Elsevier

The Lancet

Volume 356, Issue 9233, 9 September 2000, Pages 894-899
The Lancet

Articles
Alternative strategies for stroke care: a prospective randomised controlled trial

https://doi.org/10.1016/S0140-6736(00)02679-9Get rights and content

Summary

Background

Organised specialist care for stroke improves outcome, but the merits of different methods of organisation are in doubt. This study compares the efficacy of stroke unit with stroke team or domiciliary care.

Methods

A single-blind, randomised, controlled trial was undertaken in 457 acute-stroke patients (average age 76 years, 48% women) randomly assigned to stroke unit, general wards with stroke team support, or domiciliary stroke care, within 72 h of stroke onset. Outcome was assessed at 3, 6, and 12 months. The primary outcome measure was death or institutionalisation at 12 months. Analyses were by intention to treat.

Findings

152 patients were allocated to the stroke unit, 152 to stroke team, and 153 to domiciliary stroke care. 51 (34%) patients in the domiciliary group were admitted to hospital after randomisation. Mortality or institutionalisation at 1 year were lower in patients on a stroke unit than for those receiving care from a stroke team (21/152 [14%] vs 45/149 [30%]; p<0·001) or domiciliary care (21/152 [14%] vs 34/144 [24%]; p=0·03), mainly as a result of reduction in mortality. The proportion of patients alive without severe disability at 1 year was also significantly higher on the stroke unit compared with stroke team (129/152 [85%] vs 99/149 [66%]; p<0·001) or domiciliary care (129/152 [85%] vs 102/144 [71%]; p=0·02). These differences were present at 3 and 6 months after stroke.

Interpretation

Stroke units are more effective than a specialist stroke team or specialist domiciliary care in reducing mortality, institutionalisation, and dependence after stroke.

Introduction

The effectiveness of organised stroke care in reducing mortality, institutionalisation, and dependence has been clearly shown in a systematic review of major randomised trials in stroke management.1 The importance of early, organised, hospital-based management has also been emphasised in various professional recommendations for stroke care and is essential for wider use of thrombolysis and other acute interventions.2, 3, 4

Despite professional consensus 20–50% of acute-stroke patients in some countries (notably the UK) are not managed in hospitals.5 Specialised care at home has had a variable success as an alternative way to provide organised multidisciplinary care for defined conditions.6, 7 The only controlled study comparing the management of acute stroke patients at home or in hospital showed no difference in either functional recovery or stress among carers.8 However, patients were not randomised at the point of entry and only 31% of the trial patients were managed exclusively at home. In addition, comparisons with stroke-unit care were not undertaken.

It may not be possible to provide stroke-unit care in hospital for all patients because of bed constraints. A specialist stroke team, which consults throughout the hospital and provides continuity of care in the hospital and community, can overcome this limitation and has the added advantage of disseminating specialist practice to other settings where stroke patients may be managed. A randomised controlled study in 130 patients recruited within 7 days of stroke showed a non-significant decrease in mortality (25% vs 34%) but significant improvement in functional recovery in men after stroke-team intervention.9 The study was limited because of a small sample size and short duration of follow-up.

The benefits of organised stroke care have been attributed to increased multidisciplinary coordination, staff specialisation, and better communication with patients and their carers.10 Evidence on the superiority of any one method of organisation of care over others was inconclusive and direct comparisons of different methods of organised stroke care were recommended to identify the best strategy for managing stroke patients.1 The objective of this study was to compare the efficacy of stroke unit, stroke team, and domiciliary stroke care in reducing mortality, dependence, and institutionalisation in patients with moderately severe strokes.

Section snippets

Setting

The study was done in a suburban district in the UK with 291 000 residents between April, 1995, and October, 1999. The health and social-care needs of the district were provided for by one hospital trust, one community-health provider, one family-health-services authority, and one social-services agency. The delivery of care was negotiated with all interested parties before the study began. The stud was approved by the local ethics committee in February, 1995.

Patients

Patients were recruited from a

Patients

A total of 1206 suspected strokes were notified to the stroke register during the study period. Of these, 102 (8%) patients had transient ischaemic attacks,19 69 (6%) other neurological disease, and 56 (5%) had metabolic, metastatic, drug-induced, or infective disorders. The study sample was recruited from the remaining 979 (81%) patients with a clinical diagnosis of stroke (figure 1). 457 (85%) of the 535 patients meeting inclusion criteria were randomised, 152 were assigned to stroke-unit

Discussion

Our study provides evidence that stroke-unit care protects against premature death and dependence from the outset compared with other methods of organised care. Patients managed on general wards with specialist-team support had continuing higher death rate and higher levels of dependence at all time points up to 1 year. Patients in the domiciliary arm of the study had a high death rate initially that stabilised on follow-up probably because one third of these patients were transferred to the

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