vary with time after stroke: transtentorial herniation and other cerebral complications prevail during the 1st week, whereas medical complications are more prominent in the weeks thereafter. Many complications are treatable, and some are preventable. The goal of this report is to provide information on their incidence, consequences, and management.

Impairment and disability: their relation during stroke rehabilitation

OBJECTIVES

To describe the association between impairment and disability during stroke rehabilitation and to examine the effects of rehabilitation by studying the degree of disability reduction experienced by stroke patients who did not have significant reductions in impairment levels.

DESIGN

Statistical analysis of items from a database of prospectively collected information on stroke patients admitted for rehabilitation.

SETTING

Large urban academic freestanding rehabilitation facility.

PARTICIPANTS

Four hundred two patients consecutively admitted for comprehensive acute stroke inpatient rehabilitation.

MAIN OUTCOME MEASURES

The National Institutes of Health Stroke Scale (NIHSS) was used to measure impairment and the Functional Independence Measure (FIM) was used to measure disability. Motor and cognitive subscales of the FIM instrument were evaluated. Raw NIHSS and FIM scores were converted to linear measures using Rasch analysis.

METHODS

Relationships were studied between converted NIHSS and the two FIM subscales for admission, discharge, and change scores using linear regression analysis. In a second analysis, two groups of patients were identified; the 342 patients who experienced no substantial reduction of impairment comprised the "no impairment reduction (NIR) group," and the 60 patients who had a significant reduction of impairment level comprised the "impairment reduction (IR) group." Multivariate analysis of variance was used to determine and compare the amount of change in motor and cognitive FIM measures over time for each of the two groups.

RESULTS

NIHSS correlated significantly with motor and cognitive FIM subscores for admission, discharge, and change measures; R2 values ranged between .02 and .36. Both the NIR group and the IR group experienced significant decreases in disability during rehabilitation. The differences in discharge FIM measures between the two groups were relatively small.

CONCLUSIONS

Although stroke-related impairment and disability are significantly correlated with each other, reduced impairment level alone does not fully explain the reduced disability that occurs during rehabilitation. Even patients without substantial impairment reduction demonstrate disability reduction during rehabilitation, suggesting that rehabilitation has an independent role in improving function beyond that explained by neurologic recovery alone.

Stroke unit versus general medical wards, II: neurological deficits and activities of daily living: a quasi-randomized controlled trial

BACKGROUND AND PURPOSE

The efficacy of stroke units has been extensively examined. It is unknown, however, whether the superiority of the stroke unit will remain after the increased focus on stroke treatment in general medicine. This study of patients admitted to the hospital early and with a short length of stay determines the effect and identifies certain important components of a stroke unit.

METHODS

Five hundred fifty patients aged 60 years or older with acute stroke were allocated by a quasi-randomized design to a stroke unit or a general medical ward based on date of birth in the month. Patients admitted within 24 hours of onset were enrolled. Outcomes after 7 months were death, proportion needing long-term care, and change in neurological and functional state assessed by the Scandinavian Stroke Scale and Barthel Index.

RESULTS

Seven months after admission there was a trend in favor of the stroke unit in all outcome measures, but no significant differences in clinical outcomes were found except for change in the Scandinavian Stroke Scale score. Recurrent stroke during hospitalization occurred more often in the general medical ward (P = .03). The stroke unit was significantly more aggressive in mobilization out of bed (P<.01) and use of parenteral fluid (P<.0001), aspirin (P<.0001), antipyretics (P<.0001), and antibiotics (P<.0001).

CONCLUSIONS

Our study confirms the benefit of the stroke unit, but the effects on the most reliable clinical outcomes were modest and insignificant. Treatment in this stroke unit hastened recovery. More aggressive rehabilitation and use of parenteral fluid, aspirin, antipyretics, and antibiotics appeared in the stroke unit.

Recent advances in stroke therapy

Advances in stroke therapy have followed diverse paths over the past 2 years. Recent clinical trials have investigated the use of thrombolytic agents, anticoagulants, antiplatelet drugs and neuroprotective agents in acute stroke patients. The positive results of the National Institutes of Neurologic Disease and Stroke tissue plasminogen activator trial have increased interest in the field of acute stroke therapy and initiated significant changes in the management of stroke patients in the medical system. A new antiplatelet drug and a number of trials involving HMG Co-A reductase inhibitors are important advances in the secondary prevention of stroke.

Trends in medical care of hospitalized stroke patients between 1980 and 1990: The minnesota stroke survey

Recent decades have seen several advances in medical care for acute stroke patients, but there has been little systematic documentation of these changes. This study examined changes in technology use and medical therapies for hospitalized acute stroke during the 1980s. For 1980, 1985, and 1990, we obtained discharge diagnosis lists from Minneapolis-St Paul metropolitan hospitals, identified hospitalizations for acute stroke of patients aged 30 to 74 years, and selected a 50% random sample. Trained nurses abstracted the medical records. Strokes were classified as hemorrhagic or ischemic based on discharge diagnosis code (using the International Classification of Diseases, 9th Revision) and findings from computed tomography (CT) or magnetic resonance imaging (MRI). Strokes classified as ischemic totaled 459 in 1980, 549 in 1985, and 657 in 1990. There were approximately 100 hemorrhagic stroke patients in each survey year. Throughout the 1980s, there was a trend toward both greater and earlier use of CT and MRI to diagnose stroke. By 1990, only 3% of patients did not receive CT or MRI during the acute hospital stay, and the percentage of patients scanned on the first day of hospitalization almost doubled from 43% in 1980 to 76% in 1990 (P=.0001). For ischemic stroke patients, the use of carotid ultrasound doubled from 24% to 48% between 1985 and 1990 (P<.0005), and the probability of identifying a possibly embolic source increased from 27% in 1980 to 40% in 1990 (P<.0005). The use of anticoagulants to treat ischemic stroke decreased from 1985 to 1990 (heparin, 53% to 47%, P=.030; coumadin, 37% to 31%, P=.032), whereas the use of aspirin increased by over 50% (from 27% to 41%, P<.0005). Finally, the mean length of stay was halved from 20 days in 1980 to 10 days in 1990 (P=.0001). This study documented several significant time trends in acute stroke care. Whether these trends account for some of the improvement in stroke survival during the 1980s is uncertain.

