In-hospital care pathways for stroke

Pharmacy program to improve care for veterans with transient ischaemic attack: a pilot implementation evaluation

Background

Early evaluation and effective communication to manage transient ischaemic attacks (TIA) may lead to a reduction of up to 70% in recurrent events for patients with TIA/minor stroke, along with reduced costs and lengths of hospital stay.

Methods

We conducted a single site pilot evaluation of a clinical pharmacy programme to improve medication management among TIA patients. The programme included a structured protocol, online identification tool, and a templated discharge checklist. Primary effectiveness measures were change in systolic blood pressure (SBP) 90 days post discharge and prescription of high/moderate potency statins. Contextual aspects and clinical perspectives on the implementation process were evaluated through prospective semistructured interviews with key informants.

Results

The analysis included 75 patients in the preimplementation group and 61 in the postimplementation group. The mean SBP at 90 days post discharge was significantly lower in the post implementation period (pre implementation, 133.3 mm Hg (SD 17.8) vs post implementation, 126.8 mm Hg (16.6); p=0.045). The change in SBP from discharge to 90 days post discharge was greater in the postimplementation period (15.8 mm Hg (20.5) vs 24.8 mm Hg (23.2); p=0.029). The prescription of high/moderate potency statins were similar across groups (pre implementation, 66.7% vs post implementation, 77.4%; p=0.229). Front-line clinicians involved in the pilot study reported positively on the acceptability, appropriateness and feasibility of implementing the protocol without additional cost and within current scope of practice.

Conclusions

Implementation of a clinical protocol outlining medication management and provider communication to ensure rapid postdischarge treatment of TIA patients was associated with SBP improvements. The pilot evaluation demonstrates how clinical pharmacists may play a role in treating low frequency, high stakes cerebrovascular events where early treatment and follow-up are critical.

Clinical pathways and patient-related outcomes in hospital-based settings: a systematic review and meta-analysis of randomized controlled trials

Clinical pathways represent a multi-disciplinary approach to translate clinical practice guidelines into practical interventions. The literature from 2010 onward regarding the efficacy of adopting a clinical pathway on patient-related outcomes within the in-hospital setting has not been synthesized yet. For this reason, this systematic review and meta-analysis of randomized controlled trials aimed to critically synthesize the literature from 2010 onward about the efficacy of clinical pathways, compared with standard of care, on patient-related outcomes in different populations and to determine the effects of clinical pathways on patient outcomes. We searched PubMed, Scopus, CINAHL, and reference lists of the included studies. Two independent reviewers screened the 360 identified articles and selected fifteen eligible articles, which were evaluated for content and risk of bias. Eleven studies were finally included. Given the commonalities of the measured outcomes, a meta-analysis including eight studies was performed to evaluate the effect size of the associations between clinical pathways and quality of life (OR=1.472 [0.483–4.486]; p=0.496), and two meta-analyses, including four studies, were performed to evaluate the effect sizes of the associations between clinical pathways with satisfaction (OR=2.226 [0.868–5.708]; p=0.096) and length of stay (OR=0,585 [0.349–0.982]; p=0.042). Reduced length of stay appeared to be associated with clinical pathways, while it remains unclear whether adopting clinical pathways could improve levels of quality of life and satisfaction. More primary research is required to determine in specific populations the efficacy of clinical pathways on patient-related outcomes. (www.actabiomedica.it)

Development and Internal Validation of a Nomogram to Predict Post-Stroke Fatigue After Discharge

OBJECTIVES

We aimed to develop and validate a nomogram for the individualized prediction of the risk of post-stroke fatigue (PSF) after discharge.

MATERIALS AND METHODS

Fatigue was measured using the Fatigue Assessment Scale. Multivariable logistic regression analysis was applied to build a prediction model incorporating the feature selected in the least absolute shrinkage and selection operator regression model. Discrimination, calibration, and clinical usefulness of the predictive model were assessed using the C-index, calibration plot, and decision curve analysis. Internal validation was conducted using bootstrapping validation. Finally, a web application was developed to facilitate the use of the nomogram.

RESULTS

We developed a nomogram based on 95 stroke patients. The predictors included in the nomogram were sex, pre-stroke sarcopenia, acute phase fatigue, dysphagia, and depression. The model displayed good discrimination, with a C-index of 0.801 (95% confidence interval: 0.700-0.902) and good calibration. A high C-index value of 0.762 could still be reached in the interval validation. Decision curve analysis showed that the risk of PSF after discharge was clinically useful when the intervention was decided at the PSF risk possibility threshold of 10% to 90%.

CONCLUSION

This nomogram could be conveniently used to provide an individual, visual, and precise prediction of the risk probability of PSF after being discharged home. Thus, as an aid in decision-making, physicians and other healthcare professionals can use this predictive method to provide early intervention or a discharge plan for stroke patients during the hospitalization period.

Implementation interventions to promote the uptake of evidence-based practices in stroke rehabilitation

BACKGROUND

Rehabilitation based upon research evidence gives stroke survivors the best chance of recovery. There is substantial research to guide practice in stroke rehabilitation, yet uptake of evidence by healthcare professionals is typically slow and patients often do not receive evidence-based care. Implementation interventions are an important means to translate knowledge from research to practice and thus optimise the care and outcomes for stroke survivors. A synthesis of research evidence is required to guide the selection and use of implementation interventions in stroke rehabilitation.

OBJECTIVES

To assess the effects of implementation interventions to promote the uptake of evidence-based practices (including clinical assessments and treatments recommended in evidence-based guidelines) in stroke rehabilitation and to assess the effects of implementation interventions tailored to address identified barriers to change compared to non-tailored interventions in stroke rehabilitation.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, and eight other databases to 17 October 2019. We searched OpenGrey, performed citation tracking and reference checking for included studies and contacted authors of included studies to obtain further information and identify potentially relevant studies.

SELECTION CRITERIA

We included individual and cluster randomised trials, non-randomised trials, interrupted time series studies and controlled before-after studies comparing an implementation intervention to no intervention or to another implementation approach in stroke rehabilitation. Participants were qualified healthcare professionals working in stroke rehabilitation and the patients they cared for. Studies were considered for inclusion regardless of date, language or publication status. Main outcomes were healthcare professional adherence to recommended treatment, patient adherence to recommended treatment, patient health status and well-being, healthcare professional intention and satisfaction, resource use outcomes and adverse effects.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies for inclusion, extracted data, and assessed risk of bias and certainty of evidence using GRADE. The primary comparison was any implementation intervention compared to no intervention.

MAIN RESULTS

Nine cluster randomised trials (12,428 patient participants) and three ongoing trials met our selection criteria. Five trials (8865 participants) compared an implementation intervention to no intervention, three trials (3150 participants) compared one implementation intervention to another implementation intervention, and one three-arm trial (413 participants) compared two different implementation interventions to no intervention. Eight trials investigated multifaceted interventions; educational meetings and educational materials were the most common components. Six trials described tailoring the intervention content to identified barriers to change. Two trials focused on evidence-based stroke rehabilitation in the acute setting, four focused on the subacute inpatient setting and three trials focused on stroke rehabilitation in the community setting. We are uncertain if implementation interventions improve healthcare professional adherence to evidence-based practice in stroke rehabilitation compared with no intervention as the certainty of the evidence was very low (risk ratio (RR) 1.19, 95% confidence interval (CI) 0.53 to 2.64; 2 trials, 39 clusters, 1455 patient participants; I2 = 0%). Low-certainty evidence indicates implementation interventions in stroke rehabilitation may lead to little or no difference in patient adherence to recommended treatment (number of recommended performed outdoor journeys adjusted mean difference (MD) 0.5, 95% CI -1.8 to 2.8; 1 trial, 21 clusters, 100 participants) and patient psychological well-being (standardised mean difference (SMD) -0.02, 95% CI -0.54 to 0.50; 2 trials, 65 clusters, 1273 participants; I2 = 0%) compared with no intervention. Moderate-certainty evidence indicates implementation interventions in stroke rehabilitation probably lead to little or no difference in patient health-related quality of life (MD 0.01, 95% CI -0.02 to 0.05; 2 trials, 65 clusters, 1242 participants; I2 = 0%) and activities of daily living (MD 0.29, 95% CI -0.16 to 0.73; 2 trials, 65 clusters, 1272 participants; I2 = 0%) compared with no intervention. No studies reported the effects of implementation interventions in stroke rehabilitation on healthcare professional intention to change behaviour or satisfaction. Five studies reported economic outcomes, with one study reporting cost-effectiveness of the implementation intervention. However, this was assessed at high risk of bias. The other four studies did not demonstrate the cost-effectiveness of interventions. Tailoring interventions to identified barriers did not alter results. We are uncertain of the effect of one implementation intervention versus another given the limited very low-certainty evidence.

AUTHORS' CONCLUSIONS

We are uncertain if implementation interventions improve healthcare professional adherence to evidence-based practice in stroke rehabilitation compared with no intervention as the certainty of the evidence is very low.

Lean Six Sigma approach to reduce LOS through a diagnostic-therapeutic-assistance path at A.O.R.N. A. Cardarelli

Purpose

The rise of the mean age incremented the occurrence of femur fractures with respect to the past, leading thus to serious consequences, as regards morbidity and socio-economic impact. The direction of the A.O.R.N. Cardarelli of Naples has introduced a DTAP whose aim was the reduction of LOS. The paper aims to discuss this issue.

Design/methodology/approach

The aim of this paper is to analyze the introduction of DTAP, employing Lean Thinking and Six Sigma methodology based on the DMAIC cycle. To evaluate the effectiveness of DTAP, two groups of patients have been observed for 14 months (before and after the implementation of DTAP).

Findings

Statistical tests were performed on the groups and graphics were provided to visualize the decrease of LOS (29.9 per cent). The overall population was also divided in subgroups according to six variables potentially influencing LOS.

Research limitations/implications

Authors considered six variables of influences; yet, others could be taken into account in the future.

Practical implications

The decrease of costs due to the management of elderly patients with femur fracture, the optimization of care processes in hospitals and a faster recovery for patients is the tangible contribute of DTAP.

Originality/value

The implementation of DTAP allowed the hospital to obtain a significant reduction of LOS with a consequently decrease of costs alleviating the hospital and the society from the socio-economic burden and the morbidity of this pathology.

Temporal Trends and Predictors of Drug Utilization and Outcomes in First-Ever Stroke Patients: A Population-Based Study Using the Singapore Stroke Registry

INTRODUCTION

Drug utilization and outcomes research in multi-ethnic Asian stroke populations is lacking.

