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Organised inpatient (stroke unit) care for stroke

  1. Stroke Unit Trialists' Collaboration

Editorial Group: Cochrane Stroke Group

Published Online: 11 SEP 2013

Assessed as up-to-date: 28 FEB 2013

DOI: 10.1002/14651858.CD000197.pub3


How to Cite

Stroke Unit Trialists' Collaboration. Organised inpatient (stroke unit) care for stroke. Cochrane Database of Systematic Reviews 2013, Issue 9. Art. No.: CD000197. DOI: 10.1002/14651858.CD000197.pub3.

Author Information

  1. University of Glasgow, Academic Section of Geriatric Medicine, Glasgow, UK

*Peter Langhorne, Academic Section of Geriatric Medicine, University of Glasgow, 3rd Floor, Centre Block, Royal Infirmary, Glasgow, G4 0SF, UK. peter.langhorne@glasgow.ac.uk.

Publication History

  1. Publication Status: Edited (no change to conclusions), comment added to review
  2. Published Online: 11 SEP 2013

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Background

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. Feedback
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Index terms
 

Description of the condition

Stroke is now the third leading cause of disability (Murray 2012) and the second leading cause of mortality (Lozano 2012) worldwide. The global disease burden of stroke increased by 19% between 1990 and 2010 (Murray 2012) and current projections estimate the number of deaths worldwide will rise to 6.5 million in 2015 and to 7.8 million in 2030 (Strong 2007). Interventions that are applicable to a majority of stroke patients and that aim to reduce associated mortality and disability are essential.

During their initial illness, stroke patients are frequently admitted to hospital where they can receive care in a variety of ways and in a range of settings. Traditionally, the care of stroke patients was provided within departments of general (internal) medicine, neurology or medicine for the elderly where they would be managed alongside a range of other patient groups. A more-focused approach to the management of stroke patients in hospital has been developed.

 

Description of the intervention

Organised inpatient (stroke unit) care is a term used to describe the focusing of care for stroke patients in hospital under a multidisciplinary team who specialise in stroke management (SUTC 1997a). This concept is not new and its value has been debated for more than 20 years (Ebrahim 1990; Garraway 1985; Langhorne 1993; Langhorne 1998; Langhorne 2012). In essence, the debate has concerned whether the perceived effort and cost of focusing the care of hospitalised stroke patients within specially organised units would be matched by tangible benefits for the patients receiving that care. In particular, would more patients survive and make a good recovery as a result of organised inpatient (stroke unit) care?

 

Why it is important to do this review

A systematic review of all available trials (SUTC 1997a) previously described the range of characteristics of stroke unit care and addressed the question of whether improving the organisation of inpatient stroke care can bring about improvements in important patient outcomes. This review continues to be extended and updated within The Cochrane Library (SUTC 2001; SUTC 2007).

 

Objectives

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. Feedback
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Index terms

To assess the effect of stroke unit care compared with alternative forms of care for people following a stroke.

Originally, there were four broad objectives for this systematic review. To establish:

  1. the characteristic features of organised inpatient (stroke unit) care;
  2. if organised inpatient (stroke unit) care could provide better patient outcomes than alternative forms of care;
  3. if benefits were apparent across a range of patient groups;
  4. if different approaches to organised stroke unit care were effective (in particular, we hypothesised that organised care would be more effective than that of general medical wards, but that different forms of organised care would achieve similar outcomes).

Within the current version of this review, we wished to establish whether the previous conclusions were altered by the inclusion of new outcome data from recent trials and further subgroup analyses based on patient and intervention characteristics. We have structured the review to allow the inclusion of future trials that address important questions about the optimal ways to organise stroke patient care.

 

Methods

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. Feedback
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Index terms
 

Criteria for considering studies for this review

 

Types of studies

We included all randomised controlled clinical trials that compared an organised system of inpatient (stroke unit) care with an alternative form of inpatient care. This was usually the contemporary conventional care but could include an alternative model of organised inpatient care (see Types of interventions). Previous versions of this review (SUTC 1997a; SUTC 2001; SUTC 2007) have included trials with quasi-random treatment allocation (such as bed availability or date of admission). However, in an effort to ensure this ongoing systematic review focuses on data from trials with strict randomisation procedures we excluded all quasi-randomised trials for this update.

 

Types of participants

Any person admitted to hospital who had suffered a stroke was eligible. We recorded the delay between stroke onset and hospital admission but did not use this as an exclusion criterion. We used a clinical definition of stroke: focal neurological deficit due to cerebrovascular disease, excluding subarachnoid haemorrhage and subdural haematoma.

 

Types of interventions

Organised inpatient (stroke unit) care can be considered a complex organisational intervention comprising multidisciplinary staffing providing a complex package of care to stroke patients in hospital. In the original version of this review (SUTC 1997a), the primary question was whether organised inpatient (stroke unit) care could improve outcomes compared with the contemporary conventional care (usually in general medical wards). We have now modified the analyses in a minor way to reflect the emerging hierarchy of service organisation and to allow the comparison of 'more-organised' versus 'less-organised' services. We have done this because some recent trials have addressed new questions and included comparisons of two services both of which met the basic definition of organised (stroke unit) care and so could not really be described as conventional care. However, the original service descriptions used in this review (SUTC 1997a) indicated that service organisation could be considered as a hierarchy which, in descending order, was as follows.