Acute stroke therapy in Europe today

Until a few years ago, and still today, early stroke management has not been considered to be of major importance. Although it is one of the leading causes of death and permanent disability, absorbing a considerable proportion of health care budgets, and different from myocardial infarction which is the other highest-ranking disease in mortality/morbidity statistics in the industrialized countries, stroke has not been considered an emergency, and both general and special treatments for the acute stroke patient have been denied despite evidence to the contrary [1, 2].

Stroke: non-motor sequelae, medical co-morbidity and patterns of intervention after referral to a special interest service

Stroke poses a considerable financial burden on the health services as well as contributing to enormous personal suffering. A study was undertaken in 100 patients over 65 years old in a geriatric unit. Neuro-radiology confirmed cerebral infarcts in 91 and 89 per cent had additional neuro-medical problems. Specific sequelae of stroke occurred in 53 per cent of which 21 per cent related to dysphagia. Among various treatments 61 per cent were referred for physiotherapy and occupational and speech/language therapy. Knowledge of the nature and timing of complications is important in planning stroke services and the input of early medical specialist assessment has been shown to influence mortality and rehabilitation outcome.

Neuroprotection as initial therapy in acute stroke. Third Report of an Ad Hoc Consensus Group Meeting. The European Ad Hoc Consensus Group

Although a considerable body of scientific data is now available on neuroprotection in acute ischaemic stroke, this field is not yet established in clinical practice. At its third meeting, the European Ad Hoc Consensus Group considered the potential for neuroprotection in acute stroke and the practical problems attendant on the existence of a very limited therapeutic window before irreversible brain damage occurs, and came to the following conclusions. NEUROPROTECTANTS IN CLINICAL DEVELOPMENT: Convincing clinical evidence for an efficacious neuroprotective treatment in acute stroke is still required. Caution should be exercised in interpreting and extrapolating experimental results to stroke patients, who are a very heterogeneous group. The limitations of the time windows and the outcome measures chosen in trials of acute stroke therapy have an important influence on the results. The overall distribution of functional outcomes provides more statistical information than the proportion above a threshold outcome value. Neurological outcome should also be assessed. Neuroprotectants should not be tested clinically in phase II or phase III trials in a time window that exceeds those determined in experimental studies. The harmful effects of a drug in humans may override its neuroprotective potential determined in animals. Agents that act at several different levels in the ischaemic cascade may be more effective than those with a single mechanism of action. CURRENT IN-HOSPITAL MANAGEMENT OF ACUTE STROKE: The four major physiological variables that must be monitored and managed are blood pressure, arterial blood gas levels, body temperature, and glycaemia. The effects of controlling these physiological variables have not been studied in prospective trials, though they may all contribute to the outcome of acute ischaemic stroke and affect the duration of the therapeutic window. Optimal physiological parameters are inherently neuroprotective. Trials of new agents for the treatment of acute stroke should aim to maintain these physiological variables as close to normal as possible, and certainly within strictly defined limits. THE PLACE OF NEUROPROTECTANTS IN ACUTE STROKE MANAGEMENT: Stroke patients are a very heterogeneous group with respect to stroke mechanisms and severity, general condition, age and co-morbidities. At the present time, the only firm guideline than can be proposed for patient selection is the need for early admission to enable neuroprotectant and/or thrombolytic treatment to be started as soon as possible within the therapeutic window. The severity of potential side-effects will largely determine who should assess a patient with suspected stroke and initiate treatment. There is little information on which to base the duration of neuroprotectant therapy, and more experimental data are needed. Even if prehospital treatment proves to be feasible, it should not replace comprehensive stroke management in a specialist hospital unit. Clinical trials of neuroprotectants should only be performed in stroke units. The combined approach of restoring blood flow and providing neuroprotection may be the most productive in human stroke, but current clinical trial design will have to change in order to test combination therapy. Important side-effects are those that interfere with any possible benefit or increase mortality. PHARMACO-ECONOMIC ASPECTS OF NEUROPROTECTANTS: The early increase in hospital cost associated with neuroprotectant therapy may be balanced by the shorter length of hospital stay and lesser degree of disability of the surviving patients. The overall direct financial cost is highly dependent on the number of patients eligible for neuroprotectant therapy, which is itself dependent on the length of the therapeutic window and the severity of potential side-effects. A treatment that achieves a good functional outcome is the most cost-effective approach.

Neurological intensive care admissions: identifying candidates for intermediate care and the services they receive

OBJECTIVE

The high cost and scarcity of intensive care unit (ICU) beds has resulted in a need for improved utilization. This study describes the characteristics of patients who are admitted to the ICU for neurosurgical and neurological care, identifies patients who might receive all or most of their care in an intermediate care unit, and describes the services the patients would receive in an intermediate care unit.