OBJECTIVES

Our objective was to examine temporal trends and predictors of drug utilization and outcomes in a multi-ethnic Asian stroke population.

METHODS

This registry-based study included ischemic and hemorrhagic first-ever stroke patients hospitalized between 2009 and 2016. Utilization of medications included in-hospital thrombolytic agents, early antithrombotics (antiplatelets, anticoagulants) within 48 h of admission, and antithrombotics and statins at discharge. Outcomes analyzed were in-hospital all-cause mortality; 28-day, 90-day, and 1-year case fatality (CF); and discharge destination.

RESULTS

Of the 36,615 included patients, 81.6% had ischemic stroke and 18.4% had hemorrhagic stroke (15.5% intracerebral hemorrhage [ICH] and 2.8% subarachnoid hemorrhage [SAH]). For ischemic stroke, the combined use of all three guideline medications (in-hospital thrombolytic therapy, as well as antithrombotics and statins at discharge) increased (P = 0.006). Being on the stroke pathway was associated with prescription of all three guideline medications in ischemic stroke. Decreasing trends for in-hospital mortality, 28-day, 90-day, and 1-year CF and proportion of patients discharged home without rehabilitation appointment were observed in ischemic stroke (P < 0.05) but not in ICH or SAH (apart from 28-day CF). Ischemic stroke patients who received guideline medications were less likely to die or be discharged to nursing homes and chronic sick hospitals. Hemorrhagic stroke patients prescribed statins at discharge were less likely to have 28-day and 1-year CF.

CONCLUSIONS

Prescription of secondary stroke preventive medications (particularly in ischemic stroke) was associated with more favorable outcomes, highlighting the importance of physician adherence to evidence-based pharmacotherapy.

Changes in acute hospital costs after employing clinical facilitators to improve stroke care in Victoria, Australia

Background

Hospital costs for stroke are increasing and variability in care quality creates inefficiencies. In 2007, the Victorian Government (Australia) employed clinical facilitators for three years in eight public hospitals to improve stroke care. Literature on the cost implications of such roles is rare. We report changes in the costs of acute stroke care following implementation of this program.

Methods

Observational controlled before-and-after cohort design. Standardised hospital costing data were compared pre-program (financial year 2006–07) and post-program (2010–11) for all admitted episodes of stroke or transient ischaemic attack (TIA) using ICD-10 discharge codes. Costs in Australian dollars (AUD) were adjusted to a common year 2010. Generalised linear regression models were used for adjusted comparisons.

Results

A 20% increase in stroke and TIA episodes was observed: 2624 pre-program (age > 75 years: 53%) and 3142 post-program (age > 75 years: 51%); largely explained by more TIA admissions (up from 785 to 1072). Average length of stay reduced by 22% (pre-program 7.3 days to post-program 5.7 days, p < 0.001). Six hospitals provided cost data. Average per-episode costs decreased by 10% (pre-program AUD7888 to post-program AUD7115). After adjusting for age, sex, stroke type, and hospital, average per-episode costs decreased by 6.1% from pre to post program (p = 0.025). When length of stay was additionally adjusted for, these costs increased by 10.8%, indicating a greater mean cost per day (p < 0.001).

Conclusion

Cost containment of acute inpatient episodes was observed after the implementation of stroke clinical facilitators, likely associated with the shorter lengths of stay.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3836-9) contains supplementary material, which is available to authorized users.

How to practice person-centred care: A conceptual framework

BACKGROUND

Globally, health-care systems and organizations are looking to improve health system performance through the implementation of a person-centred care (PCC) model. While numerous conceptual frameworks for PCC exist, a gap remains in practical guidance on PCC implementation.

METHODS

Based on a narrative review of the PCC literature, a generic conceptual framework was developed in collaboration with a patient partner, which synthesizes evidence, recommendations and best practice from existing frameworks and implementation case studies. The Donabedian model for health-care improvement was used to classify PCC domains into the categories of "Structure," "Process" and "Outcome" for health-care quality improvement.

DISCUSSION

The framework emphasizes the structural domain, which relates to the health-care system or context in which care is delivered, providing the foundation for PCC, and influencing the processes and outcomes of care. Structural domains identified include: the creation of a PCC culture across the continuum of care; co-designing educational programs, as well as health promotion and prevention programs with patients; providing a supportive and accommodating environment; and developing and integrating structures to support health information technology and to measure and monitor PCC performance. Process domains describe the importance of cultivating communication and respectful and compassionate care; engaging patients in managing their care; and integration of care. Outcome domains identified include: access to care and Patient-Reported Outcomes.

CONCLUSION

This conceptual framework provides a step-wise roadmap to guide health-care systems and organizations in the provision PCC across various health-care sectors.

Association between patient outcomes and key performance indicators of stroke care quality: A systematic review and meta-analysis

Purpose

Translating research evidence into clinical practice often uses key performance indicators to monitor quality of care. We conducted a systematic review to identify the stroke key performance indicators used in large registries, and to estimate their association with patient outcomes.

Method

We sought publications of recent (January 2000-May 2017) national or regional stroke registers reporting the association of key performance indicators with patient outcome (adjusting for age and stroke severity). We searched Ovid Medline, EMBASE and PubMed and screened references from bibliographies. We used an inverse variance random effects meta-analysis to estimate associations (odds ratio; 95% confidence interval) with death or poor outcome (death or disability) at the end of follow-up.

Findings

We identified 30 eligible studies (324,409 patients). The commonest key performance indicators were swallowing/nutritional assessment, stroke unit admission, antiplatelet use for ischaemic stroke, brain imaging and anticoagulant use for ischaemic stroke with atrial fibrillation, lipid management, deep vein thrombosis prophylaxis and early physiotherapy/mobilisation. Lower case fatality was associated with stroke unit admission (odds ratio 0.79; 0.72-0.87), swallow/nutritional assessment (odds ratio 0.78; 0.66-0.92) and antiplatelet use for ischaemic stroke (odds ratio 0.61; 0.50-0.74) or anticoagulant use for ischaemic stroke with atrial fibrillation (odds ratio 0.51; 0.43-0.64), lipid management (odds ratio 0.52; 0.38-0.71) and early physiotherapy or mobilisation (odds ratio 0.78; 0.67-0.91). Reduced poor outcome was associated with adherence to swallowing/nutritional assessment (odds ratio 0.58; 0.43-0.78) and stroke unit admission (odds ratio 0.83; 0.77-0.89). Adherence with several key performance indicators appeared to have an additive benefit.

Discussion

Adherence with common key performance indicators was consistently associated with a lower risk of death or disability after stroke.

Conclusion

Policy makers and health care professionals should implement and monitor those key performance indicators supported by good evidence.

What Interventions Should Pharmacists Employ to Impact Health Practitioners’ Prescribing Practices?

Objective:

To determine which interventions are effective in influencing health practitioners’ prescribing practices and explore differences in intervention complexity, setting, sustainability, cost effectiveness, and impact on patient outcomes.

Methods:

A systematic search for English-language systematic reviews was performed in MEDLINE, Cumulative Index of Nursing and Allied Health Literature, EMBASE, and the Cochrane Library from the date of inception to July 2005 using search terms in accordance with Cochrane recommendations. Included reviews were required to clearly report a search strategy, inclusion/exclusion criteria, literature assessment criteria, and methods for synthesizing or summarizing information and references. Two reviewers independently identified studies for inclusion, assessed study quality, and extracted relevant information. Interventions were classified as consistently effective, inconsistently effective, and effectiveness uncertain.

Results:

Thirty-four of 4585 titles reviewed met the inclusion criteria. Quality scores ranged from 70% to 100%. Consistently effective interventions included reminders (manual and computerized), audit and feedback, educational outreach visits, organizational strategies, and patient-mediated interventions. Inconsistently effective interventions included computer decision support systems and educational meetings. Multi-faceted interventions were consistently shown to be more efficacious than single interventions. Limited data precluded exploration of the effects of interventions in different settings, sustainability of effect, cost effectiveness, and patient clinical outcomes.

Conclusions:

Interventions that are most effective for impacting prescribing practice include audit and feedback, reminders, educational outreach visits, and patient-mediated interventions. To maximize impact, pharmacists’ efforts to positively impact prescribing practices should focus on these intervention types rather than relying primarily on passive didactics or dissemination of guidelines.

Pre-hospital Delay as Determinant of Ischemic Stroke Outcome in an Italian Cohort of Patients Not Receiving Thrombolysis

BACKGROUND

Pre-hospital delay in acute stroke is critical to the administration of thrombolysis and affects patients' clinical outcome. In this study, the impact of pre-hospital delay on the outcome of ischemic stroke was investigated in an Italian cohort of patients who did not receive thrombolysis.

METHODS

Data from a cohort of 1847 patients, suffering from first-ever ischemic stroke and referred to an in-hospital clinical pathway were analyzed retrospectively. The relationship between pre-hospital delay and 1-month mortality was assessed with adjustment for demographics, premorbid disability, and stroke severity, which was graded according to the Scandinavian Stroke Scale, with higher scores indicating less severity.

RESULTS

Five hundred and twelve patients (27.7%) arrived at hospital within 2 hours of symptom onset. A significant correlation was found between early arrival and a reduced risk of 1-month mortality (hazard ratio .65; 95% confidence interval .48-.89; P = .02). There was a significant interaction (P = .01) between pre-hospital delay and the neurological score on mortality in the multivariate model, and the survival advantage of early admission was significant only for patients with scores on the Scandinavian Stroke Scale less than 18 (hazard ratio .54; 95% confidence interval .34-.85; P = .008).

CONCLUSIONS

Our study suggests that reducing pre-hospital delay can increase the probability of survival in patients with ischemic stroke, especially those who are most severely affected. Even if the patients cannot benefit from thrombolysis, survival rates can be increased provided that they are managed according to standardized care processes.

Development and implementation of acute stroke care pathway in a tertiary care hospital in India: A cluster-randomized study

BACKGROUND

In-hospital care of stroke patients can reduce the risk of death and disability. There is an emerging evidence for the routine use of care pathways (CPs) for acute stroke management. Our aim was to develop evidence-based CPs and test the hypothesis that acute stroke management by CPs is superior to that provided by conventional care.

