Stroke Unit Trialists Research Articles

Stroke: an ongoing revolution.

reported that over the last two decades of stroke research only two findings really changed case-fatality and functional depen-dence of IS survivors: the first was the seminal paper “Stroke Unit Trialists”,published by Peter Langhorne in 1997, when it became clear that stroke units not only save lives but also re-duce functional dependence. The second was the discovery of intravenous use of tissue plasminogen activator (tPA) for hyperacute stroke reperfusion in 1995. These breakthroughs buried the nihilist approach to stroke and changed the par-adigm of IS treatment worldwide. The emergence of neuro-hospitalists as crucial professionals for inpatient care has become a reality. However, intravenous thrombolysis is less able than desirable, to open large vessels such as the inter-nal carotid artery or proximal branches of the middle cere-bral artery. In the last 10 years, many randomized clinical tri-als (RCT) of thrombectomy were “negative”. After December 2014, five new randomized controlled trials showed that intra-arterial treatment combined with IV lysis was more ef-fective than IV lysis alone, leading to

Reduced Inequality in Access to Stroke Unit Care over Time: A 15-Year Follow-Up of Socioeconomic Disparities in Sweden

Background: Despite the compelling scientific evidence on the superiority of stroke unit care, far from all acute stroke patients have access to stroke unit care. In congruence with what has been observed when other new methods are introduced in health care, we hypothesized that there has been an inequality in the buildup phase of stroke units but that the gradients between patient groups have decreased as the total capacity of stroke unit care has increased. The purpose of this study was to explore if patients in a national sample who were socioeconomically disadvantaged (low education or low income) had reduced access to stroke unit care and if differences varied over time. Methods: All patients 18-74 years of age registered between 1995 and 2009 in Riks-Stroke, the Swedish stroke register, were included. The Stroke Unit Trialists' definition of a stroke unit has been adopted by Riks-Stroke and hospitals participating in the registry. Basic patient characteristics, stroke risk factors, process and outcome variables are recorded in Riks-Stroke. Socioeconomic data were accessed from Statistics Sweden. Multiple logistic regression analyses were used to calculate odds ratios (ORs) for stroke unit care between prespecified patient subgroups. Results: A total of 319,240 stroke patients were included in Riks-Stroke during the years 1995-2009, and 124,173 were aged between 18 and 74 years; they were included in the final analyses. After adjustment for confounders in a multiple regression model, women were treated in stroke units slightly less often [OR 0.97, 95% confidence interval (CI) 0.95-0.99]. There were no statistically significant associations between stroke unit care and age or between stroke unit care and cohabiting or living alone. The highest level of education predicted access to stroke unit care (secondary vs. primary school: OR 1.04, 95% CI 1.01-1.07; university vs. primary school: OR 1.06, 95% CI 1.02-1.10). Differences according to level of education diminished over time (p = 0.001). Income was not independently associated with stroke unit care, and over time the proportion of patients treated in stroke units increased at a similar rate in all income groups (p = 0.12). Conclusions: Even in a country with modest socioeconomic differences in the general population and public financing of all acute hospital care, socioeconomic inequalities in access to stroke unit care were evident during the early years, but they diminished as the total capacity for stroke unit care increased.

A systematic review and meta-analysis of acute stroke unit care: What’s beyond the statistical significance?