  1. Stroke ward: where a multidisciplinary team including specialist nursing staff based in a discrete ward cares exclusively for stroke patients. This category included the following subdivisions:
    1. acute stroke units that accept patients acutely but discharge early (usually within seven days); these appear to fall into three broad subcategories:
      1. 'intensive' model of care with continuous monitoring, high nurse staffing levels and the potential for life support;
      2. 'semi-intensive' with continuous monitoring, high nurse staffing but no life support facilities; and
      3. 'non-intensive' with none of the above;
    2. rehabilitation stroke units that accept patients after a delay, usually of seven days or more, and focus on rehabilitation; and
    3. comprehensive (ie combined acute and rehabilitation) stroke units that accept patients acutely but also provide rehabilitation for at least several weeks if necessary. Both the rehabilitation unit and comprehensive unit models offer prolonged periods of rehabilitation.
  2. Mixed rehabilitation ward: where a multidisciplinary team including specialist nursing staff in a ward provides a generic rehabilitation service but not exclusively caring for stroke patients.
  3. Mobile stroke team: where a peripatetic multidisciplinary team (excluding specialist nursing staff) provides care in a variety of settings.
  4. General medical ward: where care is provided in an acute medical or neurology ward without routine multidisciplinary input.

 

Types of outcome measures

 

Primary outcomes

The primary analysis examined death, dependency and the requirement for institutional care at the end of scheduled follow-up of the original trial (four trials subsequently extended follow-up). We categorised dependency into two groups where we took 'independent' to mean that an individual did not require physical assistance for transfers, mobility, dressing, feeding or toileting. We considered individuals who failed any of these criteria 'dependent'. The criteria for independence were approximately equivalent to a modified Rankin score of 0 to 2, or a Barthel Index of more than 18 out of 20 (Wade 1992). We took the requirement for long-term institutional care to mean care in a residential home, nursing home or hospital at the end of scheduled follow-up.

 

Secondary outcomes

Secondary outcome measures included patient quality of life, patient and carer satisfaction, and duration of stay in hospital or institution or both.

 

Search methods for identification of studies

See the 'Specialized register' section in the Cochrane Stroke Group module. We searched for trials in all languages and arranged the translation of relevant papers published in languages other than English.

 

Electronic searches

We searched the trials registers of the Cochrane Stroke Group (January 2013) and the Cochrane Effective Practice and Organisation of Care (EPOC) Group (January 2013). In addition, in collaboration with the Cochrane Stroke Group Trials Search Co-ordinator, we searched MEDLINE (2008 to September 2012) (Appendix 1), EMBASE (2008 to September 2012) (Appendix 2) and CINAHL (1982 to September 2012) (Appendix 3). To avoid duplication of effort we restricted the searches of MEDLINE and EMBASE from January 2008 as these databases have already been searched to that date for all stroke trials and relevant trials added to the Cochrane Stroke Group Trials Register.

We searched the following registers of ongoing trials using the keyword 'stroke' (January 2013):

 

Searching other resources

In an effort to identify further published, unpublished and ongoing trials, we:

  1. performed citation tracking using Web of Science Cited Reference Search for all included studies;
  2. searched the reference lists of included trials and all relevant articles;
  3. obtained further information from individual trialists;
  4. contacted other researchers in the field and publicised our preliminary findings at stroke conferences in the UK, Scandinavia, Germany, the Netherlands, Switzerland, Spain, Canada, South America, Australia, Belgium, USA and Hong Kong.

 

Data collection and analysis

 

Selection of studies

For this updated review, one author (PF) read the titles and abstracts of the records obtained from the electronic searches and excluded obviously irrelevant studies. We obtained the full copy of the remaining studies and two review authors (PF, PL) independently selected studies for inclusion based on the following eligibility criteria:

  1. randomised controlled trial;
  2. service intervention providing a form of organised inpatient (stroke unit) care;
  3. service aim is to improve functional recovery and survival after stroke;
  4. trial of stroke patients.

We established the characteristics of unpublished trials through discussion with the trial co-ordinator prior to analysis of the results.

 

Data extraction and management

If possible, the principal review author (PL) obtained descriptive information about the service characteristics of the organised inpatient (stroke unit) care and conventional care settings through a structured interview or correspondence conducted with the trial co-ordinators (n = 17). We obtained outstanding information from published sources. We then allocated trials to service subgroups. We confirmed outcome data from published sources and supplemented them with unpublished information provided by the co-ordinator of each individual trial. We asked trialists to provide information on the number of participants who were dead, dependent, requiring institutional care or missing at the end of scheduled follow up. For this updated review, for which data were available only from published sources, two review authors (PF, PL) independently extracted data using a standard data extraction form.

We sought subgroup information primarily for the combined outcome of death or requiring institutional care. We obtained unpublished aggregated data for a majority of trials but insufficient amounts of individual patient data were available to allow a comprehensive individual patient data analysis.

We obtained subgroup data regarding the following participant groups (see SUTC 1997a for details):

  1. age: up to 75 years or greater than 75 years;
  2. sex: male or female;
  3. stroke severity: dependency at the time of randomisation (usually within one week of the index stroke):
    1. mild stroke: equivalent to a Barthel Index of 10 to 20 out of 20 during the first week;
    2. moderate stroke: equivalent to a Barthel Index of 3 to 9 out of 20 during the first week;
    3. severe stroke: equivalent to a Barthel Index of 0 to 2 out of 20 during the first week;
  4. stroke type: ischaemic or haemorrhagic based on neuroimaging.