METHODS

We describe patients who received neurological care and who were part of a prospective study of 17,440 patients admitted to 42 ICUs at 40 United States hospitals. We identified patients who received only monitoring during ICU Day 1 and then used a previously validated equation to distinguish which patients were at low risk (< 10%) for subsequent active life-supporting therapy. We also describe the services these patients received during their ICU stay.

RESULTS

Among 3000 patients admitted to the ICU for neurological care, 1350 received active therapy and 1650 (55%) underwent monitoring and received concentrated nursing care on ICU Day 1. After excluding those patients who received active therapy at admission, 1288 (78%) of the 1650 patients who underwent monitoring at admission were at low risk (< 10%) for subsequent active therapy; 95.8% received no active therapy. These patients who were at low risk for subsequent active therapy were significantly (P < 0.001) more often admitted postoperatively, were younger and less severely ill, and had lower ICU and hospital mortality rates (0.9 and 3.9%, respectively) than patients who received active treatment at admission.

CONCLUSIONS

Patients receiving neurological care at an ICU who receive only monitoring during their 1st ICU day and have a less than 10% predicted risk of active treatment can be safely transferred to an intermediate care unit. Some of these patients may not require ICU admission. We suggest guidelines for equipping and staffing neurological intermediate care units based on the type and amount of therapy received by these patients.

High stroke incidence in the prospective community-based L'Aquila registry (1994-1998). First year's results

BACKGROUND AND PURPOSE

Changes in stroke incidence are likely to occur as a consequence of aging of the population, but evidence for this hypothesis is lacking.

METHODS

A prospective community-based registry of first-ever strokes (1994 to 1998) classified according to the International Classification of Diseases, 9th Revision (ICD-9) was established in the L'Aquila district, central Italy, with a total population of 297,838 (1991 census). Patients were identified by active monitoring of multiple sources, including general practitioners.

RESULTS

In 1994, 819 patients (398 men and 421 women; mean +/- SD age, 74.8 +/- 11.3 years) suffered from a first-ever stroke. Eighty-nine percent of the patients had neuroimaging studies of the brain and were reclassified with the recent Application of the International Classification of Diseases to Neurology (ICD-10 NA). The occurrence of subarachnoid hemorrhage, intracerebral hemorrhage, cerebral infarction, and ill-defined events was 2.9%, 14.9%, 80.2%, and 2.0%, respectively. Crude annual incidence of first-ever stroke was 2.75/1000 (95% confidence interval [CI], 2.57 to 2.94) and 24.23/1000 (95% CI, 21.65 to 27.10) in patients older than 80 years. Incidence rates were higher in men and steeply increased with age. The standardized rate was 2.37/1000 for the Italian and 2.28/1000 for the European population. The 30-day case-fatality rate was 25.6% (95% CI, 22.8% to 28.7%). The occurrence of death, disability, and full recovery at 1 year was 36.9%, 38.9%, and 24.2%, respectively. No differences were found in stroke incidence and case-fatality according to income and urban or rural residences.

CONCLUSIONS

In our population-based study, we found a high stroke incidence notably in the older age subgroups, suggesting that rather than declining, stroke is only being postponed until later in life.

Geriatric rehabilitation: state of the art

OBJECTIVES

To provide a clinically useful conceptual framework for the evaluation and treatment of disability in older persons, to review the rehabilitation of common conditions affecting function in older persons, and to discuss the effects of the ongoing changes in the healthcare system on geriatric rehabilitation.

METHODS

MedLine search and review of relevant texts for information on (1) geriatric disability and its treatment, (2) recent high quality research, guidelines, and review articles relevant to the rehabilitation of conditions commonly causing geriatric disability, (3) effects of recent changes in the healthcare system on geriatric rehabilitation.

RESULTS

Several pertinent models for geriatric disability were identified. These are explicated, along with information on the epidemiology of geriatric disability and its causes and relevant clinical applications. Rehabilitation is reviewed for musculoskeletal disorders, stroke and peripheral vascular disease, amputation, cardiopulmonary disorders, hip fracture, and deconditioning. Changes in the healthcare system appear to be affecting geriatric rehabilitation, especially the advent of managed care; relevant articles and opinions are reviewed, along with strategies to accommodate these changes.

CONCLUSIONS

Our understanding of the causes of disability in the older population has improved significantly over the last decade. There has also been noteworthy progress in our knowledge about the effects of selected rehabilitation interventions, especially exercise-related interventions. However, the cost-effectiveness of many rehabilitative interventions remains unclear, particularly for differing patient groups across the continuum of care. More research will be needed to evaluate the effects of managed care on rehabilitation outcomes in older persons.

Early supported hospital discharge following acute stroke: pilot study results

OBJECTIVE

To establish the feasibility and method of evaluation of an early supported hospital discharge policy for patients with acute stroke.

DESIGN

A randomized controlled trial comparing an early supported discharge service to conventional care.

SETTING

Three acute hospitals in Newcastle upon Tyne.

SUBJECTS

Ninety-two eligible patients with acute stroke admitted between 1 February 1995 and 31 January 1996.

MAIN OUTCOME MEASURES

Placement, length of stay, readmission rates, mortality, functional ability (Nottingham Extended Activities of Daily Living (ADL) Scale), handicap (Oxford Handicap Scale), global health status (Dartmouth Coop Function Charts) and carer stress (General Health Questionnaire 30 item).