BackgroundThe benefits of stroke unit care in terms of reducing death, dependency and institutional care were demonstrated in a 2009 Cochrane review carried out by the Stroke Unit Trialists’ Collaboration.MethodsAs requested by the Belgian health authorities, a systematic review and meta-analysis of the effect of acute stroke units was performed. Clinical trials mentioned in the original Cochrane review were included. In addition, an electronic database search on Medline, Embase, the Cochrane Central Register of Controlled Trials, and Physiotherapy Evidence Database (PEDro) was conducted to identify trials published since 2006. Trials investigating acute stroke units compared to alternative care were eligible for inclusion. Study quality was appraised according to the criteria recommended by Scottish Intercollegiate Guidelines Network (SIGN) and the GRADE system. In the meta-analysis, dichotomous outcomes were estimated by calculating odds ratios (OR) and continuous outcomes were estimated by calculating standardized mean differences. The weight of a study was calculated based on inverse variance.ResultsEvidence from eight trials comparing acute stroke unit and conventional care (general medical ward) were retained for the main synthesis and analysis. The findings from this study were broadly in line with the original Cochrane review: acute stroke units can improve survival and independency, as well as reduce the chance of hospitalization and the length of inpatient stay. The improvement with stroke unit care on mortality was less conclusive and only reached borderline level of significance (OR 0.84, 95% CI 0.70 to 1.00, P = 0.05). This improvement became statistically non-significant (OR 0.87, 95% CI 0.74 to 1.03, P = 0.12) when data from two unpublished trials (Goteborg-Ostra and Svendborg) were added to the analysis. After further also adding two additional trials (Beijing, Stockholm) with very short observation periods (until discharge), the difference between acute stroke units and general medical wards on death remained statistically non-significant (OR 0.86, 95% CI 0.74 to 1.01, P = 0.06). Furthermore, based on figures reported by the clinical trials included in this study, a slightly higher proportion of patients became dependent after receiving care in stroke units than those treated in general medical wards – although the difference was not statistically significant. This result could have an impact on the future demand for healthcare services for individuals that survive a stroke but became dependent on their care-givers.ConclusionsThese findings demonstrate that a well-conducted meta-analysis can produce results that can be of value to policymakers but the choice of inclusion/exclusion criteria and outcomes in this context needs careful consideration. The financing of interventions such as stroke units that increase independency and reduce inpatient stays are worthwhile in a context of an ageing population with increasing care needs. One limitation of this study was the selection of trials published in only four languages: English, French, Dutch and German. This choice was pragmatic in the context of this study, where the objective was to support health authorities in their decision processes.

Stroke centers and quality of stroke care

There can be no doubt that we are getting better at treating stroke patients. According to the 2011 Heart Disease and Stroke Statistics Update, from 1997 to 2007 the annual stroke death rate decreased 34.3% and the actual number of stroke deaths declined 18.8%.1 Stroke center implementation may have contributed to these improvements. Ten years ago, the Brain Attack Coalition introduced recommendations for the establishment of primary stroke centers (PSCs)2 and the Joint Commission (JC) subsequently began certifying PSCs in 2003. In 2007, the Stroke Unit Trialists' Collaboration reported that patients with strokes treated in a stroke unit had better outcomes than those who did not.3 A recent study of state-designated stroke-certified hospitals in New York also found a lower 30-day mortality and readmission rate compared with noncertified hospitals.4 To date, data specifically regarding outcomes in JC-certified hospitals have been lacking. In this issue of Neurology ®, Lichtman et al.5 compare the 30-day risk-standardized mortality and readmission rates in JC-certified hospitals in 2006 with …

Stroke Unit Care Is Beneficial Both for the Patient and for the Health Service and Should Be Widely Implemented

See related article, pages 18–23. Stroke unit (SU) care is the only treatment option for acute stroke with proven reduction of death.1 It is also the only intervention that has shown a reduction in long-term dependency, and the majority of stroke patients benefit from this intervention.1 Hence, SU care is by far the most important treatment for stroke patients and the only treatment of acute stroke that has a major impact on the burden of stroke.1–3 It is important to recognize that the organization of stroke services per se plays a key role in improving the overall outcome after a stroke. Despite impressive results, the implementation of SU care is remarkably slow in many countries. A hospital survey from the United States showed that SU care was established at only 38% of the hospitals.4 In a registry of the Canadian Stroke Network, only 31% of stroke patients received care in an SU.5 Similar problems in translating knowledge into practice are also present in many other regions and countries worldwide.6,7 It is mainly the Scandinavian countries that have implemented SUs on a large scale,8 especially Sweden, where >80% of all patients with acute stroke are offered SU care. The positive effects of SU care not only are found in randomized trials but also persist when SUs are implemented in routine clinical practice.9 Hence, the consequences of the lack of a wide implementation of SUs are probably that many stroke patients will die unnecessarily or will become dependent and require long-term institutional …

Stroke: The silent Cinderella!