 

Assessment of risk of bias in included studies

We assessed risk of bias using The Cochrane Collaboration's risk of bias tool, as described in Chapter 8 of the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011). We identified the method of concealment of treatment allocation, the presence of an intention-to-treat analysis and the presence of blinding of outcome assessment as potentially important factors for sensitivity analyses, but we did not use them as exclusion criteria.

 

Measures of treatment effect

Where our primary outcomes of death, dependency or institutionalisation after the end of scheduled follow-up were reported, we analysed these using the odds ratio (OR) and 95% confidence interval (CI) of an adverse outcome.

As a secondary outcome, we aimed to record length of stay in hospital or an institution as the mean and standard deviation (SD). Where only medians were available, we assumed these were approximate to the mean. Where no other data were provided with the mean value, we inferred the SD as being at least as large as those in the comparable trials using the same measure. Because length of stay was reported in a variety of ways we used standardised mean difference (SMD) and 95% CI.

 

Unit of analysis issues

We anticipated that the majority of trials would have a simple parallel-group design in which each individual was randomised to one of two treatment groups. We planned to perform subgroup analyses should a trial have three (or more) treatment groups.

 

Dealing with missing data

Where data were missing for the outcomes of death, dependency or institutionalisation we assumed the participant to be alive, independent and living at home. We aimed to explore the implications of these assumptions in sensitivity analyses.

 

Assessment of heterogeneity

We planned to determine heterogeneity using the I² statistic. We defined significant heterogeneity as an I² of greater than 50%. Where significant heterogeneity occurred, we explored potential sources using pre-planned sensitivity analyses.

 

Assessment of reporting biases

We employed a comprehensive search strategy in an effort to avoid reporting biases. To identify unpublished studies we searched trial registers and contacted trialists and other experts in the field.

 

Data synthesis

We checked all individual patient data for internal consistency and consistency with published reports. One review author entered data into the Review Manager software (RevMan 5.2) (RevMan 2012) and a second review author checked the entries. We analysed binary outcome data using OR and 95% CI. We analysed continuous outcome data using SMD and 95% CI. We used a fixed-effect model first but replaced this with a random-effects model if there was significant heterogeneity.

 

Subgroup analysis and investigation of heterogeneity

Subgroup analyses involved a reanalysis stratified by participant or service subgroup using tabular subgroup data provided by the trialists. We used a fixed-effect approach unless there was statistically significant heterogeneity, in which case results were confirmed using a random-effects statistical model.

 

Sensitivity analysis

We planned sensitivity analyses around the key aspects of trial quality that we identified during our assessment of risk of bias (that is method of randomisation (concealment of treatment allocation), blinding of outcome assessment and a fixed period of follow-up).

 

Results

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. Feedback
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Index terms
 

Description of studies

See: Characteristics of included studies; Characteristics of excluded studies; Characteristics of studies awaiting classification; Characteristics of ongoing studies.

 

Results of the search

The search strategy for previous versions of this review identified 48 potentially eligible trials, of which we excluded 13 (Abissi 1995; Asplund 2000; Davis 2000; Di Lauro 2003; Durastanti 2005; Koton 2005; Langhorne 2001; Moloney 1999; Ricauda 2004; Ronning 1998a; Ronning 1998b; Silva 2004; Walter 2005), two were ongoing (Stone 1998; Wang 2004) and two were awaiting further assessment (HAMLET 2009; Pearson 1988). Therefore, the previous version of this review included 31 trials (6936 participants) in quantitative data syntheses.

For this updated review, the searches of MEDLINE, EMBASE and CINAHL identified 5478 records and from these and the searches of the Cochrane trials registers and other sources, we identified 18 new potentially eligible trials for consideration using the four selection criteria (Figure 1). In addition, we identified newly published data for one previously included trial (Athens 1995).

 FigureFigure 1. Flow diagram illustrating the results of the updated searches

The assessors agreed on the inclusion of four trials (Guangdong 2008; Guangdong 2009; Huaihua 2004; Hunan 2007) and the exclusion of four trials (Diagana 2008; Middleton 2006; Pappa 2009; Shiraishi 2004) (see Excluded studies), which were newly identified for this updated review. We require further information for seven trials (Anhui 2008; China (Hao) 2010; China (Pei) 2011; China (Wang) 2008; China (Wu) 2007; Haikou 2007; Shanghai 2006) in order to assess eligibility, and an additional three trials (Baden 2007; Beijing 2009; Shanghai 2009) do not yet have available outcome data.

After formal risk of bias assessment the assessors also agreed on the exclusion of seven of the 31 trials included in the previous version of this review. These seven trials employed informal randomisation procedures (quasi-randomised) based on bed availability (Cavallini 2003; Strand 1985; von Arbin 1980; Yagura 2005), a strict admission rota (Hamrin 1982; Patel 2000) or patient date of birth (Ronning 1998). Of the four trials that were awaiting further assessment or were ongoing at the time of the previous literature search, the assessors excluded three trials as no outcome data were available (Pearson 1988; Stone 1998; Wang 2004) and one trial as no data for the comparison of intensive monitoring versus standard ward-based care have been reported for non-surgical control participants (HAMLET 2009).

Therefore, this updated review incorporates an individual patient data meta-analysis for 28 randomised controlled trials with 5855 participants.