MATERIALS AND METHODS

An acute stroke CP was designed in accordance with the recent American Stroke Association (ASA)/American Heart Association (AHA) stroke guidelines and the Indian Academy of Neurology (IAN) stroke management guidelines in India. A total of 162 acute stroke patients, who were managed within 72 hours of onset of their symptoms, were enrolled prospectively in two groups-the stroke care pathway (CP) arm (n = 77) and the conventional care (CC) arm (n = 85). The incidence of aspiration pneumonia, complications during the hospital stay, and death or dependency at discharge and at 90 days were among the main outcomes of our study.

RESULTS

The CP arm had a lower incidence of aspiration pneumonia (AP) in comparison with the CC arm (6.5% vs. 15.3%, risk ratio [RR] = 0.42, 95% confidence interval [CI] = 0.16-1.14, P = 0.062). The CP group had a decreased risk of requirement of mechanical ventilation (7.8% vs. 17.6%, odds ratio [OR] = 0.39, 95% CI = 0.14-1.07, P = 0.05). Barthel and modified Rankin Scale scores were similar in both the groups, but death at 90 days was significantly lesser in the CP arm (7.8% vs. 20%, P = 0.022). This benefit was most prominent in the Glasgow Coma Scale (GCS) subgroup scoring 9-15 (RR = 0.16, 95% CI = 0.03-0.71). There were no significant differences in the other outcome measures.

CONCLUSION

Stroke CPs reduce the incidence of aspiration pneumonia, the need for mechanical ventilation, and the risk of death, when assessed at a follow-up of 90 days.

End-of-life care pathways for improving outcomes in caring for the dying

BACKGROUND

This is an updated version of a Cochrane review published in Issue 11, 2013 in the Cochrane Library. In many clinical areas, integrated care pathways are utilised as structured multidisciplinary care plans that detail essential steps in caring for patients with specific clinical problems. In particular, care pathways for the dying have been developed as a model to improve care of patients who are in the last days of life. The care pathways were designed with an aim of ensuring that the most appropriate management occurs at the most appropriate time, and that it is provided by the most appropriate health professional. Since the last update, there have been sustained concerns about the safety of implementing end-of-life care pathways, particularly in the United Kingdom (UK). Therefore, there is a significant need for clinicians and policy makers to be informed about the effects of end-of-life care pathways via a systematic review.

OBJECTIVES

To assess the effects of end-of-life care pathways, compared with usual care (no pathway) or with care guided by another end-of-life care pathway across all healthcare settings (e.g. hospitals, residential aged care facilities, community).In particular, we aimed to assess the effects on symptom severity and quality of life of people who are dying, or those related to the care, such as families, carers and health professionals, or a combination of these.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL; Cochrane Library; 2015, Issue 6), MEDLINE, EMBASE, PsycINFO, CINAHL, review articles, trial registries and reference lists of relevant articles. We conducted the original search in September 2009, and the second updated search in July 2015.

SELECTION CRITERIA

All randomised controlled trials (RCTs), quasi-randomised trials or high quality controlled before-and-after studies comparing use versus non-use of an end-of-life care pathway in caring for the dying.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the results of the searches against the predetermined criteria for inclusion, assessed risk of bias, and extracted data. We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

We screened 3028 titles, and included one Italian cluster RCT with 16 general medicine wards (inpatient units in hospitals) and 232 carers of cancer patients in this updated review. We judged the study to be at a high risk of bias overall, mainly due to a lack of blinding and rates of attrition. Only 34% of the participants (range 14% to 75% on individual wards) were cared for in accordance with the care pathway as planned. However, these issues were to be expected due to the nature of the intervention and condition. The study population was all cancer patients in their last days of life. Participants were allocated to care using the Liverpool Care Pathway (LCP-I, Italian version of a continuous quality improvement programme of end-of-life care) or to standard care. The primary outcomes of this review were physical symptom severity, psychological symptom severity, quality of life, and any adverse effects. Physical symptom severity was assessed as overall control of pain, breathlessness, and nausea and vomiting. There was very low quality evidence of a difference in overall control of breathlessness that favoured the Liverpool Care Pathway group compared to usual care: the study reported an odds ratio (OR) of 2.0 with 95% confidence intervals (CIs) 1.1 to 3.8. Very low quality evidence of no difference was found for pain (OR 1.3, 95% CI 0.7 to 2.6, P = 0.461) and nausea and vomiting (OR 1.5, 95% CI 0.7 to 3.2, P = 0.252). None of the other primary outcomes were assessed by the study. Limited data on advance care planning were collected by the study authors, making results for this secondary outcome unreliable. None of our other secondary outcomes were assessed by the study.

AUTHORS' CONCLUSIONS

There is limited available evidence concerning the clinical, physical, psychological or emotional effectiveness of end-of-life care pathways.

Discharge planning from hospital

BACKGROUND

Discharge planning is a routine feature of health systems in many countries. The aim of discharge planning is to reduce hospital length of stay and unplanned readmission to hospital, and to improve the co-ordination of services following discharge from hospital.This is the third update of the original review.

OBJECTIVES

To assess the effectiveness of planning the discharge of individual patients moving from hospital.

SEARCH METHODS

We updated the review using the Cochrane Central Register of Controlled Trials (CENTRAL) (2015, Issue 9), MEDLINE, EMBASE, CINAHL, the Social Science Citation Index (last searched in October 2015), and the US National Institutes of Health trial register (ClinicalTrials.gov).

SELECTION CRITERIA

Randomised controlled trials (RCTs) that compared an individualised discharge plan with routine discharge care that was not tailored to individual participants. Participants were hospital inpatients.

DATA COLLECTION AND ANALYSIS

Two authors independently undertook data analysis and quality assessment using a pre-designed data extraction sheet. We grouped studies according to patient groups (elderly medical patients, patients recovering from surgery, and those with a mix of conditions) and by outcome. We performed our statistical analysis according to the intention-to-treat principle, calculating risk ratios (RRs) for dichotomous outcomes and mean differences (MDs) for continuous data using fixed-effect meta-analysis. When combining outcome data was not possible because of differences in the reporting of outcomes, we summarised the reported data in the text.

MAIN RESULTS

We included 30 trials (11,964 participants), including six identified in this update. Twenty-one trials recruited older participants with a medical condition, five recruited participants with a mix of medical and surgical conditions, one recruited participants from a psychiatric hospital, one from both a psychiatric hospital and from a general hospital, and two trials recruited participants admitted to hospital following a fall. Hospital length of stay and readmissions to hospital were reduced for participants admitted to hospital with a medical diagnosis and who were allocated to discharge planning (length of stay MD - 0.73, 95% CI - 1.33 to - 0.12, 12 trials, moderate certainty evidence; readmission rates RR 0.87, 95% CI 0.79 to 0.97, 15 trials, moderate certainty evidence). It is uncertain whether discharge planning reduces readmission rates for patients admitted to hospital following a fall (RR 1.36, 95% CI 0.46 to 4.01, 2 trials, very low certainty evidence). For elderly patients with a medical condition, there was little or no difference between groups for mortality (RR 0.99, 95% CI 0.79 to 1.24, moderate certainty). There was also little evidence regarding mortality for participants recovering from surgery or who had a mix of medical and surgical conditions. Discharge planning may lead to increased satisfaction for patients and healthcare professionals (low certainty evidence, six trials). It is uncertain whether there is any difference in the cost of care when discharge planning is implemented with patients who have a medical condition (very low certainty evidence, five trials).

AUTHORS' CONCLUSIONS

A discharge plan tailored to the individual patient probably brings about a small reduction in hospital length of stay and reduces the risk of readmission to hospital at three months follow-up for older people with a medical condition. Discharge planning may lead to increased satisfaction with healthcare for patients and professionals. There is little evidence that discharge planning reduces costs to the health service.

Development and validation of Australian aphasia rehabilitation best practice statements using the RAND/UCLA appropriateness method

OBJECTIVES

To develop and validate a national set of best practice statements for use in post-stroke aphasia rehabilitation.

DESIGN

Literature review and statement validation using the RAND/UCLA Appropriateness Method (RAM).

PARTICIPANTS

A national Community of Practice of over 250 speech pathologists, researchers, consumers and policymakers developed a framework consisting of eight areas of care in aphasia rehabilitation. This framework provided the structure for the development of a care pathway containing aphasia rehabilitation best practice statements. Nine speech pathologists with expertise in aphasia rehabilitation participated in two rounds of RAND/UCLA appropriateness ratings of the statements. Panellists consisted of researchers, service managers, clinicians and policymakers.

MAIN OUTCOME MEASURES

Statements that achieved a high level of agreement and an overall median score of 7-9 on a nine-point scale were rated as 'appropriate'.

RESULTS

74 best practice statements were extracted from the literature and rated across eight areas of care (eg, receiving the right referrals, providing intervention). At the end of Round 1, 71 of the 74 statements were rated as appropriate, no statements were rated as inappropriate, and three statements were rated as uncertain. All 74 statements were then rated again in the face-to-face second round. 16 statements were added through splitting existing items or adding new statements. Seven statements were deleted leaving 83 statements. Agreement was reached for 82 of the final 83 statements.

CONCLUSIONS

This national set of 82 best practice statements across eight care areas for the rehabilitation of people with aphasia is the first to be validated by an expert panel. These statements form a crucial component of the Australian Aphasia Rehabilitation Pathway (AARP) (http://www.aphasiapathway.com.au) and provide the basis for more consistent implementation of evidence-based practice in stroke rehabilitation.

Hegemann's disease and fishtail deformity: aetiopathogenesis, radiographic appearance and clinical outcome

PURPOSE

A systematic review regarding clinical studies on Hegemann's disease and fishtail deformity was performed with the aims to: (1) formulate the most up-to-date theory on aetiology in order to better define these conditions, (2) summarise the most frequent radiographic descriptions on radiographs and (3) give an overview of different treatment options.

METHODS

A systematic review of studies to date on Hegemann's disease and fishtail deformity was performed. Studies were eligible if: (1) the article provides a description of Hegemann's disease or fishtail deformity, (2) original data of at least one patient was available, (3) the article was written in English, German or Dutch and (4) a full manuscript was available. Animal studies, reviews and expert opinions were not included.

RESULTS

We included a total of 22 articles: seven regarding Hegemann's disease including eight patients and 15 regarding fishtail deformity including 58 patients.

CONCLUSIONS

Fishtail deformity and Hegemann's disease seem to be a spectrum of vascular disorders of the distal humerus, varying from a benign mild vascular disorder to a complete avascular necrosis after fractures. Additional imaging is advised to confirm the presence of a fishtail deformity, intra-articular loose bodies and signs of osteoarthritis to decide if, and what, operative treatment is needed. As long as no clear aetiology for both diseases exist and the clinical symptoms and radiographic appearance are difficult to distinguish, both entities should preferably be named as 'vascular disturbance of the trochlear growth plate' to overcome confusing definitions and discussions.

