Article Text

PDF
Review: organised stroke unit care reduces mortality more than other forms of care for inpatients

Statistics from Altmetric.com

P Langhorne

Professor P Langhorne, University of Glasgow, Glasgow, UK; p.langhorne{at}clinmed.gla.ac.uk

QUESTION

For patients in hospital with stroke, does organised stroke unit (OSU) care improve patient outcomes more than alternative forms of care?

REVIEW SCOPE

Studies selected compared OSU care with alternative care for patients in hospital with stroke, defined as a focal neurological deficit due to cerebrovascular disease, excluding subarachnoid haemorrhage and subdural haematoma. Core features of inpatient OSUs included delivery of a complex package of care by a multidisciplinary team specialising in stroke management. Outcomes were mortality and composite outcomes of mortality and dependency (need for physical assistance with transfers, mobility, dressing, feeding, or toileting) or need for institutional care (residential or nursing home care, or continued hospital stay) at the end of scheduled follow-up.

REVIEW METHODS

Cochrane Stroke Group Trials Register (Apr 2006) and reference lists were searched for randomised or quasi-randomised controlled trials. Experts and coordinators of included trials were also contacted. 31 trials (n = 6936; median follow-up 12 mo) were included. 16 trials reported an adequate method for allocation concealment, and 10 used blinding for the final assessment; 9 trials had missing data.

MAIN RESULTS

Meta-analyses showed that inpatient OSUs reduced mortality after stroke more than alternative forms of care including general medical wards (table). Results for mortality were consistent at 5-year follow-up (3 trials, n = 1139, relative risk reduction [RRR] 12%, 95% confidence interval [CI] 3 to 21) and 10-year follow-up (2 trials, n = 535, RRR 13%, CI 5 to 21). For composite outcomes of mortality and institutional care or dependency, meta-analyses showed that OSUs reduced event rates more than alternative forms of care (table). Results of prespecified subgroup analyses comparing different forms of inpatient OSUs (1–4 trials) were mixed.

Organised stroke unit care v alternative forms of care for patients in hospital with stroke*

CONCLUSION

For patients in hospital with stroke, care in organised stroke units reduces mortality more than alternative forms of care.

A modified version of this abstract appears in ACP Journal Club.

ABSTRACTED FROM

Stroke Unit Trialists’ Collaboration. Organised inpatient (stroke unit) care for stroke. Cochrane Database Syst Rev 2007;(4):CD000197.

Clinical impact ratings: General/internal medicine 5/7; Neurology 5/7

Commentary

The updated Cochrane review by the Stroke Unit Trialists’ Collaboration (SUTC) provides an extended analysis of the benefits of OSUs compared with alternative approaches to stroke care. Using strong review methodology, the SUTC presented substantial evidence indicating the benefits of OSU care as evidenced by narrow CIs for the outcomes. The review findings reiterate and support previous conclusions that inpatient OSUs reduce mortality.

The features of inpatient OSUs described by the SUTC include coordinated multidisciplinary team care, staff with a specialist interest in stroke or rehabilitation, continuing education and training, and routine involvement of families. Depending on the type of stroke unit, the need for specialised coordinated team care differs.1 One of the main priorities for acute stroke care is to provide not only specialised acute interventions but also to incorporate rehabilitation strategies early in the care of patients. Subgroup analyses of different types of stroke care units compared acute, comprehensive, and rehabilitative stroke units to alternative services. The results were not conclusive and do not clearly identify the best approach to OSU care. Exactly how specialised stroke units reduce mortality and improve outcomes after stroke remains unclear. Further investigation is needed to better understand the complex inner detailed workings of an OSU and support specialised care for patients who have had an acute stroke.

However, it is clear that some form of organised, inpatient multidisciplinary or interdisciplinary collaboration and coordination is essential to improve outcomes after stroke. Despite this, service providers do not universally implement OSUs in acute hospital settings. It remains to be seen what service providers will do with such strong evidence in support of dedicated inpatient OSUs.

View Abstract

Footnotes

  • Source of funding: Chest, Heart and Stroke, Scotland, UK.

Request permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.

References