 

Included studies

 

Service characteristics within organised (stroke unit) care and conventional care settings

Descriptive information was available for all trials: in seven trials we had access to published information only (Birmingham 1972; Guangdong 2008; Guangdong 2009; Huaihua 2004; Hunan 2007; Illinois 1966; New York 1962), in two trials we had detailed unpublished information (Beijing 2004; Joinville 2003) and in the remaining 19 trials a structured interview was carried out with the trial co-ordinator to determine the service characteristics.

Our original publication outlined the features of the stroke unit trials (SUTC 1997a). In summary, organised inpatient (stroke unit) care was characterised by: (1) co-ordinated multidisciplinary rehabilitation, (2) staff with a specialist interest in stroke or rehabilitation, (3) routine involvement of carers in the rehabilitation process and (4) regular programmes of education and training. Several factors indicating a more intensive or more comprehensive input of care were also associated with the stroke unit setting. Various service models of care exist ( Table 1) but the core characteristics (SUTC 1997a) that were invariably included in the stroke unit setting were: (1) multidisciplinary staffing - that is medical, nursing and therapy staff (usually including physiotherapy, occupational therapy, speech therapy, social work); and (2) co-ordinated multidisciplinary team care incorporating meetings at least once per week. Where both the services compared could satisfy the description of stroke unit care the more-organised system of care was taken as the index service.

Service comparisons within the 28 trials with outcome data are detailed in  Table 2. The total number of comparisons is greater than the number of trials because in three trials participants could be randomised to one of two alternatives to stroke unit care; two of these trials used a stratified randomisation procedure (Nottingham 1996; Orpington 1993) and one did not (Dover 1984). In two small trials the conventional care (general medical) group also received some input from a specialist nurse (Illinois 1966; New York 1962). Although this was not strictly general medical ward care, we have included this information since relatively little novel nursing input appears to have been available. The exclusion of these trials would not alter the conclusions of the systematic review substantially. In one trial, some participants appear to have been treated outside the rehabilitation wards (that is by peripatetic team care) but the number is unclear (New York 1962). This trial is currently classified as a mixed rehabilitation ward.

Of the four trials newly identified for this update, three compared a model of stroke unit care using integrated traditional Chinese medicine (TCM) (e.g. acupuncture and herbal remedies) versus standard 'Western medicine' stroke unit care (Guangdong 2008; Hunan 2007) or a general medical ward (Guangdong 2009); one trial compared a comprehensive stroke ward within a neurology unit with a general medical ward (Huaihua 2004). The duration of rehabilitation provided in all four newly identified trials was unclear and in only two trials was the timing of randomisation reported (Guangdong 2009; Huaihua 2004).

Of the 24 previously included trials, 22 incorporated rehabilitation lasting several weeks if required; 16 of these units admitted participants acutely and eight after a delay of one or two weeks. Two trials evaluated an acute stroke (semi-intensive) unit with no continuing rehabilitation. One trial proved difficult to categorise as it contained elements of an acute (semi-intensive) unit but offered some rehabilitation (Athens 1995). It is classified here as a comprehensive stroke unit. No trials evaluated an 'intensive care' model of stroke unit.

 

Excluded studies

See Characteristics of excluded studies.

Of the 28 excluded studies, 14 were not strictly randomised, four were evaluations of care pathways, four did not have available outcome data, three evaluated an intervention that did not fit our description of organised inpatient (stroke unit) care, two managed intervention and control participants within the same unit and one reported retrospective data from a previous study.

 

Risk of bias in included studies

See the 'Risk of bias' graph (Figure 2), the 'Risk of bias' summary (Figure 3) and the Characteristics of included studies table.

 FigureFigure 2. Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
 FigureFigure 3. Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

 

Allocation

Fifteen trials (Athens 1995; Dover 1984; Edinburgh 1980; Goteborg-Ostra 1988; Goteborg-Sahlgren 1994; Groningen 2003; Helsinki 1995; Kuopio 1985; Manchester 2003; Montreal 1985; Orpington 1993; Orpington 2000; Svendborg 1995; Tampere 1993; Trondheim 1991) used a clearly concealed randomisation procedure.

 

Blinding

Eleven trials (Goteborg-Sahlgren 1994; Groningen 2003; Helsinki 1995; Hunan 2007; Joinville 2003; Kuopio 1985; Manchester 2003; Montreal 1985; Nottingham 1996; Orpington 2000; Perth 1997) used an unequivocally blinded final assessment for all participants.

 

Incomplete outcome data

Nine trials had minor omissions of death and place of residence data (18 stroke unit participants and 35 controls in total) (Birmingham 1972; Dover 1984; Edinburgh 1980; Manchester 2003; Montreal 1985; Nottingham 1996; Orpington 1993; Orpington 2000; Tampere 1993). For the purpose of our analysis these participants were assumed to be alive and living at home, which may have introduced a minor bias in favour of the control group.

 

Effects of interventions

The results of the systematic review are presented in six sections as follows.

Section 1: Organised inpatient (stroke unit) care versus alternative care. First, we have outlined the main outcomes for the comparison of organised inpatient (stroke unit) care with an alternative service. Therefore, this section examines the impact of increased levels of organisation of stroke care on patient outcomes. Where both services compared could satisfy the definition of stroke unit care, the more-organised system of care was taken as the index service.

Section 2: Organised inpatient (stroke unit) care versus general medical ward. We have then described the results for the most common comparison: organised stroke unit care versus a general medical ward. This section includes analyses of different subgroups of patient and service type.