Panner's disease: literature review and treatment recommendations

PURPOSE

To determine the most up-to-date theory on the aetiology of Panner's disease, to form a consensus on the assessment of radiographs and to evaluate clinical outcome in order to summarise the best available evidence for diagnosis and treatment.

METHODS

A review of studies to date on Panner's disease. Studies were eligible if: (1) the study provided criteria for defining Panner's disease in order to eliminate confounding data on other radiographic entities that were mistakenly grouped and presented as Panner's disease; (2) original data of at least one patient was presented; (3) manuscripts were written in English, German or Dutch; and (4) a full-text article was available. Animal studies, reviews and expert opinions were not included. Because the majority of the studies were case reports, we did not use an overall scoring system to evaluate methodological quality.

RESULTS

Twenty-three articles reporting on Panner's disease were included. Most cases of Panner's disease were unilateral in distribution and occurred in boys during the first decade of life. In general, conservative treatment is advised for Panner's disease. Panner's disease is a self-limiting disease and the majority of patients heal without clinical impairment.

CONCLUSIONS

Based on the results of this review, Panner's disease should be treated conservatively. Uniform names and descriptions of signs on radiographs would help to make the correct diagnosis. Since Panner's disease is very rare, higher quality studies are not likely to be performed and, thus, this review provides the best level of evidence on the current knowledge about Panner's disease.

Retrospective assessment of the implementation of critical pathway in stroke patients in a single university hospital

Objective

To evaluate the effects of the implementation of critical pathway (CP) in stroke patients treated at a single university hospital.

Methods

A retrospective medical review collected data from 497 patients who had suffered acute stroke in the rehabilitation center. Stroke outcomes were compared between before and after the implementation of CP based on factors including demographic factors, stroke characteristics, pre-existing medical conditions, medical complications, functional states, and length of stay (LOS).

Results

After the implementation of CP, the patients showed significantly higher stage for upper proximal (p=0.008) and lower extremity (p=0.001) on Brunnstrom stage and significantly lower scores for modified Rankin Scale (p=0.003) at transfer. For those with pre-existing medical conditions, there were significantly increased osteoarthritis (p=0.002) and valvular heart disease (p=0.011). Regarding medical complications during acute inpatient rehabilitation, there were significantly decreased shoulder pain (p=0.001) and dysphagia (p=0.017), and significantly increased gastrointestinal symptoms (p=0.001). Functional gain and efficiency of stroke patients during rehabilitation center hospitalization did not significantly change after implementation of CP. But, shorter LOS of total hospitalization, pre-rehabilitation center hospitalization, and rehabilitation center hospitalization were evident.

Conclusion

After the implementation of CP, patients less often developed complications and displayed no changes in functional gain and efficiency. They had shorter LOS of total hospitalization, pre-rehabilitation center hospitalization and rehabilitation center hospitalization.

Clinical pathways for chronic cough in children

BACKGROUND

Chronic cough (a cough lasting longer than four weeks) is a common problem internationally. Chronic cough has associated economic costs and is distressing to the child and to parents; ignoring cough may lead to delayed diagnosis and progression of serious underlying respiratory disease. Clinical guidelines have been shown to lead to efficient and effective patient care and can facilitate clinical decision making. Cough guidelines have been designed to facilitate the management of chronic cough. However, treatment recommendations vary, and specific clinical pathways for the treatment of chronic cough in children are important, as causes of and treatments for cough vary significantly from those in adults. Therefore, systematic evaluation of the use of evidence-based clinical pathways for the management of chronic cough in children would be beneficial for clinical practice and for patient care. Use of a management algorithm can improve clinical outcomes; such management guidelines can be found in the guidelines for cough provided by the American College of Chest Physicians (ACCP) and the British Thoracic Society (BTS).

OBJECTIVES

To evaluate the effectiveness of using a clinical pathway in the management of children with chronic cough.

SEARCH METHODS

The Cochrane Register of Controlled Trials (CENTRAL), the Cochrane Airways Group Specialised Register, MEDLINE, EMBASE, review articles and reference lists of relevant articles were searched. The latest search was conducted in January 2014.

SELECTION CRITERIA

All randomised controlled trials of parallel-group design comparing use versus non-use of a clinical pathway for treatment of chronic cough in children (< 18 years of age).

DATA COLLECTION AND ANALYSIS

Results of searches were reviewed against predetermined criteria for inclusion. Two review authors independently selected studies and performed data extraction in duplicate.

MAIN RESULTS

One study was included in the review. This multi-centre trial was based in five Australian hospitals and recruited 272 children with chronic cough. Children were randomly assigned to early (two weeks) or delayed (six weeks) referral to respiratory specialists who used a cough management pathway. When an intention-to-treat analysis was performed, clinical failure at six weeks post randomisation (defined as < 75% improvement in cough score, or total resolution for fewer than three consecutive days) was significantly less in the early pathway arm compared with the control arm (odds ratio (OR) 0.35, 95% confidence interval (CI) 0.21 to 0.58). These results indicate that one additional child will be cured for every five children treated via the cough pathway (number needed to treat for an additional beneficial outcome (NNTB) = 5, 95% CI 3 to 9) at six weeks. Cough-specific parent-reported quality of life scores were significantly better in the early-pathway group; the mean difference (MD) between groups was 0.60 (95% CI 0.19 to 1.01). Duration of cough post randomisation was significantly shorter in the intervention group (early-pathway arm) compared with the control group (delayed-pathway arm) (MD -2.70 weeks, 95% CI -4.26 to -1.14).

AUTHORS' CONCLUSIONS

Current evidence suggests that using a clinical algorithm for the management of children with chronic cough in hospital outpatient settings is more effective than providing wait-list care. Futher high-quality randomised controlled trials are needed to perform ongoing evaluation of cough management pathways in general practitioner and other primary care settings.

Organising health care services for people with an acquired brain injury: an overview of systematic reviews and randomised controlled trials

BACKGROUND

Acquired brain injury (ABI) is the leading cause of disability worldwide yet there is little information regarding the most effective way to organise ABI health care services. The aim of this review was to identify the most up-to-date high quality evidence to answer specific questions regarding the organisation of health care services for people with an ABI.

METHODS

We conducted a systematic review of English papers using MEDLINE, EMBASE, PsycINFO, CINAHL and the Cochrane Library. We included the most recently published high quality systematic reviews and any randomised controlled trials, non-randomised controlled trials, controlled before after studies or interrupted time series studies published subsequent to the systematic review. We searched for papers that evaluated pre-defined organisational interventions for adults with an ABI. Organisational interventions of interest included fee-for-service care, integrated care, integrated care pathways, continuity of care, consumer engagement in governance and quality monitoring interventions. Data extraction and appraisal of included reviews and studies was completed independently by two reviewers.

RESULTS

A total of five systematic reviews and 21 studies were included in the review; eight of the papers (31%) included people with a traumatic brain injury (TBI) or ABI and the remaining papers (69%) included only participants with a diagnosis of stroke. We found evidence supporting the use of integrated care to improve functional outcome and reduce length of stay and evidence supporting early supported discharge teams for reducing morbidity and mortality and reducing length of stay for stroke survivors. There was little evidence to support case management or the use of integrated care pathways for people with ABI. We found evidence that a quality monitoring intervention can lead to improvements in process outcomes in acute and rehabilitation settings. We were unable to find any studies meeting our inclusion criteria regarding fee-for-service care or engaging consumers in the governance of the health care organisation.

CONCLUSIONS

The review found evidence to support integrated care, early supported discharge and quality monitoring interventions however, this evidence was based on studies conducted with people following stroke and may not be appropriate for all people with an ABI.

Implementation of evidence-based stroke care: enablers, barriers, and the role of facilitators

A stroke care strategy was developed in 2007 to improve stroke services in Victoria, Australia. Eight stroke network facilitators (SNFs) were appointed in selected hospitals to enable the establishment of stroke units, develop thrombolysis services, and implement protocols. We aimed to explain the main issues being faced by clinicians in providing evidence-based stroke care, and to determine if the appointment of an SNF was perceived as an acceptable strategy to improve stroke care. Face-to-face semistructured interviews were used in a qualitative research design. Interview transcripts were verified by respondents prior to coding. Two researchers conducted thematic analysis of major themes and subthemes. Overall, 84 hospital staff participated in 33 interviews during 2008. The common factors found to impact on stroke care included staff and equipment availability, location of care, inconsistent use of clinical pathways, and professional beliefs. Other barriers included limited access to specialist clinicians and workload demands. The establishment of dedicated stroke units was considered essential to improve the quality of care. The SNF role was valued for identifying gaps in care and providing capacity to change clinical processes. This is the first large, qualitative multicenter study to describe issues associated with delivering high-quality stroke care and the potential benefits of SNFs to facilitate these improvements.

Interventions to improve safe and effective medicines use by consumers: an overview of systematic reviews

BACKGROUND

Many systematic reviews exist on interventions to improve safe and effective medicines use by consumers, but research is distributed across diseases, populations and settings. The scope and focus of such reviews also vary widely, creating challenges for decision-makers seeking to inform decisions by using the evidence on consumers' medicines use.This is an update of a 2011 overview of systematic reviews, which synthesises the evidence, irrespective of disease, medicine type, population or setting, on the effectiveness of interventions to improve consumers' medicines use.

OBJECTIVES

To assess the effects of interventions which target healthcare consumers to promote safe and effective medicines use, by synthesising review-level evidence.

METHODS

SEARCH METHODS

We included systematic reviews published on the Cochrane Database of Systematic Reviews and the Database of Abstracts of Reviews of Effects. We identified relevant reviews by handsearching databases from their start dates to March 2012.

SELECTION CRITERIA

We screened and ranked reviews based on relevance to consumers' medicines use, using criteria developed for this overview.

DATA COLLECTION AND ANALYSIS

We used standardised forms to extract data, and assessed reviews for methodological quality using the AMSTAR tool. We used standardised language to summarise results within and across reviews; and gave bottom-line statements about intervention effectiveness. Two review authors screened and selected reviews, and extracted and analysed data. We used a taxonomy of interventions to categorise reviews and guide syntheses.