Australia’s National Stroke Foundation (2004) states that a stroke occurs every 11 min and that it is one of the leading causes of disability in adults. Stroke is a chronic disease, which, with our ageing population, is going to make increasing demands on occupational therapists and stroke services. The search is on for improved outcomes for stroke survivors and improved interventions in stroke management, prevention and health promotion. Dr Graeme Hankey, a world renowned Australian medical specialist in neurology and stroke, nominated stroke as the ‘Cinderella’ in health care, and went on to say that ‘progress in stroke management has been hindered by ignorance, nihilism and negativity’ but that this ‘has all changed in the past decade’ (preface) (Hankey, 2002). For Australian occupational therapists, perhaps the most noticeable change in stroke management in the past decade has been the very recent proliferation of what are being referred to as ‘stroke units’. A stroke unit has been defined as ‘any unit or ward within the hospital/trust that is designated by local agreement as a stroke unit either for the acute care or for the rehabilitation of stroke or both’ (Irwin, Hoffman, Lowe, Pearson & Rudd, 2005, p. 307). This proliferation has been a direct result of one of the most significant items of evidence concerning stroke management. This evidence has been supported by a number of systematic reviews, the highest level of evidence available at present, including three Cochrane reviews (Outpatient Service Trialists, 2003; Stroke Unit Trialists’ Collaboration, 2001, 2005). What is this outstanding piece of evidence? It is the fact that stroke units have been shown to be the single most effective tool in improving outcomes for stroke survivors! This one item of evidence should cause great excitement among occupational therapists, as it has profound implications for our professional contribution into the health-care management of those affected by stroke. Stroke units are phenomena that have been found to be effective as a ‘package’, as opposed to being a single component or variable. Therefore, even if you were able to measure each of the individual variables that makes up this ‘package’, chances are, the sum of the individual variables would not equal the sum of the package. Put another way, there is evidence that the interplay between all the individual components making up a stroke unit appears to be both statistically and clinically significant. A stroke unit incorporates a complex component: the multiprofessional team, which is neither easily defined nor researched. Yet this integral component has been highlighted as a result of using the very research methodology and rating tools that have been so supportive of the biomedical model; a model so much a part of health care in the past decade (Reynolds, 2005). Considering how important this piece of evidence is to the profession of occupational therapy, there appears to be scant awareness among us of this exciting and significant finding. Is it possible that occupational therapists may still be hindered in their progress in stroke management by ‘ignorance, nihilism and negativity’ (Hankey, 2002; preface). This paper will aim to explore these issues.

Ｓｔｒｏｋｅ Ｕｎｉｔの現状と課題：急性期脳卒中診療体制に関する全国アンケート調査から

Guideline for Stroke Treatment 2004 published in Japan strongly recommended that acute stroke patients should be managed in dedicated stroke care unit or stroke unit. We conducted a nation-wide survey of all hospitals providing acute stroke care. We sent a questionnaire to 7, 835 hospitals and obtained 2, 603 answers (33.2%). According to the meta-analysis by Stroke Unit Trialists' Collaboration, service organizations were classified into five categories as a hierarchy in descending order as follows ; acute stroke units, comprehensive stroke units, mixed rehabilitation ward, mobile stroke team, and general medical ward. Only 8.3% of hospitals had organized stroke units (acute stroke units ; 0.9%, comprehensive stroke units ; 7.4%), and 63.8% of hospitals managed acute stroke patients in general medical words. The categorization of stroke service organizations was highly correlated with the number of patients admitted in a year. We compared performance levels of the key elements recommended for establishing primary stroke centers by the Brain Attack Coalition among the five categories, such as acute stroke teams, stroke units, written care protocols, and an integrated emergency response system, availability and interpretation of computed tomography scans 24 hours everyday, access to neurosurgeon within 2 hours and rapid laboratory testing. Currently there are very few hospitals with performance levels required for the primary stroke center. More importantly, measures were taken for the quality improvement of stroke care only by 6.5% of hospitals. Intravenous thrombolytic therapy is now widely available in Japan. Establishment of clearly defined stroke units or stroke care units is urgently needed.