Sections 3, 4, 5 and 6: Comparisons of different forms of organised inpatient (stroke unit) care. Finally, we have presented the results for direct comparisons of different forms of organised stroke unit care.

 

Section 1 : Organised stroke unit care versus alternative care

 

Comparison 1.1: Death by the end of scheduled follow-up

Outcome data were available for all 28 trials (5855 participants) in which a novel organised inpatient (stroke unit) intervention was compared with an alternative (less-organised) service ( Analysis 1.1). Case fatality recorded at the end of scheduled follow-up (median follow-up 12 months; range six weeks to 12 months) was lower in the organised (stroke unit) care group in 21 of 28 trials. The overall summary estimate was an OR of 0.76 (95% CI 0.66 to 0.88; P = 0.0001). There was a borderline significant subgroup interaction (P = 0.04) with more positive effects seen in subgroups based on trials of stroke wards. When we restricted the analysis to those trials in which scheduled follow-up was continued for a fixed period of six months or one year (that is excluding Beijing 2004; Goteborg-Ostra 1988; Groningen 2003; Guangdong 2008; Guangdong 2009; Illinois 1966; Montreal 1985; New York 1962; Orpington 1993; Orpington 1995), the overall OR was essentially unchanged (OR 0.80, 95% CI 0.69 to 0.93; P = 0.0001).

 

Comparison 1.2: Death or institutional care by the end of scheduled follow-up

Outcome data were available for 23 trials (4840 participants) ( Analysis 1.2). The median duration of follow-up was one year. The summary result indicated a significant reduction in the odds of a patient dying or requiring long-term institutional care (OR 0.76, 95% CI 0.67 to 0.86; P = 0.0001). There was a borderline significant subgroup interaction (P = 0.02) with more positive effects usually seen in subgroups based on trials of stroke wards. When we excluded trials that had a very short or variable period of follow-up (Beijing 2004; Goteborg-Ostra 1988; Groningen 2003; Illinois 1966; Montreal 1985; New York 1962; Orpington 1993; Orpington 1995), we found that the overall estimate of apparent benefit was unaffected (OR 0.75, 95% CI 0.65 to 0.86; P = 0.0001)

 

Comparison 1.3: Death or dependency by the end of scheduled follow-up

Outcome data were available for 23 trials (4807 participants) ( Analysis 1.3). The summary result indicated a significant reduction in the odds of the combined adverse outcomes of death or dependency (OR 0.80, 95% CI 0.67 to 0.97; P < 0.00001) with no significant heterogeneity. The conclusions were not altered by the exclusion of trials with a variable follow-up period. The main methodological difficulty when using dependency as an outcome was the degree of blinding at final assessment and the potential for bias if the assessor was aware of the treatment allocation. The results were unchanged (OR 0.74, 95% CI 0.61 to 0.90; P = 0.002) when restricted to those trials in which an unequivocally blinded final assessment for all participants was undertaken (Goteborg-Sahlgren 1994; Groningen 2003; Helsinki 1995; Joinville 2003; Kuopio 1985; Manchester 2003; Montreal 1985; Nottingham 1996; Orpington 2000).

 

Comparison 1.4 and 1.5: Length of stay (days) in a hospital or institution or both

Length of stay data were available for 18 individual trials (4115 participants) ( Analysis 1.4;  Analysis 1.5). Mean (or median) length of stay ranged from 11 to 162 days in the stroke unit groups and from 12 to 129 days in the control groups. Twelve trials reported a shorter length of stay in the stroke unit group and six a more prolonged stay. The calculation of a summary result for length of stay was subject to major methodological limitations: length of stay was calculated in different ways (for example acute hospital stay, total stay in hospital or institution), two trials recorded median rather than mean length of stay and in two trials the SD had to be inferred from the P value or from the results of similar trials. Overall, using a random-effects model, there was no significant reduction in the length of stay in the stroke unit group (SMD -0.15, 95% CI -0.32 to 0.02; P = 0.09). The summary estimate was complicated by considerable heterogeneity that limits the extent to which more general conclusions can be inferred.

We reanalysed results according to whether length of stay was defined as stay in acute hospital only or the total length of stay in a hospital or institution in the first year after stroke ( Analysis 1.5). There was no significant difference between the two groups and no reduction in heterogeneity.

 

Comparisons 1.6, 1.7 and 1.8: Death, death or institutional care, and death or dependency at five-year follow-up

Three trials (1139 participants) carried out supplementary studies extending participant follow-up to five years post-stroke (Athens 1995; Nottingham 1996; Trondheim 1991) for the outcome of death, and two trials (535 participants) carried out supplementary studies extending participant follow-up to five years post-stroke (Nottingham 1996; Trondheim 1991) for the outcomes of death or institutionalisation and death or dependency. The OR for adverse outcomes continued to favour stroke unit care but with some heterogeneity: death 0.74 (95% CI 0.59 to 0.94; P = 0.01) ( Analysis 1.6), death or institutional care 0.59 (95% CI 0.33 to 1.05; P = 0.07) ( Analysis 1.7) and death or dependency 0.54 (95% CI 0.22 to 1.34; P = 0.18) ( Analysis 1.8).