RESULTS

The median length of stay for patients randomized to early supported discharge was 13 days compared to 22 days in the conventional care group (p = 0.02). The median Barthel ADL index at seven days post stroke of patients randomized to early supported discharge was 15, and 13 for those randomized to conventional care (NS). At three months post stroke the median Nottingham EADL score of patients randomized to early supported discharge was 10 compared to 7 for those who received conventional care (NS). There were no statistically significant differences in the global health status of patients or carer stress.

CONCLUSION

An early supported discharge service following acute stroke with individualized rehabilitation in the community is feasible and can be evaluated by a randomized controlled trial but a larger multicentre trial is needed before such a service is widely adopted.

The uptake and costs of guidelines for stroke in a district of southern England

STUDY OBJECTIVE

To assess the impact of guidelines for stroke management on the utilisation of services by patients and the cost consequences of implementation.

DESIGN

Prospective audit.

SETTING

District health authority in southern England.

PATIENTS

A total of 468 live non-comatose stroke patients registered between November 1991 and May 1993.

MAIN OUTCOME MEASURES

A comparison between the three, six month periods for investigations performed and rehabilitation received and their associated costs.

RESULTS

The appropriateness of the use of investigations improved over time to between 88 and 92% except for computed tomography (CT) (24%). Younger, more severely impaired patients in a medical bed were more likely to have CT. Overall levels of rehabilitation were low. There was no change in use of physiotherapy (61% to 63%), a significant increase in occupational therapy (26% to 39%) and a non significant change in speech therapy (34% to 25%) over time. Guideline introduction caused a modest 23 Pounds increase in costs per patient in the 2nd six months and 41 Pounds in the 3rd six months but this sum could rise to 430 Pounds per patient if full implementation of the guidelines occurred which is still only around 13% of the costs of nursing care while in hospital.

CONCLUSIONS

This 18 month aduit shows only modest changes in practice compared with guidelines, and overall levels of rehabilitation were low. The costs of full implementation seem considerable, but in fact constitute only a small proportion of nursing care costs.

Stroke unit treatment. Long-term effects

BACKGROUND AND PURPOSE

We have previously shown that treatment in our combined acute and rehabilitation Stroke Unit improves outcome during the first year after onset of stroke compared with stroke patients treated in general wards. The aim of the present trial was to examine the long-term effects of the stroke unit care.

METHODS

In a randomized controlled trial, 110 patients with symptoms and signs of an acute stroke were allocated to the Stroke Unit and 110 to general wards. No significant differences existed in baseline characteristics between the two groups. The outcome after 5 years was measured by the proportion of patients at home, the proportion of patients in an institution, the mortality, and the functional state assessed by Barthel Index.

RESULTS

After 5 years, 38 (34.5%) of the patients randomized to the Stroke Unit and 20 (18.2%) of the patients randomized to the general wards were at home (P = .006). Sixty-five (59.1%) of the patients from the Stroke Unit and 78 (70.9%) of the patients from the general wards were dead (P = .041), while 7 (6.4%) and 12 (10.9%), respectively, were in an institution (e.g., nursing home) (P = NS). Functional state was significantly better for patients treated in the Stroke Unit.

CONCLUSIONS

For the first time it is shown that stroke unit care improves long-term survival and functional state and increases the proportion of patients able to live at home 5 years after the stroke. Combined acute and rehabilitation stroke units appear to be an effective way of organizing treatment for acute stroke patients.

Early management and outcome of acute stroke in Auckland

BACKGROUND

Studies of acute stroke management in stroke units and tertiary referral hospitals may not accurately reflect practice within the population. Reliable information on the management of stroke within a population is sparse.

AIMS

To compare clinical practice in acute stroke management in Auckland with guidelines for the management and treatment of stroke in other countries; to provide a baseline measure against which future changes in management can be evaluated.

METHODS

All new stroke events in Auckland residents in 12 months were traced through multiple case finding sources. For each patient, a record of investigations and treatment during the first week of hospital admission was kept.

RESULTS

One thousand eight hundred and three stroke events (including subarachnoid haemorrhages) occurred in 1761 patients in one year. Twenty-seven per cent of all events were managed outside hospital and 73% of the stroke events were treated in an acute hospital. Of the 1242 stroke events admitted to an acute hospital in the first week, only 6% were managed on the neurology and neurosurgery ward, 83% were managed by a general physician or geriatrician and 42% had computed tomography (CT). Of 376 validated ischaemic strokes, 44% were treated with aspirin and 12% with intravenous heparin. Of the 690 unspecified strokes (no CT or autopsy), 38% received aspirin and 0.5% heparin. The 28 day in-hospital case fatality for all stroke events admitted to an acute hospital during the first week was 25%.

CONCLUSIONS

In Auckland, management of acute stroke differed from clinical guidelines in the high proportion of patients managed in the community, the low rate of neurological consultation, and the low frequency of CT scanning. Despite these deficiencies in management, the 28 day hospital case fatality in Auckland was similar to other comparable studies which had a high proportion of cases evaluated by a neurologist and CT.

[Causes of unjustified hospital stay following cerebral infarction]

The frequency and causes of prolonged length of stay (LOS) in patients with acute ischemic stroke were studied in 20 patients admitted to a university hospital participating in the International Stroke Trial (IST). The protocol for prolonged LOS study designed by R. S. Goldman et al. (1996) was reproduced. Mean (+/- SD) LOS was 13.1 +/- 11.5 days (median = 10 days). Prolonged LOS occurred in 12 (60%) patients. In these 12 patients, a total of 83 (62%) of 134 days were found to be unnecessary (6.9 +/- 4.6). Most of these patients remained hospitalized while awaiting for routinely performed tests, such as 2D echocardiogram or carotid Doppler. LOS was not influenced by patient characteristics (age or gender) or specific location in the hospital (emergency room or other). In conclusion, LOS and hospitalization costs can be markedly reduced in this hospital by rational use of already available diagnostic tests.