Early supported discharge: a valuable alternative for some stroke patients

In this issue of The Lancet, Peter Langhorne and colleagues report the benefits of early supported discharge (ESD) teams as an effective health-service option for a selected group of stroke patients. Since 1997, when Langhorne and his co-workers in the Stroke Unit Trialists Collaboration reported the advantages of integrated stroke care, 1 Stroke Unit Trialists Collaboration How do stroke units improve patient outcomes?. Stroke. 1997; 28: 2139-2144 Crossref PubMed Google Scholar this care is now embedded in most stroke services worldwide. However, between countries the organisation of stroke care differs; different types of institutions participate, which have their own specific treatment modalities. Several treatment options are usually available, depending on the patient's need for further rehabilitation therapy; each option has specific admission criteria, and consists of some form of inpatient or outpatient treatment in specialised care centres. District sick bays or similar institutions might serve as hotel facilities where the patient can recover from the stroke during a limited period without receiving specific rehabilitation treatment. Some countries have inhospital rehabilitation facilities, which lengthen hospital stay, while in other countries, transfer to a specialised rehabilitation centre will take place as soon as the patient is medically stable. In their recent meta-analysis Langhorne and his fellow Early Supported Discharge Trialists refer to treatment at home given or coordinated by a multidisciplinary team as ESD; 2 Early Supported Discharge Trialists. Early supported discharge services for stroke patients: Cochrane Database Syst Rev (in press). Google Scholar in today's Lancet they evaluate the effects of this new health-service product. Early supported discharge services for stroke patients: a meta-analysis of individual patients' dataAppropriately resourced ESD services provided for a selected group of stroke patients can reduce long-term dependency and admission to institutional care as well as shortening hospital stays. Full-Text PDF

Early supported discharge: a valuable alternative for some stroke patients

In this issue of The Lancet, Peter Langhorne and colleagues report the benefits of early supported discharge (ESD) teams as an effective health-service option for a selected group of stroke patients. Since 1997, when Langhorne and his co-workers in the Stroke Unit Trialists Collaboration reported the advantages of integrated stroke care,1 this care is now embedded in most stroke services worldwide. However, between countries the organisation of stroke care differs; different types of institutions participate, which have their own specific treatment modalities.