MAIN RESULTS

We included 75 systematic reviews of varied methodological quality. Reviews assessed interventions with diverse aims including support for behaviour change, risk minimisation and skills acquisition. No reviews aimed to promote systems-level consumer participation in medicines-related activities. Medicines adherence was the most frequently-reported outcome, but others such as knowledge, clinical and service-use outcomes were also reported. Adverse events were less commonly identified, while those associated with the interventions themselves, or costs, were rarely reported.Looking across reviews, for most outcomes, medicines self-monitoring and self-management programmes appear generally effective to improve medicines use, adherence, adverse events and clinical outcomes; and to reduce mortality in people self-managing antithrombotic therapy. However, some participants were unable to complete these interventions, suggesting they may not be suitable for everyone.Other promising interventions to improve adherence and other key medicines-use outcomes, which require further investigation to be more certain of their effects, include:· simplified dosing regimens: with positive effects on adherence;· interventions involving pharmacists in medicines management, such as medicines reviews (with positive effects on adherence and use, medicines problems and clinical outcomes) and pharmaceutical care services (consultation between pharmacist and patient to resolve medicines problems, develop a care plan and provide follow-up; with positive effects on adherence and knowledge).Several other strategies showed some positive effects, particularly relating to adherence, and other outcomes, but their effects were less consistent overall and so need further study. These included:· delayed antibiotic prescriptions: effective to decrease antibiotic use but with mixed effects on clinical outcomes, adverse effects and satisfaction;· practical strategies like reminders, cues and/or organisers, reminder packaging and material incentives: with positive, although somewhat mixed effects on adherence;· education delivered with self-management skills training, counselling, support, training or enhanced follow-up; information and counselling delivered together; or education/information as part of pharmacist-delivered packages of care: with positive effects on adherence, medicines use, clinical outcomes and knowledge, but with mixed effects in some studies;· financial incentives: with positive, but mixed, effects on adherence.Several strategies also showed promise in promoting immunisation uptake, but require further study to be more certain of their effects. These included organisational interventions; reminders and recall; financial incentives; home visits; free vaccination; lay health worker interventions; and facilitators working with physicians to promote immunisation uptake. Education and/or information strategies also showed some positive but even less consistent effects on immunisation uptake, and need further assessment of effectiveness and investigation of heterogeneity.There are many different potential pathways through which consumers' use of medicines could be targeted to improve outcomes, and simple interventions may be as effective as complex strategies. However, no single intervention assessed was effective to improve all medicines-use outcomes across all diseases, medicines, populations or settings.Even where interventions showed promise, the assembled evidence often only provided part of the picture: for example, simplified dosing regimens seem effective for improving adherence, but there is not yet sufficient information to identify an optimal regimen.In some instances interventions appear ineffective: for example, the evidence suggests that directly observed therapy may be generally ineffective for improving treatment completion, adherence or clinical outcomes.In other cases, interventions may have variable effects across outcomes. As an example, strategies providing information or education as single interventions appear ineffective to improve medicines adherence or clinical outcomes, but may be effective to improve knowledge; an important outcome for promoting consumers' informed medicines choices.Despite a doubling in the number of reviews included in this updated overview, uncertainty still exists about the effectiveness of many interventions, and the evidence on what works remains sparse for several populations, including children and young people, carers, and people with multimorbidity.

AUTHORS' CONCLUSIONS

This overview presents evidence from 75 reviews that have synthesised trials and other studies evaluating the effects of interventions to improve consumers' medicines use.Systematically assembling the evidence across reviews allows identification of effective or promising interventions to improve consumers' medicines use, as well as those for which the evidence indicates ineffectiveness or uncertainty.Decision makers faced with implementing interventions to improve consumers' medicines use can use this overview to inform decisions about which interventions may be most promising to improve particular outcomes. The intervention taxonomy may also assist people to consider the strategies available in relation to specific purposes, for example, gaining skills or being involved in decision making. Researchers and funders can use this overview to identify where more research is needed and assess its priority. The limitations of the available literature due to the lack of evidence for important outcomes and important populations, such as people with multimorbidity, should also be considered in practice and policy decisions.

Depression and adherence to treatment in diabetic children and adolescents: a systematic review and meta-analysis of observational studies

Depression compromises diabetes treatment in juveniles, and this study aimed to identify influential targets most likely to improve adherence to treatment and glycemic control. Prospective observational studies investigating associations between depression and treatment adherence in juveniles with type 1 diabetes were extracted from MEDLINE, EMBASE, CINAHL, PsycINFO and Cochrane Central. Nineteen studies comprising 2,935 juveniles met our criteria. Median effect sizes between depression and treatment adherence were 0.22 (interquartile range (IQR), 0.16–0.35) by patient and 0.13 (IQR, 0.12–0.24) caregiver report. Corresponding values for depression/glycemic control were 0.16 (IQR, 0.09– 0.23) and 0.08 (IQR, 0.04–0.14), respectively. Effect sizes varied with study design, publication year and assessment tools: CES-D yielded a higher effect size than other assessment tools for depression, where associations for depression and either adherence or glycemic control was investigated. Several behaviours influenced adherence and glycemic control.

CONCLUSION

This study showed moderate associations between depression and poor treatment adherence. Targeting behaviour and social environments, however, may ultimately provide more cost-effective health gains than targeting depressive symptoms.

End-of-life care pathways for improving outcomes in caring for the dying

BACKGROUND

This is an updated version of a Cochrane review first published in Issue 1, 2010 of The Cochrane Library. In many clinical areas, integrated care pathways are utilised as structured multidisciplinary care plans that detail essential steps in caring for patients with specific clinical problems. In particular, care pathways for the dying have been developed as a model to improve care of patients who are in the last days of life. The care pathways were designed with an aim of ensuring that the most appropriate management occurs at the most appropriate time and that it is provided by the most appropriate health professional. There have been sustained concerns about the safety of implementing end-of-life care pathways, particularly in the UK. Therefore, there is a significant need for clinicians and policy makers to be informed about the effects of end-of-life care pathways with a systematic review.

OBJECTIVES

To assess the effects of end-of-life care pathways, compared with usual care (no pathway) or with care guided by another end-of-life care pathway across all healthcare settings (e.g. hospitals, residential aged care facilities, community).In particular, we aimed to assess the effects on symptom severity and quality of life of people who are dying; those related to the care such as families, carers and health professionals; or a combination of these.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (Issue 6, 2013), MEDLINE, EMBASE, PsycINFO, CINAHL, review articles and reference lists of relevant articles. We conducted the original search in September 2009, and the updated search in June 2013.

SELECTION CRITERIA

All randomised controlled trials (RCTs), quasi-randomised trial or high-quality controlled before-and-after studies comparing use versus non-use of an end-of-life care pathway in caring for the dying.

DATA COLLECTION AND ANALYSIS

Two review authors assessed the results of the searches against the predetermined criteria for inclusion.

MAIN RESULTS

The original review identified 920 titles. The updated search found 2042 potentially relevant titles (including the original 920), but no additional studies met criteria for inclusion in the review update.

AUTHORS' CONCLUSIONS

With sustained concerns about the safety of the pathway implementation and the lack of available evidence on important patient and relative outcomes, recommendations for the use of end-of-life pathways in caring for the dying cannot be made. Since the last version of this review, no new studies met criteria for inclusion in the review update. With recently documented concerns related to the potential adverse effects associated with Liverpool Care Pathway (the most commonly used end-of-life care pathway), we do not recommend decision making based on indirect or low-quality evidence. All health services using end-of-life care pathways are encouraged to have their use of the pathway, to date, independently audited. Any subsequent use should be based on carefully documented evaluations. Large RCTs or other well-designed controlled studies are urgently required for the evaluation of the use of end-of-life care pathways in caring for dying people in various clinical settings. In future studies, outcome measures should include benefits or harms concerning the outcomes of interest in this review in relation to patients, families, carers and health professionals.

In-hospital risk prediction for post-stroke depression: development and validation of the Post-stroke Depression Prediction Scale

BACKGROUND AND PURPOSE

The timely detection of post-stroke depression is complicated by a decreasing length of hospital stay. Therefore, the Post-stroke Depression Prediction Scale was developed and validated. The Post-stroke Depression Prediction Scale is a clinical prediction model for the early identification of stroke patients at increased risk for post-stroke depression.

METHODS

The study included 410 consecutive stroke patients who were able to communicate adequately. Predictors were collected within the first week after stroke. Between 6 to 8 weeks after stroke, major depressive disorder was diagnosed using the Composite International Diagnostic Interview. Multivariable logistic regression models were fitted. A bootstrap-backward selection process resulted in a reduced model. Performance of the model was expressed by discrimination, calibration, and accuracy.

RESULTS

The model included a medical history of depression or other psychiatric disorders, hypertension, angina pectoris, and the Barthel Index item dressing. The model had acceptable discrimination, based on an area under the receiver operating characteristic curve of 0.78 (0.72-0.85), and calibration (P value of the U-statistic, 0.96). Transforming the model to an easy-to-use risk-assessment table, the lowest risk category (sum score, <-10) showed a 2% risk of depression, which increased to 82% in the highest category (sum score, >21).

CONCLUSIONS

The clinical prediction model enables clinicians to estimate the degree of the depression risk for an individual patient within the first week after stroke.

Discharge planning from hospital to home

BACKGROUND

Discharge planning is a routine feature of health systems in many countries. The aim of discharge planning is to reduce hospital length of stay and unplanned readmission to hospital, and improve the co-ordination of services following discharge from hospital.

OBJECTIVES

To determine the effectiveness of planning the discharge of individual patients moving from hospital.

SEARCH METHODS

We updated the review using the Cochrane EPOC Group Trials Register, MEDLINE, EMBASE and the Social Science Citation Index (last searched in March 2012).

SELECTION CRITERIA

Randomised controlled trials (RCTs) that compared an individualised discharge plan with routine discharge care that was not tailored to the individual patient. Participants were hospital inpatients.

DATA COLLECTION AND ANALYSIS

Two authors independently undertook data analysis and quality assessment using a pre designed data extraction sheet. Studies are grouped according to patient group (elderly medical patients, patients recovering from surgery and those with a mix of conditions) and by outcome. Our statistical analysis was done on an intention to treat basis, we calculated risk ratios for dichotomous outcomes and mean differences for continuous data using fixed-effect meta-analysis. When combining outcome data was not possible, because of differences in the reporting of outcomes, we have presented the data in narrative summary tables.