Effects of intensity of rehabilitation after stroke. A research synthesis

BACKGROUND AND PURPOSE

A research synthesis was performed to (1) critically review controlled studies evaluating effects of different intensities of stroke rehabilitation in terms of disabilities and impairments and (2) quantify patterns by calculating summary effect sizes. The influences of organizational setting of rehabilitation management, blind recording, and amount of rehabilitation on the summary effect sizes were calculated.

METHODS

A Medline literature search was performed for a critical review of the literature. The internal and external validity of the studies was evaluated. In addition, a meta-analysis was performed by applying the fixed (Hedges's g) effects model.

RESULTS

The effects of different intensities of rehabilitation were studied in nine controlled studies involving 1051 patients. Analysis of the methodological quality revealed scores varying from 14% to 47% of the maximum feasible score. Meta-analysis demonstrated a statistically significant summary effect size for activities of daily living (0.28 +/- 0.12). Lower summary effect sizes (0.19 +/- 0.17) were found for studies in which experimental and control groups were treated in the same setting compared with studies in which the two groups of patients were treated in different settings (0.40 +/- 0.19). Variables defined on a neuromuscular level (0.37 +/- 0.24) showed larger summary effect sizes than variables defined on a functional level (0.10 +/- 0.21). Weighting individual effect sizes for the difference in amount of rehabilitation between experimental and control groups resulted in larger summary effect sizes for activities of daily living and functional outcome parameters for studies that were not confounded by organizational setting.

CONCLUSIONS

A small but statistically significant intensity-effect relationship in the rehabilitation of stroke patients was found. Insufficient contrast in the amount of rehabilitation between experimental and control conditions, organizational setting of rehabilitation management, lack of blinding procedures, and heterogeneity of patient characteristics were major confounding factors.

Stroke syndromes

Emergency physicians must stay cognizant of the rapid and dramatic changes underway in the management of patients with acute stroke syndrome. The future clearly points towards a time when emergency physicians will be called upon to treat "brain attacks" in a manner similar to heart attacks, with early recognition and treatment. As effective interventions are developed, we will be able to alter the course, increase the survival, and decrease the morbidity and long-term disability of stroke patients.

Comments on Meta-Analysis with Longitudinal Studies: Controlling for Analytical Bias

This article provides a critique of a previous meta-analysis and claims to have produced contradictory results; however, the criticism is based on a misunderstanding of the previous Lancet meta-analysis.

The role of nursing in the rehabilitation of acute stroke patients: toward a unified theoretical perspective

A review of existing literature indicates an uncertainty about the specific therapeutic role of nurses in the rehabilitation of stroke patients. Two different conceptualizations of the nursing role exist, but neither is related to specific rehabilitation goals and patient outcomes. A beginning theoretical account of the specific role of nursing in stroke recovery is offered as a structure to integrate the therapeutic aspects of the coordinating, maintenance, and training functions of the nurse. Existing research literature is reviewed to substantiate the account. Further research is needed to develop the specific content and focus of nursing in stroke recovery.

A prediction model for functional recovery in stroke

BACKGROUND AND PURPOSE

Stroke-related physical disability can diminish quality of daily living, place care burden on families, and increase need for long-term institutionalization. We developed a prognostic index for use in research and with potential for adaptation to clinical practice that establishes the likelihood of an individual achieving a specific stage of functional recovery after stroke rehabilitation.

METHODS

We constructed the index using logistic regression based on 3760 patient records from 96 rehabilitation facilities in 31 states. The stage, as measured by the Functional Independence Measure, includes achievement of the following: independence in eating, grooming, and dressing the upper body; continence in bowel and bladder; and transfer between a bed and chair with supervision only.

RESULTS

This stage was achieved by 26.1% of patients functioning below it at rehabilitation admission. Disability onset of less than 60 days was associated with more than a 3-fold increase in the likelihood of achieving the stage (adjusted odds ratio, 3.5; 95% confidence interval, 2.0 to 6.0). Each eight-point increase in an eight-item activities of daily living score, measured at admission to rehabilitation, increased the odds 2.5-fold (95% confidence interval, 2.3 to 2.8). For those living alone or employed before the stroke, the odds of achieving the stage increased by factors of 1.3 and 2.2, respectively. The index showed minimal shrinkage on cross validation. The achievement of this profile of function is important because 95.3% of stroke patients who achieved or exceeded it were discharged home, as opposed to only 66.8% of those who did not achieve it.

CONCLUSIONS

The index can be used to establish prognoses for individual stroke patients at admission to rehabilitation with regard to achieving this stage. Achievement of the stage is associated with a high likelihood of discharge to home.