Bone-marrow fibrin-ring granuloma

appraisal of the design and reporting of studies of imaging and measurement of carotid stenosis. Stroke 2000; 31: 1444–50. 88 Patel SG, Collie D, Wardlaw JM, et al. Outcome, observer reliability, and patient preferences if CTA, MRA, or Doppler ultrasound were used, individually or together, instead of digital subtraction angiography before carotid endarterectomy. J Neurol Neurosurg Psychiatry 2002; 73: 21–28. 89 The Cochrane Library, Issue 3, 2002. Oxford: Update Software. 90 Rothwell PM, Warlow CP, on behalf for the European Carotid Surgery Trialists’ Collaborative Group. Prediction of benefit from carotid endarterectomy in individual patients: a risk-modelling study. Lancet 1999; 353: 2105–10. 91 CAVATAS Investigators. Endovascular versus surgical treatment in patients with carotid stenosis in the Carotid and Vertebral Transluminal Angioplasty Study (CAVATAS): a randomised trial. Lancet 2001; 357: 1729–37. 92 Beral V, Banks E, Reeves G. Evidence from randomised trials on the long-term effects of hormone replacement therapy. Lancet 2002; 360: 942–44. 93 Stroke Unit Trialists’ Collaboration. Organised inpatient (stroke unit) care for stroke (Cochrane Review). In: The Cochrane Library, Issue 1, 2003. Oxford: Update Software. 94 Langhorne P, Pollock A in conjunction with the Stroke Unit Trialists Collaboration. What are the components of effective stroke unit care? Age Ageing 2002; 31: 365–71. 95 Ronning OM, Guldvog B. Should stroke victims routinely receive supplemental oxygen? Stroke 1999; 30: 2033–37. 96 Scott JF, Robinson GM, French JM, O’Connell JE, Alberti KGMM, Gray CS. Glucose potassium insulin infusions in the treatment of acute stroke patients with mild to moderate hyperglycaemia. Stroke 1999; 30: 793–99. 97 Bassetti C, Aldrich MS. Sleep apnoea in acute cerebrovascular diseases: final report on 128 patients. Sleep 1999; 22: 217–22. 98 The FOOD Trial Collaboration. Performance of a statistical model to predict stroke outcome in the context of a large simple randomised controlled trial of feeding. Stroke (in press). 99 Burn J, Dennis M, Bamford J, Sandercock P, Wade D, Warlow C. Epileptic seizures after a first-ever stroke: the Oxfordshire Community Stroke Project. BMJ 1998; 315: 1582–87. 100House A, Dennis MS, Molyneux A, Warlow C, Hawton K. Emotionalism after stroke. BMJ 1989; 298: 991–94. 101Davis M, Hollymann C, McGiven M, Chambers I, Egbuji J, Barer D. Physiological monitoring in acute stroke. Age Ageing 1999; 28 (suppl 1): P45. SEMINAR

The evolution of stroke units-towards a more intensive approach?

The last five to ten years have seen an intensive research effort to find novel treatments for acute stroke with many more large trials of thrombolytic1,,2 and neuroprotective agents.3,,4 Unfortunately, none of these treatments have proven effective enough to recommend routine use in acute stroke. Although results from thrombolysis trials are promising,1,,2 uncertainty persists about more widespread usage, and it is likely that only a small proportion of stroke patients will ever be eligible for treatment because of the short time window for triage and treatment.5,,6 Perhaps the most significant advance in stroke management therefore has not been pharmacological, but concerns the process of care for stroke patients, with convincing evidence that changing the approach to the way stroke patients are managed has a beneficial impact on both mortality and morbidity.7 The concept of organized care on geographically‐defined units has given rise to a more disease‐specific approach to the management of stroke. In practical terms, this has cut across the more generic approach to general medical admissions within acute hospitals, particularly in the UK, and creation of stroke units often requires a substantial reorganization of beds within hospitals. This article aims to define which aspects of stroke unit care make the difference and how the process of care for stroke patients may evolve further in the future. In 1993, results from all existing randomized controlled trials comparing the outcome of patients managed in defined stroke units with outcomes from conventional settings of care were examined in a meta‐analysis.8 This showed that care on a stroke unit reduced mortality by 28% and also reduced the risk of patients requiring institutionalized care at a median of 12 months after stroke. Subsequently, the Stroke Unit Trialists' Collaboration within the …