MAIN RESULTS

We included twenty-four RCTs (8098 patients); three RCTS were identified in this update. Sixteen studies recruited older patients with a medical condition, four recruited patients with a mix of medical and surgical conditions, one recruited patients from a psychiatric hospital, one from both a psychiatric hospital and from a general hospital, and two trials patients admitted to hospital following a fall (110 patients). Hospital length of stay and readmissions to hospital were statistically significantly reduced for patients admitted to hospital with a medical diagnosis and who were allocated to discharge planning (mean difference length of stay -0.91, 95% CI -1.55 to -0.27, 10 trials; readmission rates RR 0.82, 95% CI 0.73 to 0.92, 12 trials). For elderly patients with a medical condition there was no statistically significant difference between groups for mortality (RR 0.99, 95% CI 0.78 to 1.25, five trials) or being discharged from hospital to home (RR 1.03, 95% CI 0.93 to 1.14, two trials). This was also the case for trials recruiting patients recovering from surgery and a mix of medical and surgical conditions. In three trials, patients allocated to discharge planning reported increased satisfaction. There was little evidence on overall healthcare costs.

AUTHORS' CONCLUSIONS

The evidence suggests that a discharge plan tailored to the individual patient probably brings about reductions in hospital length of stay and readmission rates for older people admitted to hospital with a medical condition. The impact of discharge planning on mortality, health outcomes and cost remains uncertain.

The effect of clinical interventions on hospital readmissions: a meta-review of published meta-analyses

BACKGROUND

The economic impact and ease of measurement of all-cause hospital readmission rates (HRR) have led to the current debate as to whether they are reducible, and whether they should be used as a publicly reported quality indicators of medical care.

OBJECTIVE

To assess the efficacy of broad clinical interventions in preventing HRR of patients with chronic diseases

METHOD

A meta-review of published systematic reviews of randomized controlled trials (RCTs) of clinical interventions that have included HRR among the patients' outcomes of interest.

MAIN FINDINGS

Meta-analyses of RCTs have consistently found that, in the community, disease management programs significantly reduced HRR in patients with heart failure, coronary heart disease and bronchial asthma, but not in patients with stroke and in unselected patients with chronic disorders. Inhospital interventions, such as discharge planning, pharmacological consultations and multidisciplinary care, and community interventions in patients with chronic obstructive pulmonary diseases had an inconsistent effect on HRR. MAIN STUDY LIMITATION: Despite their economic impact and ease of measurement, HRR are not the most important outcome of patient care, and efforts aimed at their reduction may compromise patients' health by reducing also justified re-admissions.

CONCLUSIONS

The efficacy of inhospital interventions in reducing HRR is in need of further study. In patients with heart diseases and bronchial asthma, HRR may be considered as a publicly reported quality indicator of community care, provided that future research confirms that efforts to reduce HRR do not adversely affect other patients' outcomes, such as mortality, functional capacity and quality of life. Future research should also focus on the reasons for the higher efficacy of community interventions in patients with heart diseases and bronchial asthma than in those with other chronic diseases.

A cluster randomized trial to assess the effect of clinical pathways for patients with stroke: results of the clinical pathways for effective and appropriate care study

BACKGROUND

Clinical pathways (CPs) are used to improve the outcomes of acute stroke, but their use in stroke care is questionable, because the evidence on their effectiveness is still inconclusive. The objective of this study was to evaluate whether CPs improve the outcomes and the quality of care provided to patients after acute ischemic stroke.

METHODS

This was a multicentre cluster-randomized trial, in which 14 hospitals were randomized to the CP arm or to the non intervention/usual care (UC) arm. Healthcare workers in the CP arm received 3 days of training in quality improvement of CPs and in use of a standardized package including information on evidence-based key interventions and indicators. Healthcare workers in the usual-care arm followed their standard procedures. The teams in the CP arm developed their CPs over a 6-month period. The primary end point was mortality. Secondary end points were: use of diagnostic and therapeutic procedures, implementation of organized care, length of stay, re-admission and institutionalization rates after discharge, dependency levels, and complication rates.

RESULTS

Compared with the patients in the UC arm, the patients in the CP arm had a significantly lower risk of mortality at 7 days (OR = 0.10; 95% CI 0.01 to 0.95) and significantly lower rates of adverse functional outcomes, expressed as the odds of not returning to pre-stroke functioning in their daily life (OR = 0.42; 95 CI 0.18 to 0.98). There was no significant effect on 30-day mortality. Compared with the UC arm, the hospital diagnostic and therapeutic procedures were performed more appropriately in the CP arm, and the evidence-based key interventions and organized care were more applied in the CP arm.

CONCLUSIONS

CPs can significantly improve the outcomes of patients with ischemic patients with stroke, indicating better application of evidence-based key interventions and of diagnostic and therapeutic procedures. This study tested a new hypothesis and provided evidence on how CPs can work.

TRIAL REGISTRATION

ClinicalTrials.gov ID: [NCT00673491].

The effect of care pathways for hip fractures: a systematic review

We performed a systematic review for primary studies on care pathways (CPs) for hip fracture (HF). The online databases MEDLINE-PubMed, Ovid-EMBASE, CINAHL-EBSCO host, and The Cochrane Library (Cochrane Central Register of Clinical Trials, Health Technology Assessment Database, NHS Economic Evaluation Database) were searched. Two researchers reviewed the literature independently. Primary studies that met predefined inclusion criteria were assessed for their methodological quality. A total of 15 publications were included: 15 primary studies corresponding with 12 main investigations. Primary studies were evaluated for clinical outcomes, process outcomes, and economic outcomes. The studies assessed a wide range of outcome measures. While a number of divergent clinical outcomes were reported, most studies showed positive results of process management and health-services utilization. In terms of mortality, the results provided evidence for a positive impact of CPs on in-hospital mortality. Most studies also showed a significantly reduced risk of complications, including medical complications, wound infections, and pressure sores. Moreover, time-span process measures showed that an improvement in the organization of care was achieved through the use of CPs. Conflicting results were observed with regard to functional recovery and mobility between patients treated with CPs compared to usual care. Although our review suggests that CPs can have positive effects in patients with HF, the available evidence is insufficient for formal recommendations. There is a need for more research on CPs with selected process and outcome indicators, for in-hospital and postdischarge management of HF, with an emphasis on well-designed randomized trials.

The European quality of care pathways (EQCP) study on the impact of care pathways on interprofessional teamwork in an acute hospital setting: study protocol: for a cluster randomised controlled trial and evaluation of implementation processes

Background

Although care pathways are often said to promote teamwork, high-level evidence that supports this statement is lacking. Furthermore, knowledge on conditions and facilitators for successful pathway implementation is scarce. The objective of the European Quality of Care Pathway (EQCP) study is therefore to study the impact of care pathways on interprofessional teamwork and to build up understanding on the implementation process.

Methods/design

An international post-test-only cluster Randomised Controlled Trial (cRCT), combined with process evaluations, will be performed in Belgium, Ireland, Italy, and Portugal. Teams caring for proximal femur fracture (PFF) patients and patients hospitalized with an exacerbation of chronic obstructive pulmonary disease (COPD) will be randomised into an intervention and control group. The intervention group will implement a care pathway for PFF or COPD containing three active components: a formative evaluation of the actual teams’ performance, a set of evidence-based key interventions, and a training in care pathway-development. The control group will provide usual care. A set of team input, process and output indicators will be used as effect measures. The main outcome indicator will be relational coordination. Next to these, process measures during and after pathway development will be used to evaluate the implementation processes. In total, 132 teams have agreed to participate, of which 68 were randomly assigned to the intervention group and 64 to the control group. Based on power analysis, a sample of 475 team members per arm is required. To analyze results, multilevel analysis will be performed.

Discussion

Results from our study will enhance understanding on the active components of care pathways. Through this, preferred implementation strategies can be defined.

Trail registration

NCT01435538

Stroke rehabilitation

Stroke is a common, serious, and disabling global health-care problem, and rehabilitation is a major part of patient care. There is evidence to support rehabilitation in well coordinated multidisciplinary stroke units or through provision of early supported provision of discharge teams. Potentially beneficial treatment options for motor recovery of the arm include constraint-induced movement therapy and robotics. Promising interventions that could be beneficial to improve aspects of gait include fitness training, high-intensity therapy, and repetitive-task training. Repetitive-task training might also improve transfer functions. Occupational therapy can improve activities of daily living; however, information about the clinical effect of various strategies of cognitive rehabilitation and strategies for aphasia and dysarthria is scarce. Several large trials of rehabilitation practice and of novel therapies (eg, stem-cell therapy, repetitive transcranial magnetic stimulation, virtual reality, robotic therapies, and drug augmentation) are underway to inform future practice.

Consumer-oriented interventions for evidence-based prescribing and medicines use: an overview of systematic reviews

BACKGROUND

Numerous systematic reviews exist on interventions to improve consumers' medicines use, but this research is distributed across diseases, populations and settings. The scope and focus of reviews on consumers' medicines use also varies widely. Such differences create challenges for decision makers seeking review-level evidence to inform decisions about medicines use.

OBJECTIVES

To synthesise the evidence from systematic reviews on the effects of interventions which target healthcare consumers to promote evidence-based prescribing for, and medicines use, by consumers. We sought evidence on the effects on health and other outcomes for healthcare consumers, professionals and services.

METHODS

We included systematic reviews published on the Cochrane Database of Systematic Reviews and the Database of Abstracts of Reviews of Effects. We identified relevant reviews by handsearching both databases from start date to Issue 3 2008. We screened and ranked reviews based on relevance to consumers' medicines use, using criteria developed for this overview. Standardised forms were used to extract data, and reviews were assessed for methodological quality using the AMSTAR instrument. We used standardised language to summarise results within and across reviews; and a further synthesis step was used to give bottom-line statements about intervention effectiveness. Two review authors selected reviews, extracted and analysed data. We used a taxonomy of interventions to categorise reviews.

MAIN RESULTS

We included 37 reviews (18 Cochrane, 19 non-Cochrane), of varied methodological quality.Reviews assessed interventions with diverse aims including support for behaviour change, risk minimisation, skills acquisition and information provision. No reviews aimed to promote systems-level consumer participation in medicines-related activities. Medicines adherence was the most commonly reported outcome, but others such as clinical (health and wellbeing), service use and knowledge outcomes were also reported. Reviews rarely reported adverse events or harms, and the evidence was sparse for several populations, including children and young people, carers, and people with multimorbidity.Promising interventions to improve adherence and other key medicines use outcomes (eg adverse events, knowledge) included self-monitoring and self-management, simplified dosing and interventions directly involving pharmacists. Other strategies showed promise in relation to adherence but their effects were less consistent. These included reminders; education combined with self-management skills training, counselling or support; financial incentives; and lay health worker interventions.No interventions were effective to improve all medicines use outcomes across all diseases, populations or settings. For some interventions, such as information or education provided alone, the evidence suggests ineffectiveness; for many others there is insufficient evidence to determine effects on medicines use outcomes.