Access to rehabilitation facilities in an unselected hospital population affected by acute stroke

The aim of this study was to evaluate the selection criteria and characteristics of the patients who have access to rehabilitation facilities after having experienced an acute stroke. Between January 1993 and February 1994, 383 patients were recruited in 13 hospitals in Lombardy, and telephonically followed up four months after study entry. The data were collected by members of the Associazione Volontari Ospedalieri (Hospital Volunteers' Association). The 4-month mortality rate was 23%. The primary selection criterion for gaining access to rehabilitation facilities was the degree of disability; the secondary factor was age. Rehabilitation facilities were not available to very severely afflicted or self-sufficient patients, but were preferentially made available to young, partially-dependent patients. A rehabilitative intervention within the first month was made available to fewer than 50% of the patients for whom it was indicated. The absence of care for elderly patients and the delay in its availability for those who actually receive it underline the need for new organisational methods. The data presented here also show that voluntary associations can work as observers of the health service. A more complete study is required in order to understand the real dimensions of the problem and the clinical and social characteristics of the population involved.

Length of hospital stay and discharge delays in stroke patients

BACKGROUND AND PURPOSE

In The Netherlands, many stroke patients stay in the hospital for some time merely waiting for discharge placement. This indicates an inefficient use of hospital resources, as well as a possible deficiency in the quality of care, because hospitals are not adequately equipped to care for these patients. In this study, we tried to quantify this "waiting problem."

METHODS

Six hospitals and 29 neurologists participated in this prospective study. The neurologists were asked during weekly interviews to specify for 154 patients the reason for retention in the hospital on a day-to-day basis. The reasons were noted on a list specified by the authors in advance.

RESULTS

The mean length of hospital stay was 28 days. On average, there were "hard" medical reasons for 15 days (54%) and "soft" medical reasons for 3 days (10%), whereas the remaining 10 days (36%) were explained by nonmedical reasons (most frequently, waiting for placement in a nursing home).

CONCLUSIONS

The length of hospital stay for stroke patients in The Netherlands can be reduced considerably without compromising the quality of care. This might be realized by increasing the capacity of long-term care facilities, improving the efficiency of the discharge procedures, or creating "stroke services."

Redefining 'doing something': health professionals' views on their role in the care of stroke patients

Stroke has traditionally been considered, both by lay people and by many people working within the health services, to be a tragic yet essentially uninteresting condition, possibly because of its associations with old age, chronicity and the widespread perception that very little can be done about it. This study explored health professionals' views about their role in caring for people with stroke, and about what they gained from and contributed to this work. Questionnaires were distributed to staff working on an elderly care unit, a general medical ward and a stroke unit. Nurses and physiotherapists were positive and reported that they had much to offer people with stroke, and many rewards to gain from their work. Occupational therapists reported that in theory they had much to contribute to people with stroke, but in practice lack of resources and staff shortages prevented them from fulfilling their potential. Speech therapists also complained of scarce resources, and of a lack of recognition of their specialty, but felt able to contribute to improving peoples' quality of life. Both psychologists reported that their work with people with stroke was satisfying and stimulating. However, with the exception of the consultant on the stroke unit, doctors reported feeling they had little to offer, and little to gain from working with people with stroke. Therapists on the elderly care unit, and speech therapists in all settings reported difficulties within the multidisciplinary team. Although each profession had different concerns and priorities, the majority seemed to have a positive approach to their work with people with stroke. Similarly, the majority reported that the best thing about their work was when people recovered, although professions defined recovery differently.

Meta-analysis with longitudinal studies: controlling for analytical bias

A recent study published in an international medical journal presented an opportunity to demonstrate the difficulties of interpreting meta-analysis results with longitudinal data. We conducted a new meta-analysis using identical data from the published study and showed contradictory results.

Hospital charges for stroke patients

BACKGROUND AND PURPOSE

Stroke is a common disease with a yearly cost in the United States of approximately $30 billion. The increasing prevalence of managed care and cost-containment measures may affect the delivery of stroke care now and in the future. This study was performed to determine (1) hospital charges and test utilization for stroke patients and (2) the effectiveness of educational efforts in modifying test utilization and related hospital charges.

METHODS

Patients with a diagnosis of stroke who were discharged from either the neurology service or another service of the Department of Medicine (DOM) were identified. Data on test utilization and hospital charges were collected and analyzed. Following this analysis, educational sessions were held in an effort to reduce the use of specific diagnostic tests. The effectiveness of these methods was studied in a second group of stroke patients.

RESULTS

In the baseline period there were 303 stroke patients, of which 262 (86%) were discharged from the neurology service and 41 (14%) were discharged from other services of the DOM. Patients on the neurology service had a lower mean length of stay than patients on the other services of the DOM (9.2 days versus 10.5 days) and lower mean total charges per case ($13,149 versus $15,727), although the respective differences were not statistically significant. Patient on the neurology service were more likely to have both brain CT and MRI performed (82 of 262 patients, 31.3%) than patients on the other services of the DOM (4 of 41, 9.8%, P = .005). In addition, patients on the neurology service were more likely to undergo a transthoracic echocardiogram than patients on the other services of the DOM (71.8% versus 53.7%, P = .025). After educational sessions, the percentage of stroke patients on the neurology service having both CT and MRI fell from 31.3% to 17.7% (P = .005), and the number of stroke patients having a transthoracic echocardiogram fell from 71.8% to 60.3% (P = .025). However, the overall charges for stroke patients on the neurology services did not decrease.

CONCLUSIONS

Education can be successful in reducing the utilization of and associated charges for specific diagnostic tests for some stroke patients. A multidisciplinary approach to case management, using tools such as care maps, may be necessary to realize significant cost savings in certain groups of stroke patients.

Vertebrobasilar thrombosis: diagnosis, management, and the use of intra-arterial thrombolytics

OBJECTIVES

To review the diagnosis and management of vertebrobasilar thrombosis and to discuss the use of thrombolytics in the treatment of this disease.