 

Comparisons 1.9, 1.10 and 1.11: Death, death or institutional care, and death or dependency at 10-year follow-up

Three trials (1152 participants) extended follow-up to 10 years post stroke for the outcome of death (Athens 1995; Nottingham 1996; Trondheim 1991) and two trials (535 participants) extended follow-up to 10 years post stroke for the outcomes of death or institutionalisation and death or dependency (Nottingham 1996; Trondheim 1991). Again, the summary results continued to favour stroke unit care but with increased heterogeneity and a loss of statistical significance for the outcomes of death and death or dependency: OR for death 0.67 (95% CI 0.43 to 1.03; P = 0.07) ( Analysis 1.9), death or institutional care 0.57 (95% CI 0.37 to 0.88; P = 0.01) ( Analysis 1.10) and death or dependency 0.70 (95% CI 0.27 to 1.80; P = 0.45) ( Analysis 1.11).

 

Participant satisfaction and quality of life

Only three trials recorded outcome measures related to participant quality of life (Nottingham Health Profile; EuroQol Quality of Life Scale) (Manchester 2003; Nottingham 1996; Trondheim 1991). In Nottingham 1996 and Trondheim 1991, there was a pattern of improved results among stroke unit survivors with the results attaining statistical significance in the two trials. However, for the Manchester 2003 trial there was no statistically significant difference between the study groups. We could find no systematically gathered information on participant preferences.

 

Sensitivity analyses by trial characteristics

In view of the variety of trial methodologies described we carried out a sensitivity analysis based only on those trials with a low risk of bias: (1) secure randomisation procedures; (2) unequivocally blinded outcome assessment; (3) a fixed one-year period of follow-up. Seven trials met all of these criteria (Goteborg-Sahlgren 1994; Groningen 2003; Helsinki 1995; Kuopio 1985; Manchester 2003; Nottingham 1996; Orpington 2000). Stroke unit care was associated with a statistically non-significant reduction in the odds of death (OR 0.82, 95% CI 0.64 to 1.05; P = 0.12) and statistically significant reductions in the odds of death or institutional care (OR 0.77, 95% CI 0.63 to 0.96; P = 0.02) and death or dependency (OR 0.76, 95% CI 0.62 to 0.93; P = 0.009).

 

Subgroup analyses by patient characteristics

Predefined subgroup analyses were based on previous versions of this review (SUTC 1997a) and each subgroup analysis included data from at least nine trials (at least 1111 participants). These were based on participants' age, sex and initial stroke severity. For this updated version we have incorporated additional data based on pathological stroke type (ischaemic or haemorrhagic stroke). See Figure 4, Figure 5 and Figure 6.

 FigureFigure 4. Analysis of patient characteristics on effectiveness of organised stroke unit care versus alternative service for the outcome of death by the end of scheduled follow-up.
 FigureFigure 5. Analysis of patient characteristics on effectiveness of organised stroke unit care versus alternative service for the outcome of death or institutionalisation by the end of scheduled follow-up.
 FigureFigure 6. Analysis of patient characteristics on effectiveness of organised stroke unit care versus alternative service for the outcome of death or dependency by the end of scheduled follow-up.

Caution is needed when interpreting these subgroup analyses particularly as a relatively small number of outcome events were observed, which limits the statistical power. Furthermore, the results may change depending on the outcome chosen. These results indicate that in general the magnitude of benefit seemed greater for participants with more-severe stroke. However, stroke unit benefits are apparent across a range of participant subgroups (that is age, sex, initial stroke severity and stroke type). Analysis by stroke severity confirmed that there was no statistically significant reduction in case fatality in mild stroke patients (OR 1.03, 95% CI 0.67 to 1.58). However, mild stroke patients managed in stroke units had a reduced risk of dependency (OR 0.76, 95% CI 0.58 to 1.00).

 

Section 2: Organised stroke unit care versus general medical wards

 

Comparisons 2.1, 2.2 and 2.3: Death, death or institutional care, and death or dependency by the end of scheduled follow-up

A variety of predefined subgroup analyses were carried out based on service characteristics. Two different models of care (comprehensive stroke ward, mixed assessment or rehabilitation ward) tended to be more effective than general medical ward care. However, for the comparison of rehabilitation stroke wards or mobile team care (peripatetic service) versus general medical wards there were no statistically significant differences. Overall, stroke unit care showed reductions in the odds of death recorded at final (median one year) follow-up (OR 0.81, 95% CI 0.69 to 0.94; P = 0.005) ( Analysis 2.1), the odds of death or institutionalised care (OR 0.78, 95% CI 0.68 to 0.89; P = 0.0003) ( Analysis 2.2) and the odds of death or dependency (OR 0.79, 95% CI 0.68 to 0.90; P = 0.0007) ( Analysis 2.3). Interpretation of length of stay data was complicated by substantial heterogeneity. There was no evidence of a systematic increase in length of stay.

 

Sections 3, 4, 5 and 6: Comparisons of different forms of organised stroke unit care

In planning our analyses we specified in advance that an important question for service planning would be whether the benefits of stroke unit care depended upon the establishment of a ward dedicated only to stroke care (stroke ward) or could be achieved through a mobile stroke team or a generic disability service (mixed rehabilitation unit) that specialises in the management of disabling illness including stroke. We therefore analysed those trials that directly compared two different forms of organised stroke unit care that met the basic descriptive criteria of stroke unit care (see 'Description of Studies'): multidisciplinary staffing co-ordinated through regular team meetings.

