Multicenter Comparison of Processes of Care Between Stroke Units and Conventional Care Wards in Australia

Abstract

Background and Purpose-Approximately 23% of Australian hospitals provide Stroke Units (SUs). Evidence suggests that clinical outcomes are better in SUs than with conventional care. Reasons may include greater adherence to processes of care (PoC). The primary hypothesis was that adherence to selected PoC is greater in SUs than in other acute care models. Methods-Prospective, multicenter, single-blinded design. Models of care investigated: SUs, mobile services, and conventional care. Selected PoC were related to care models and participant outcomes. Data were collected at acute hospitalization (median 9 days) and at medians of 8 and 28 weeks after stroke. Results-1701 patients were screened from 8 hospitals, 823 were eligible, and 468 participated. Response rate was 96% at final follow-up. Mean age was 73 years (SD 14). Overall PoC adherence rates for individual care models were SU 75%, mobile service 65%, and conventional care 52% (PϽ0.001). The adjusted odds of participants being alive at discharge if adhering to all or all but 1 PoC was significant (aOR 3.63; 95% CI: 1.04 to 12.66; Pϭ0.043). Important trends at 28 weeks were found for being at home (aOR 3.09; 95% CI: 0.96 to 9.87; Pϭ0.058) and independent (aOR 2.61; 95% CI: 0.96 to 7.10; Pϭ0.061), with complete PoC adherence. Conclusion-Adherence to key PoC was higher in SUs than in other models. For all patients, adherence to PoC was associated with improved mortality at discharge and trends found with independence at home, providing support for the need to increase access to stroke units.

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

“…Seven studies (17,24,25,32,34,36,38) had consistent findings whereby adherence to a combination of several KPIs ("bundle") was associated with a greater decrease in stroke mortality. A lower risk for poor outcome was also reported when full stroke care bundle was achieved (25,36).…”

“…18 The majority (23/30) Coma Scale (36), while the remainder used stroke severity proxies such as level of consciousness, incontinence, dysphagia, dysphasia, paralysis, and disability.…”

Stroke Unit care in Italy. Results from PROSIT (Project on Stroke Services in Italy). A nationwide study

“…We considered the structural indicators (setting and staffing) as well as the performance indicators (process of care and diagnostic availability) because both types of parameters could influence the patient's outcome [34,35]. Adherence to a process of care was evaluated in SUs with respect to stroke teams in single unit trials [36] and in SUs with respect to mobile teams or conventional care in a multicentre cohort study [8]. These two studies demonstrated that a closer adherence to a well defined process of care explains the effectiveness of SU hospitalisation.…”

“…In fact, despite the meta-analysis providing evidence in favour of the comprehensive SU model, SUs currently implemented vary significantly in structure and organisation [4][5][6][7]. Randomised clinical trials and other research have been used to evaluate the efficacy of the individual elements of care that would improve stroke patient outcomes [4,[8][9][10][11][12]. But clear evidence of the relative efficacy for different models combining different structural and performance characteristics is very poor [10].…”

Assessment of Rehabilitation Capacity in Ghana

“…The lack of comprehensive stroke centres capable of delivering the full spectrum of care to clients with stroke, will lead to predictably worse outcomes. Strong evidence exists to support, comprehensive stroke units (Cadilhac et al, 2004;Koton et al, 2005;Ko and Sheppard, 2006;Walsh et al, 2006). These dedicated units with multidisciplinary rehabilitation teams are associated with reductions in length of stay at hospitals, healthcare costs, death, and dependency, while improving functional outcomes compared to other stroke unit models (Anderson et al, 2000;Moodie et al, 2006;Chan et al, 2013).…”