DATA SOURCES

Selected references discussing epidemiology, anatomy, pathophysiology, diagnosis, therapy, and rehabilitation of vertebrobasilar occlusive disease.

STUDY SELECTION

Studies addressing acute intervention and outcome in the therapy of vertebrobasilar thrombosis were reviewed.

DATA EXTRACTION

Only those studies with angiographic documentation of arterial thrombosis and, in the case of thrombolysis, recanalization, were considered valid.

DATA SYNTHESIS

Thrombosis of the vertebrobasilar system is a highly fatal disease and should be treated as a neurologic emergency. The key to effective management depends on early recognition of the symptom complex and a thorough understanding of the anatomy and pathophysiology of the disease process.

CONCLUSIONS

A timely, integrated, multidisciplinary approach to the patient with vertebrobasilar thrombosis can improve outcome. The use of thrombolytics in the treatment of vertebrobasilar occlusion holds promise but the benefits have not yet been proven in a controlled, randomized study.

The Copenhagen Stroke Study experience

The Copenhagen Stroke (COST) Study was a prospective, consecutive, community-based study of 1,197 patients with acute stroke who underwent acute stroke care and rehabilitation in a stroke unit setting. This article reviews the results of this study with respect to (1) the effect of organized stroke care and rehabilitation, (2) neurological outcome and functional outcome of stroke in relation to initial stroke severity and functional disability, (3) recovery of upper-extremity function and walking, (4) time course of neurological and functional recovery relative to initial stroke severity, (5) mechanisms of stroke recovery, and (6) the effect on stroke recovery of various demographic, medical, and pathophysiological factors, such as stroke in progression, spontaneous reperfusion age, diabetes, blood glucose on admission, stroke type (hemorrhage/infarction), silent infarction, and leuco-araiosis.

Can contracts drive clinical care?

The instrument through which a commissioner purchases health services from a provider is, as in other walks of life, a contract, so considerable importance has been attached by the NHS Executive to the contracting mechanism. A contract should in theory influence the quality of the service provided, but they are in many cases an inappropriate vehicle for driving clinical care. Much clinical activity is related to the management of chronic diseases and the effects of aging. The implicit contract here is based not on process and outcome measures but on mutual trust between doctors and patients that the doctors will provide the best care they can within budgetary constraints.

Specialist nurse support for patients with stroke in the community: a randomised controlled trial

OBJECTIVE

To evaluate whether specialist nurse visits enhance the social integration and perceived health of patients with stroke or alleviate stress in carers in longer term stroke care.

DESIGN

Stratified randomised controlled trial; both groups assessed at time of recruitment and at 3, 6, and 12 months.

SETTING

Patients with disability related to new stroke who lived in their own homes in the Bradford Metropolitan District.

SUBJECTS

240 patients aged 60 years or over, randomly allocated to control group (n = 120) or intervention group (n = 120). Intervention--Visits by specialist outreach nurses over 12 months to provide information, advice, and support; minimum of six visits during the first six months. The control group received no visits.

MAIN OUTCOME MEASURES

The Barthel index (functional ability), the Frenchay activities index (social activity), the Nottingham health profile (perceived health status). Stress among carers was indicated by the general health questionnaire-28 (28 items). The nurses recorded their interventions in trial diaries.

RESULTS

There were no significant differences in perceived health, social activities, or stress among carers between the treatment and control groups at any of the assessments points. A subgroup of mildly disabled patients with stroke (Barthel index 15-19) had an improved social outcome at six months (Frenchay activities index, Median difference 3 (95% confidence interval 0 to 6; P = 0.03) and for the full 12 months of follow up (analysis of covariance P = 0.01) compared with the control group.

CONCLUSIONS

The specialist nurse intervention resulted in a small improvement in social activities only for the mildly disabled patients. No proved strategy yet exists that can be recommended to address the psychosocial difficulties of patients with stroke and their families.

Functional electrostimulation in poststroke rehabilitation: a meta-analysis of the randomized controlled trials

OBJECTIVE

To assess the efficacy of functional electrical stimulation (FES) in the rehabilitation of hemiparesis in stroke.

DESIGN

A meta-analysis combined the reported randomized controlled trials of FES in stroke, using the effect size method of Glass, and the DerSimonian-Laird Random Effects Method for pooling studies.

SETTING

The included studies were published between 1978 and 1992. They were conducted in academic rehabilitation medicine settings.

PATIENTS

In all included studies, patients were in poststroke rehabilitation. The mean time after stroke varied from 1.5 to 29.2 months.

INTERVENTION

FES applied to a muscle or associated nerve in a hemiparetic extremity was compared to No FES.

MAIN OUTCOME MEASURE

Change in paretic muscle force of contraction following FES was compared to change without FES.

RESULTS

For the four included studies, the mean effect size was .63 (95% CI: .29, .98). This result was statistically significant (p < .05).

CONCLUSION

Pooling from randomized trials supports FES as promoting recovery of muscle strength after stroke. This effect is statistically significant. There is a reasonable likelihood of clinical significance as well.

Can regional variation in "avoidable" mortality be explained by deaths outside hospital? A study from Sweden, 1987-90

STUDY OBJECTIVE

This study aimed to calculate the proportion of deaths outside hospital in Sweden for some conditions for which the acute medical management may be important to the outcome and to analyse whether the proportion of deaths outside hospital can explain regional variations in mortality from these causes of death.