Of the eight trials identified for which outcome data were available, one compared an acute (semi-intensive) stroke ward with a comprehensive stroke ward (Groningen 2003), one compared an acute (semi-intensive) stroke ward with a mixed rehabilitation ward (Tampere 1993), one compared a stroke ward that combined acute care and rehabilitation (comprehensive stroke ward) with a general medical ward where care was co-ordinated by a multidisciplinary team (mobile team care) (Orpington 2000), two compared a stroke ward with integrated TCM with a 'Western medicine' stroke ward (Guangdong 2008; Hunan 2007) and three incorporated designs in which patients could be randomised either to a stroke rehabilitation ward or to conventional care in either a general medical ward or mixed rehabilitation ward within a Department of Geriatric Medicine (Dover 1984; Nottingham 1996; Orpington 1993). Data were available for both these subgroups of participants.

 

Section 3: Acute stroke ward versus alternative service

 
Analysis 3.1, Analysis 3.2, Analysis 3.3 and Analysis 3.4: Death, death or institutional care, death or dependency by the end of scheduled follow-up and length of stay in hospital or institution

Overall, acute (monitoring) units did not have statistically significant different odds of death, death or requiring institutional care, or death or dependency when compared with acute (non-intensive) units. Interpretation of length of stay data was complicated by substantial heterogeneity. There was no evidence of a systematic increase in length of stay.

 

Section 4: Comprehensive stroke ward versus alternative service

 
Analysis 4.1, Analysis 4.2, Analysis 4.3 and Analysis 4.4: Death, death or institutional care, death or dependency by the end of scheduled follow-up and length of stay in hospital or institution

One trial compared a comprehensive stroke ward (providing acute care and rehabilitation) with admission to general wards where care was provided by a mobile stroke team (Orpington 2000). They found statistically significant (P < 0.001) reductions in death and the combined outcome of death or institutional care among the comprehensive stroke ward group. Fewer comprehensive stroke ward participants were dead or dependent at the end of follow-up, but this result did not achieve statistical significance. However, Orpington 2000 is the only trial in this analysis comparing comprehensive stroke wards with an alternative service so these results require confirmation. There was no significant difference in length of stay.

 

Section 5: Rehabilitation stroke ward versus alternative service

 
Analysis 5.1, Analysis 5.2, Analysis 5.3 and Analysis 5.4: Death, death or institutional care, death or dependency by the end of scheduled follow-up and length of stay in hospital or institution

There was a pattern of improved outcomes in the stroke rehabilitation ward with statistically significantly fewer deaths (P = 0.02) and a statistically non-significant trend for fewer participants with the composite end points of death or requiring institutional care and death or dependency. However, the numbers were small and no definite conclusions could be drawn. Interpretation of length of stay data was complicated by substantial heterogeneity. There was no evidence of a systematic increase in length of stay.

 

Section 6: Stroke ward plus TCM versus alternative service

 
Analysis 6.1: Death at the end of scheduled follow-up

There was no significant difference in the odds of death in a stroke ward with integrated TCM when compared with a standard 'Western medicine' stroke ward. The type of care provided in a stroke unit with integrated TCM has not been well described. The overall estimate is based on the results of a single trial and no definitive conclusions can be drawn.

 

Discussion

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. Feedback
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Index terms
 

Summary of main results

 

Main analysis

The updated information in Section 1 confirms our previous observations that people receiving organised inpatient (stroke unit) care were more likely to survive, regain independence and return home than those receiving a less-organised service. This apparent effect remains of moderate statistical significance for case fatality. The conclusions could be overturned by a number of unpublished randomised trials with neutral results. However, the observed reductions in the combined adverse outcomes (death or institutionalisation, death or dependency) are much more robust statistically. The three trials that have extended follow-up for five or 10 years have found a sustained benefit among stroke unit patients.

The requirement for long-term care is a useful surrogate for disability (Barer 1993) and is likely to show good inter-observer agreement. The absolute rates of institutionalisation, however, will be influenced by a variety of national and cultural factors. The combined adverse outcome of death or dependency is a more direct measure of patient outcome, but is subject to potential observer bias where final assessments were not carried out in a blinded manner. The sensitivity analysis based on those trials that used an unequivocally blinded assessment suggested that such bias has not seriously influenced the results.

The analysis of length of stay is complicated by the different methods of reporting results, the widely varying control group lengths of stay and the statistically significant heterogeneity between different trials. The most reasonable conclusion appears to be that there was no systematic increase in length of stay associated with organised (stroke unit) care and there may have been a modest reduction.

 

Subgroup analyses

In any discussion of the comparison of results in different subgroups it is worth bearing in mind that the main issue is not whether a subgroup result is statistically different from zero but whether there is statistically significant heterogeneity between the estimates of effect in each of the relevant subgroups. Our analyses are limited by relatively low statistical power and so must be interpreted with great caution. The subgroup analyses indicate that the observed benefits of organised stroke unit care are not limited to any one subgroup of patients or models of stroke unit organisation that were examined. Apparent benefits were seen in people of both sexes, aged under and over 75 years, with ischaemic or haemorrhagic stroke and across a range of stroke severities.

The apparent relation between stroke severity and outcome must be interpreted with caution. People with more severe stroke symptoms are at greater risk of death or requiring institutional care and hence stand to gain more from treatment. Patients with a mild stroke appeared to benefit from stroke unit care when death or dependency was the chosen outcome (Figure 6), but this effect was less certain for the outcomes of death, or death or institutional care. Two approaches to stroke unit care, that is comprehensive units and mixed assessment/rehabilitation units, tended to be more effective than care in a general medical ward. There was a similar trend for rehabilitation stroke units. However, mobile stroke care appeared to have a more neutral effect. Apparent benefits were seen in units with acute admission policies as well as those with delayed admission policies and in units which could offer a period of rehabilitation lasting several weeks.