AUTHORS' CONCLUSIONS

Systematically assembling the evidence across reviews allows identification of effective or promising interventions to improve consumers' medicines use, as well as those for which the evidence indicates ineffectiveness or uncertainty.Decision makers faced with implementing interventions to improve consumers' medicines use can use this overview to inform these decisions and also to consider the range of interventions available; while researchers and funders can use this overview to determine where research is needed. However, the limitations of the literature relating to the lack of evidence for important outcomes and specific populations, such as people with multimorbidity, should also be considered.

Effectiveness of citronella preparations in preventing mosquito bites: systematic review of controlled laboratory experimental studies

OBJECTIVE

This review aims to examine the effectiveness of citronella preparation used as a mosquito repellent.

METHODS

Multiple computerized databases such as MEDLINE, EMBASE, Cochrane CENTRAL, CINAHL, and AMED, were searched for controlled laboratory experiments that compared the effectiveness of citronella products to control in repelling Aedes, Anopheles and Culex mosquitoes using the cage or room methods. Outcomes measures were protection time and percentage repellency. The weighted mean difference and 95% confidence interval were calculated comparing the outcomes in the citronella and control groups. Meta-analysis was performed using the DerSimonian and Laird method under a random-effects model.

RESULTS

Eleven studies met inclusion criteria. Based on a meta-analysis of studies using the cage method, protection time of the citronella oil for preventing Aedes mosquitoes was less than that in the DEET (N,N-diethyl-m-toluamide) group, with a difference in protection time of 253 min (95% confidence interval: 169-336). The combination of citronella oil and vanillin is likely to have a longer protection time compared with citronella oil alone. In studies using the room method, citronella oil and/or the combination of citronella oil and vanillin provided complete repellency at least 3 h. In Anopheles and Culex mosquitoes, a combination of citronella oil and vanillin product demonstrated a comparable protection time against DEET; however, it remained inconclusive due to a limited number of studies.

CONCLUSIONS

Citronella products are less effective than DEET products in terms of duration of protection. Adding vanillin to citronella oil products could prolong the protection time.

Introducing care pathway commissioning to primary dental care: the concept

Care pathways are defined as 'a methodology for the mutual decision making and organisation of care for a well-defined group of patients during a well-defined period'. Although most often used in Europe as a tool to improve the quality of care and to aid the continuity of care between disciplines and settings, care pathways also have an application in underpinning the commissioning process. This paper describes the development of a new model of commissioning for general dental practice services based on a need and risk assessment linked to specified care pathways for preventive care. In this system dentists are monitored on adherence to care protocols based on nationally accepted guidelines for preventive care interventions as well as recommended recall intervals for routine dental examinations. A traffic light system to distinguish between patients with different levels of need and risk of disease is being used.

End-of-life care pathways for improving outcomes in caring for the dying

BACKGROUND

In many clinical areas, integrated care pathways are utilised as structured multidisciplinary care plans which detail essential steps in caring for patients with specific clinical problems. Particularly, care pathways for the dying have been developed as a model to improve the end-of-life care of all patients. They aim to ensure that the most appropriate management occurs at the most appropriate time and that it is provided by the most appropriate health professional. Clinical pathways for end-of-life care management are used widely around the world and have been regarded as the gold standard. Therefore, there is a significant need for clinicians to be informed about the utilisation of end-of-life care pathways with a systematic review.

OBJECTIVES

To assess the effects of end-of-life care pathways, compared with usual care (no pathway) or with care guided by another end-of-life care pathway across all healthcare settings (e.g. hospitals, residential aged care facilities, community).

SEARCH STRATEGY

The Cochrane Register of controlled Trials (CENTRAL), the Pain, Palliative and Supportive Care Review group specialised register, MEDLINE, EMBASE, review articles and reference lists of relevant articles were searched. The search was carried out in September 2009.

SELECTION CRITERIA

All randomised controlled trials (RCTs), quasi-randomised trial or high quality controlled before and after studies comparing use versus non-use of an end-of-life care pathway in caring for the dying.

DATA COLLECTION AND ANALYSIS

Results of searches were reviewed against the pre-determined criteria for inclusion by two review authors.

MAIN RESULTS

The search identified 920 potentially relevant titles, but no studies met criteria for inclusion in the review.

AUTHORS' CONCLUSIONS

Without further available evidence, recommendations for the use of end-of-life pathways in caring for the dying cannot be made. RCTs or other well designed controlled studies are needed for evaluating the use of end-of-life care pathways in caring for dying people.

Discharge planning from hospital to home

BACKGROUND

Discharge planning is a routine feature of health systems in many countries. The aim of discharge planning is to reduce hospital length of stay and unplanned readmission to hospital, and improve the co-ordination of services following discharge from hospital.

OBJECTIVES

To determine the effectiveness of planning the discharge of patients moving from hospital.

SEARCH STRATEGY

We updated the review using the Cochrane EPOC Group Trials Register, MEDLINE, EMBASE and the Social Science Citation Index (last searched in March 2009).

SELECTION CRITERIA

Randomised controlled trials (RCTs) that compared an individualised discharge plan with routine discharge care that was not tailored to the individual patient. Participants were hospital inpatients.

DATA COLLECTION AND ANALYSIS

Two authors independently undertook data analysis and quality assessment using a predesigned data extraction sheet. Studies are grouped according to patient group (elderly medical patients, surgical patients and those with a mix of conditions) and by outcome.

MAIN RESULTS

Twenty-one RCTs (7234 patients) are included; ten of these were identified in this update. Fourteen trials recruited patients with a medical condition (4509 patients), four recruited patients with a mix of medical and surgical conditions (2225 patients), one recruited patients from a psychiatric hospital (343 patients), one from both a psychiatric hospital and from a general hospital (97 patients), and the final trial recruited patients admitted to hospital following a fall (60 patients). Hospital length of stay and readmissions to hospital were significantly reduced for patients allocated to discharge planning (mean difference length of stay -0.91, 95% CI -1.55 to -0.27, 10 trials; readmission rates RR 0.85, 95% CI 0.74 to 0.97, 11 trials). For elderly patients with a medical condition (usually heart failure) there was insufficient evidence for a difference in mortality (RR 1.04, 95% CI 0.74 to 1.46, four trials) or being discharged from hospital to home (RR 1.03, 95% CI 0.93 to 1.14, two trials). This was also the case for trials recruiting patients recovering from surgery and a mix of medical and surgical conditions. In three trials patients allocated to discharge planning reported increased satisfaction. There was little evidence on overall healthcare costs.

AUTHORS' CONCLUSIONS

The evidence suggests that a structured discharge plan tailored to the individual patient probably brings about small reductions in hospital length of stay and readmission rates for older people admitted to hospital with a medical condition. The impact of discharge planning on mortality, health outcomes and cost remains uncertain.

The suitability of care pathways for integrating processes and information systems in healthcare

Purpose

The purpose of this paper is to examine the suitability of current care pathway modelling techniques for supporting business improvement and the development of information systems. This is in the light of current UK government policies advocating the use of care pathways as part of the £12.4 billion programme for Information Technology and as a key strategy to reducing waiting times.

Design/methodology/approach

A qualitative analysis of the variety in purpose, syntax and semantics in a selection of existing care pathways is conducted.

Findings

Care pathways are typically modelled in an ad hoc manner with little reference to formal syntax or semantics.

Research limitations/implications

The research reviews a small selection of existing pathways. The feature set used for evaluation could be further refined. Future research should examine the suitability of applying existing process modelling techniques to care pathways and explore the motivations for modelling care pathways in an ad hoc manner.

Practical implications

The development of care pathways can aid process improvement and the integration of information systems. However, while syntax and semantics are not standardised the impact of care pathways in the work of Department of Health agencies, in particular Connecting for Health, is likely to be limited.

Originality/value

The results provide insight into the limitations of the state of the art in care pathway models. This highlights a significant omission in the Department of Health's approach and identifies an important direction for further development that will aid Connecting for Health, healthcare organisations and healthcare professionals to deliver more effective services.

Effects of clinical pathways in the joint replacement: a meta-analysis

BACKGROUND

A meta-analysis was performed to evaluate the use of clinical pathways for hip and knee joint replacements when compared with standard medical care. The impact of clinical pathways was evaluated assessing the major outcomes of in-hospital hip and knee joint replacement processes: postoperative complications, number of patients discharged at home, length of in-hospital stay and direct costs.

METHODS

Medline, Cinahl, Embase and the Cochrane Central Register of Controlled Trials were searched. The search was performed from 1975 to 2007. Each study was assessed independently by two reviewers. The assessment of methodological quality of the included studies was based on the Jadad methodological approach and on the New Castle Ottawa Scale. Data analysis abided by the guidelines set out by The Cochrane Collaboration regarding statistical methods. Meta-analyses were performed using RevMan software, version 4.2.

RESULTS

Twenty-two studies met the study inclusion criteria and were included in the meta-analysis for a total sample of 6,316 patients. The aggregate overall results showed significantly fewer patients suffering postoperative complications in the clinical pathways group when compared with the standard care group. A shorter length of stay in the clinical pathway group was also observed and lower costs during hospital stay were associated with the use of the clinical pathways. No significant differences were found in the rates of discharge to home.

CONCLUSION

The results of this meta-analysis show that clinical pathways can significantly improve the quality of care even if it is not possible to conclude that the implementation of clinical pathways is a cost-effective process, because none of the included studies analysed the cost of the development and implementation of the pathways. Based on the results we assume that pathways have impact on the organisation of care if the care process is structured in a standardised way, teams critically analyse the actual organisation of the process and the multidisciplinary team is highly involved in the re-organisation. Further studies should focus on the evaluation of pathways as complex interventions to help to understand which mechanisms within the clinical pathways can really improve the quality of care. With the need for knee and hip joint replacement on the rise, the use of clinical pathways might contribute to better quality of care and cost-effectiveness.

A systematic review and meta-analysis of the effects of clinical pathways on length of stay, hospital costs and patient outcomes

Background

To perform a systematic review about the effect of using clinical pathways on length of stay (LOS), hospital costs and patient outcomes. To provide a framework for local healthcare organisations considering the effectiveness of clinical pathways as a patient management strategy.