DESIGN

The place of death was registered on all death certificates in Sweden during the period 1987-90. The proportion of deaths outside hospital was calculated at the national level for selected causes of death. Variation in cause-specific mortality among the 26 administrative health areas in Sweden was analysed. Death rate ratios were calculated with standardisation for age and sex using the national rate as standard. The correlation between the proportion of deaths outside hospital in each health area and the cause specific mortality irrespective of place of death was calculated. For areas with a significantly high death rate the ratios for mortality outside hospital as well as in hospital were analysed in order to decide which component of mortality represented a high mortality risk.

SETTING AND PARTICIPANTS

All death registration in Swedish citizens and other residents in Sweden aged under 70 years between 1987 and 1990 which gave diabetes, asthma, ischaemic heart disease, cerebrovascular diseases, or ulcer of the stomach or duodenum as the underlying cause of death.

MAIN RESULTS

For asthma (58%) and ischaemic heart disease (54%), most deaths occurred outside hospital. For most causes of death, however, no correlation was found among the health areas between the proportion of deaths outside hospital and the SMR for mortality irrespective of the place of death. A high death rate was associated with a high proportion of deaths outside hospital, for diabetes in one area in the north of Sweden (Norrbotten) and for ulcer of the stomach and duodenum in one large municipality (Göteborg).

CONCLUSIONS

The high proportion of deaths outside hospital at the national level for some of the conditions studied suggests that in-depth studies of the process preceding death and the functioning of medical care are needed. In most cases, however, no evidence was found that regional variation in mortality could be explained by death outside hospital. The results for diabetes in Norbotten and ulcer of stomach and duodenum in Göteborg indicate that in-depth studies on the quality of care are required.

The assessment of acute stroke in general medical wards

In order to assess the completeness of clinical clerking, a retrospective study was made of the medical notes of 194 patients admitted with acute stroke over a 1-year period. The noting of clinical features associated with disease severity and prognosis, such as level of consciousness, proprioception, neglect, mental test score and continence was assessed. These features were rarely noted. Factors likely to influence placement following recovery were also poorly reported. In order to allow an accurate guide to stroke severity and prognosis these factors must be noted. An alternative form of clinical clerking is suggested in order to improve patient management.

Stroke is an emergency

Stroke is an emergency. Ischemic stroke is similar to myocardial infarction in that the pathogenesis is loss of blood supply to the tissue, which can result in irreversible damage if blood flow is not restored quickly. Public education is needed to emphasize the warning signs of stroke. Patients should seek medical help immediately, using emergency transport systems. Therapy geared toward minimizing the damage from an acute stroke should be started without delay in the emergency room. This includes measures to protect brain tissue, support perfusion pressure, and minimize cerebral edema. Strategies for improving recovery should also begin immediately. All major medical centers need stroke teams and stroke units. Stroke prevention should be given high priority as a public health strategy. Risk factor management should be part of general health care and should begin in childhood, with emphasis on nutrition, exercise, weight control, and avoidance of tobacco. Health screening and early treatment of hypertension and hypercholesterolemia has decreased the incidence of stroke and heart disease, but these efforts need to be expanded to reach all segments of the population. Basic research has opened the door to new therapies aimed at re-establishing blood flow and limiting tissue damage. Clinical trials have already led to changes in stroke prevention, including studies of carotid endarterectomy and ticlopidine and warfarin therapy (for patients with atrial fibrillation). Trials in progress are testing the usefulness of ancrod, neuroprotective agents, antioxidant agents, anti-inflammatory agents, low-molecular-weight heparin, thrombolytic drugs, and angioplasty. Any delay starting therapy after an acute stroke will result in progressive, irreversible loss of brain tissue. Clinicians should remember that for a stroke patient, time is brain tissue.

Nutritional assessment: a primary component of multidimensional geriatric assessment in the acute care setting

OBJECTIVE

To test the prognostic role of nutritional variables as a component of geriatric multidimensional assessment and to study the effect of hospitalization on nutritional status.

DESIGN

Validation cohort study: multidimensional assessment on admission and at discharge and a weekly nutritional assessment.

SETTING

General Medicine and Geriatrics wards in an acute-care university hospital.

PATIENTS

A consecutive sample of 302 patients aged 79 +/- 6 years, range 70-96 years.

MAIN OUTCOME MEASURES

Mortality, longstay (> 29 days), loss of lean body mass as expressed by a negative change in mid-arm muscle circumference (MAMC).

RESULTS

Incidence of mortality, longstay, and decreased MAMC was 6.9%, 24.8%, and 64.2%, respectively. According to logistic regression analysis, mortality was independently predicted by preadmission dependency in at least one Activity of Daily Living (odds ratio = 2.08, confidence limits = 1.19-3.65), clinical diagnosis of malnutrition (OR = 1.89, CL = 1.11-3.21), serum albumin < 3.5 g/dL (OR = 1.82, CL = 1.06-3.14). This predictive model allowed us to recognize 75% of the patients at risk of death by targeting 23% of the population. Longstay was independently predicted by stroke (OR = 1.54, CL = 1.01-2.35), clinical diagnosis of malnutrition (OR = 1.41, CL = 1.04-1.93), and more than five comorbid diseases (OR = 1.39, CL = 1.01-1.94). Dependency in at least one ADL was the only independent predictor of decreased MAMC (OR = 1.71, CL = 1.27-2.30).

CONCLUSIONS

Nutrition variables are a cardinal component of multidimensional assessment in the acute-care setting. Nutritional status deteriorates during the hospital stay, mostly in physically dependent patients.