Effectiveness of special stroke units in treatment of acute stroke

In Germany the implementation of specialized wards for the care of stroke patients is proposed. However, which type of organized inpatient stroke unit care is most effective and which group of patients will benefit most remains unclear. Based on the analyses of the Stroke Unit Trialists' Collaboration this paper reports results of randomized and quasi-randomized trials that compared organized inpatient (stroke unit) care with contemporary conventional care. The primary analyses examined death, dependency and institutionalization. Secondary outcome measures included patient quality of life, patient and carer satisfaction and length of stay in hospital and/or institution. The analysis of twenty trails with 3864 patients showed a reduction in the rate of deaths in the stroke unit group as compared with the control group (OR 0.83, 95% CI 0.71-0.97). The odds of death or institutionalized care were lower (OR 0.76, 95% CI 0.65-0.90) as were death or dependency (OR 0.75, 95% CI 0.65-0.87). The results were independent of patient age, sex, stroke severity, and type of stroke unit organization. Organized care in stroke units resulted in benefits for stroke patients with regard to survival, independence, and probability of living at home. However, these results refer exclusively to Anglo-American and Scandinavian trials. German stroke unit services are organized in a different way. No data about the effectiveness of the German model is yet available.

Stroke units for rehabilitation after acute care reduced death and dependence

TherapeuticsSeptember 1, 1998Stroke units for rehabilitation after acute care reduced death and dependenceRichard L. Harvey, MDRichard L. Harvey, MDThe Rehabilitation Institute of Chicago, Chicago, Illinois, USA (R.L.H.)Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/ACPJC-1998-129-2-029 SectionsAboutFull Text ToolsAdd to favoritesDownload CitationsTrack Citations ShareFacebookTwitterLinkedInRedditEmail Source CitationRønning OM, Guldvog B. Outcome of subacute stroke rehabilitation. A randomized controlled trial. Stroke. 1998 Apr;29:779-84.References1 Stroke Unit Trialists' Collaboration. Collaborative systematic review of the randomised trials of organised inpatient (stroke unit) care after stroke. BMJ. 1997;314:1151-9. Google Scholar2 Kramer AM, Steiner JF, Schlenker RE, et al. Outcomes and costs after hip fracture and stroke. A comparison of rehabilitation settings. JAMA. 1997;277:396-404. Google Scholar Author, Article, and Disclosure InformationAffiliations: The Rehabilitation Institute of Chicago, Chicago, Illinois, USA (R.L.H.) Nextarticle Advertisement FiguresReferencesRelatedDetails September 1, 1998Volume 129, Issue 2Page: 29KeywordsDeath ratesHospitalizationsHospitalsInpatientsLong-term careMedical educationNursing educationNursing homesPatientsProspective studiesQuality of lifeStrokeStroke rehabilitation ePublished: 9 March 2020 Issue Published: September 1, 1998 Copyright & PermissionsCopyright © 1998 by American College of Physicians. All Rights Reserved.Loading ...

How do stroke units improve patient outcomes? A collaborative systematic review of the randomized trials. Stroke Unit Trialists Collaboration.

We sought to clarify the way in which organized inpatient (stroke unit) care can produce reductions in case fatality and in the need for institutional care after stroke. We performed a secondary analysis of a collaborative systematic review of all randomized trials that compared organized inpatient (stroke unit) care with contemporary conventional care. Nineteen trials were included, of which 18 (3246 patients) could provide outcome data on death, place of residence, and final functional outcome. Data were less complete (but always available for at least 12 trials; 1611 patients) for subgroup analyses examining timing and cause of death and outcomes in patients with different levels of severity of initial stroke. The reduction in case fatality of patients managed in a stroke unit setting developed between 1 and 4 weeks after the index stroke. The reduction in the odds of death was evident across all causes of death and most marked for those deaths considered to be secondary to immobility. However, data were insufficient to permit a firm conclusion. The relative increase in the number of patients discharged home from stroke units as opposed to conventional care was largely attributable to an increase in the number of patients returning home physically independent. Across the range of stroke severity, stroke unit care was associated with nonsignificant increases in the number of patients regaining independence. Within the limitations of the available data, we conclude that organized inpatient stroke unit care probably benefits a wide range of stroke patients in a variety of different ways, ie, reducing death from secondary complications of stroke and reducing the need for institutional care through a reduction in disability.