Methods

As participants, we considered hospitalized children and adults of every age and indication whose treatment involved the management strategy "clinical pathways". We include only randomised controlled trials (RCT) and controlled clinical trials (CCT), not restricted by language or country of publication. Single measures of continuous and dichotomous study outcomes were extracted from each study. Separate analyses were done in order to compare effects of clinical pathways on length of stay (LOS), hospital costs and patient outcomes. A random effects meta-analysis was performed with untransformed and log transformed outcomes.

Results

In total 17 trials met inclusion criteria, representing 4,070 patients. The quality of the included studies was moderate and studies reporting economic data can be described by a very limited scope of evaluation. In general, the majority of studies reporting economic data (LOS and hospital costs) showed a positive impact. Out of 16 reporting effects on LOS, 12 found significant shortening. Furthermore, in a subgroup-analysis, clinical pathways for invasive procedures showed a stronger LOS reduction (weighted mean difference (WMD) -2.5 days versus -0.8 days)).

There was no evidence of differences in readmission to hospitals or in-hospital complications. The overall Odds Ratio (OR) for re-admission was 1.1 (95% CI: 0.57 to 2.08) and for in-hospital complications, the overall OR was 0.7 (95% CI: 0.49 to 1.0). Six studies examined costs, and four showed significantly lower costs for the pathway group. However, heterogeneity between studies reporting on LOS and cost effects was substantial.

Conclusion

As a result of the relatively small number of studies meeting inclusion criteria, this evidence base is not conclusive enough to provide a replicable framework for all pathway strategies. Considering the clinical areas for implementation, clinical pathways seem to be effective especially for invasive care. When implementing clinical pathways, the decision makers need to consider the benefits and costs under different circumstances (e.g. market forces).

A systematic review and meta-analysis of the effects of clinical pathways on length of stay, hospital costs and patient outcomes

BACKGROUND

To perform a systematic review about the effect of using clinical pathways on length of stay (LOS), hospital costs and patient outcomes. To provide a framework for local healthcare organisations considering the effectiveness of clinical pathways as a patient management strategy.

METHODS

As participants, we considered hospitalized children and adults of every age and indication whose treatment involved the management strategy "clinical pathways". We include only randomised controlled trials (RCT) and controlled clinical trials (CCT), not restricted by language or country of publication. Single measures of continuous and dichotomous study outcomes were extracted from each study. Separate analyses were done in order to compare effects of clinical pathways on length of stay (LOS), hospital costs and patient outcomes. A random effects meta-analysis was performed with untransformed and log transformed outcomes.

RESULTS

In total 17 trials met inclusion criteria, representing 4,070 patients. The quality of the included studies was moderate and studies reporting economic data can be described by a very limited scope of evaluation. In general, the majority of studies reporting economic data (LOS and hospital costs) showed a positive impact. Out of 16 reporting effects on LOS, 12 found significant shortening. Furthermore, in a subgroup-analysis, clinical pathways for invasive procedures showed a stronger LOS reduction (weighted mean difference (WMD) -2.5 days versus -0.8 days)).There was no evidence of differences in readmission to hospitals or in-hospital complications. The overall Odds Ratio (OR) for re-admission was 1.1 (95% CI: 0.57 to 2.08) and for in-hospital complications, the overall OR was 0.7 (95% CI: 0.49 to 1.0). Six studies examined costs, and four showed significantly lower costs for the pathway group. However, heterogeneity between studies reporting on LOS and cost effects was substantial.

CONCLUSION

As a result of the relatively small number of studies meeting inclusion criteria, this evidence base is not conclusive enough to provide a replicable framework for all pathway strategies. Considering the clinical areas for implementation, clinical pathways seem to be effective especially for invasive care. When implementing clinical pathways, the decision makers need to consider the benefits and costs under different circumstances (e.g. market forces).

Frequency and determinants of pneumonia and urinary tract infection during stroke hospitalization

BACKGROUND

Patients with acute stroke are at risk for pneumonia and urinary tract infection (UTI). Identifying patients with stroke at high risk for common infections could enhance timely treatment and improve clinical outcomes. We aimed to identify risk factors associated with the occurrence of pneumonia and UTI during stroke hospitalization.

METHODS

We analyzed the frequency of pneumonia and UTI and their influence on outcomes during hospitalization in patients diagnosed with ischemic stroke in the California Acute Stroke Prototype Registry. Generalized estimating equations were used to identify factors and outcomes independently associated with pneumonia and UTI.

RESULTS

Overall, 663 patients were admitted with acute ischemic stroke at 11 hospitals. Pneumonia occurred in 66 (10%) and UTI in 84 (13%). Older age, atrial fibrillation, and congestive heart failure were independently associated with greater risk for developing pneumonia, whereas a history of dementia was associated with lesser risk. Women and patients with a history of cerebrovascular events were significantly more likely to experience a UTI. Both pneumonia and UTI were associated with significantly greater length of stay, but only pneumonia was independently associated with higher inpatient mortality and poorer discharge ambulatory status.

CONCLUSIONS

Several factors are associated with an increased risk of developing pneumonia and UTI during ischemic stroke hospitalization. Early identification and treatment of these patients may improve clinical outcomes.

Clinical pathways for chronic cough in children

BACKGROUND

Chronic cough (a cough lasting longer than 4 weeks) is a common symptom presenting to primary care in Australia and internationally. Chronic cough costs the community, is distressing to parents, and ignoring cough may lead to delayed diagnosis and illness progression of serious underlying respiratory disease. Clinical guidelines have been shown to provide more efficient and effective patient care and can clarify clinical decision making. Cough guidelines have been designed to facilitate management of chronic cough, however treatment recommendations vary and specific clinical pathways for the treatment of chronic cough in children are important, as the cause and treatments for cough in a child vary significantly adults. Therefore, it would be beneficial to clinical practice to systematically evaluate the use of clinical pathways for the treatment of chronic cough in children.

OBJECTIVES

To evaluate the effectiveness of using a clinical pathway in the management of children with chronic cough.

SEARCH STRATEGY

The Cochrane Register of controlled Trials (CENTRAL), the Cochrane Airways Group Specialised Register, MEDLINE, EMBASE, review articles and reference lists of relevant articles were searched. The search was carried out in May 2007.

SELECTION CRITERIA

All randomised controlled trials with parallel group design comparing use vs non-use of a clinical pathway for treatment of chronic cough in children.

DATA COLLECTION AND ANALYSIS

Results of searches were reviewed against the pre-determined criteria for inclusion. Two reviewers independently selected the studies and it was planned that data extraction would have been done in duplicate.

MAIN RESULTS

The search identified 471 potentially relevant titles but no studies met criteria for inclusion in the review.

AUTHORS' CONCLUSIONS

Without further available evidence, recommendations for the use of clinical pathways for the treatment of chronic cough in children cannot be made. Until further evidence is available, the decision for further investigation and treatment for the child presenting with chronic cough should be made on an individual basis (i.e. dependent on symptoms and signs) with consideration for existing data from other Cochrane reviews on specific treatments for cough. Trials are required to provide evidence on the effectiveness of clinical pathways for the treatment of chronic cough in children.

An audit of the impact of implementation of a stroke care pathway in an acute teaching hospital

BACKGROUND

In 2002, a survey of stroke management was conducted in our institution benchmarked against the UK National Stroke Audit 2002. The conclusion was that management of stroke patients lacked organised and specialised care. The introduction of a stroke care pathway was recommended.

AIMS

This audit assessed the clinical impact of implementation of a stroke care pathway by the general medical teams in an acute teaching hospital.

METHODS

A random sample of 48/131 patients were surveyed in 2002 compared to 55 consecutive patients admitted with stroke in 2005.

RESULTS

Despite introduction of a stroke care pathway, marked deficits persisted in acute management including delays in brain imaging and aspirin administration, assessment of acute parameters and interdisciplinary care.

CONCLUSIONS

Optimal care of stroke patients cannot be achieved by introducing a stroke care pathway alone. We recommend the urgent establishment of a stroke unit with a specialist consultant-led multidisciplinary stroke team.

Care pathways for acute stroke care and stroke rehabilitation: from theory to evidence

Care pathways aim to promote evidence- and guideline-based care, improve the organisation and efficiency of care, and reduce cost. In the past decade, care pathways have been increasingly implemented as a tool in acute stroke care and stroke rehabilitation. In the most recent Cochrane systematic review, which included three randomised and 12 non-randomised studies, patient management with stroke care pathways was found to have no significant benefit on functional outcome, and patient satisfaction and quality of life might actually be worse. On the other hand, it was associated with a higher proportion of patients receiving investigations and a lower risk of developing certain complications such as infections and readmissions. Overall, the evidence supports the use of care pathways in acute stroke but not stroke rehabilitation. Future developments, including electronic care pathways, patient pathways, and pre-hospital care pathways for hyperacute stroke, will be discussed.

Effects of care pathways on stroke care practices at regional hospitals

BACKGROUND

Our previous work identified deficiencies in stroke care practices at regional hospitals in comparison to standards suggested by published stroke care guidelines. These deficiencies might be improved by the implementation of clinical pathways. The aim of this study was to assess changes in acute stroke care practices following the implementation of stroke care pathways at four regional Queensland hospitals.

METHODS

The medical records of two cohorts of 120 patients with a discharge diagnosis of stroke or transient ischaemic attack were retrospectively audited before and after implementation of stroke care pathways to identify differences in the use of acute interventions, investigations and secondary prevention strategies.

RESULTS

Following pathway implementation there were clinically important, but not statistically significant, increases in the rates of swallow assessment, allied health assessment (significant for occupational therapy, P = 0.04) and use of deep vein thrombosis prevention strategies (also significant, P = 0.006). Fewer patients were discharged on no anti-thrombotic therapy (statistically significant in the subgroup of patients with atrial fibrillation, P = 0.02). Only 37% of the patients audited were actually enrolled on the pathway. Among this subgroup there were significant increases in the rates of swallow assessment (first 24 h, P = 0.01; any time during admission, P = 0.0001), allied health assessments (all P < 0.05), estimation of blood glucose level (P = 0.0015) and the use of deep vein thrombosis prevention strategies (P = 0.0003).

CONCLUSION

Stroke care pathways appear to improve the process of care. Whether this influences outcomes such as mortality, functional and neurological recovery, the incidence of complications, length of stay or the cost of care was beyond the scope of this study and will require further examination.