 

Comparison of different types of stroke unit care

Results Sections 3 to 6 of the review focused on those trials that directly compared two different forms of care, both of which met our basic definition of organised inpatient (stroke unit) care: multidisciplinary team care co-ordinated through regular meetings. The results of this analysis indicate statistically significantly improved results from a dedicated stroke ward over a mobile stroke team. There were also trends towards better outcomes within the dedicated stroke rehabilitation ward setting as opposed to the mixed rehabilitation ward, and within the acute (semi-intensive) ward as opposed to the comprehensive ward. However, in none of the three primary outcomes was there a convincing statistically significant result and more information is required. No firm conclusions could be drawn for the comparisons of a stroke ward integrated with TCM versus a 'Western medicine' stroke ward or an acute (semi-intensive) ward with a mixed rehabilitation unit.

 

Costs and benefits

Stroke units appear to improve outcomes, but at what cost? In cost terms, length of stay is likely to dominate any individual component of acute patient care and rehabilitation. Longer-term costs are likely to be dominated by the need for nursing care. Studies from several developed countries (Warlow 2008) have shown that fixed costs (particularly nursing staff salaries) account for over 90% of spending on people with acute stroke. Remedial therapy represents only a small proportion of the total cost of hospitalisation. In one analysis, stroke unit care was not clearly associated with an increase in total health and social care costs, but these conclusions were sensitive to some variations in cost estimates (Major 1998). More research is required to elucidate the cost implications of stroke units.

 

Overall completeness and applicability of evidence

Our original systematic review of organised inpatient (stroke unit) care (SUTC 1997a) addressed the question of whether improving the organisation of inpatient stroke care could bring about important improvements in patient outcomes in comparison with the contemporary conventional care. This analysis has now been extended and updated in Section 1 to reflect the comparison of 'more-organised' versus 'less-organised' care. We have done this because some recent trials have included service comparisons where a stroke unit service based in a stroke ward was compared with a less-organised alternative service (such as mixed rehabilitation ward or mobile stroke team) that was not strictly conventional care. This approach to analysis allows one to view all service comparisons before focusing on various subgroup comparisons.

This update includes four new trials (763 participants), but the overall conclusions remain unaltered in comparison with previous versions. The review now summarises data from a total of 28 trials (5855 participants) from 12 countries in Asia, Australasia, Europe, North America and South America. The majority of trials have been performed in high-income countries; the applicability of stroke unit care in low- or middle-income countries is less clear (Langhorne 2012).

As discussed, our subgroup analyses suggest the benefits of organised inpatient (stroke unit) care are seen across a wide range of stroke patients. This is supported by evidence from observational studies of stroke unit care (Seenan 2007), which have established that stroke units can operate effectively in routine settings beyond a specialised research environment. The current analysis does not explain how stroke units may improve patient outcomes. This could be due to greater staff expertise, better diagnostic procedures, better nursing care, early mobilisation, the prevention of complications or more effective rehabilitation procedures (Langhorne 1998).

 

Quality of the evidence

The quality of evidence in this updated review has been made more uniform by the exclusion of several quasi-randomised prospective controlled clinical trials that were previously included in the data synthesis (see Description of studies). The main reason for this change was to simplify the inclusion criteria for this and future updates. However, it is worth noting that the exclusion of these trials did not affect the overall estimate of treatment effect.

We judged some trials to be at high risk of bias due to poor allocation concealment and unblinded outcome assessment; in others, these important methodological aspects were not clearly reported making a judgement of risk of bias difficult. The improvement in survival observed with stroke unit care no longer remained statistically significant in sensitivity analyses restricted to the seven trials at low risk of bias. It is possible that methodological limitations within the trials led to an overestimation of the effect size for this outcome. It is reassuring that effect sizes for the composite adverse outcomes of death or institutionalisation or death or dependency remained largely unaltered.

We recognise that some of the included trials are relatively old, possibly with entirely different standards of care from those used currently. Similarly, although a majority of included trials were fairly recent, most would still have been undertaken in an era without routine access to intravenous thrombolysis for acute stroke. While essentially all stroke patients would be eligible for admission to a stroke unit, only a small proportion would be eligible for treatment with thrombolysis even in the most established acute centres. Moreover, all included trials were randomised, therefore any differences in the standard of care should not have had a confounding effect on the final conclusions.

 

Potential biases in the review process

Through a comprehensive search strategy and established connections with other researchers in the field we are confident that we have identified all potentially relevant studies. We did not search the Chinese databases. However, we were unable to classify or obtain useable outcome data for seven of the 11 Chinese studies we did identify for this update (Anhui 2008; China (Hao) 2010; China (Pei) 2011; China (Wang) 2008; China (Wu) 2007; Haikou 2007; Shanghai 2006). We recognise that the absence of data from these studies in our meta-analysis could potentially introduce bias.

Methodological limitations may also have influenced the analysis of descriptive information about service organisation (SUTC 1997a). We collated service descriptions retrospectively through discussion with the trialists who ran the organised (stroke unit) care. Our findings may therefore be biased towards the expectations of the trialists and by a tendency to discuss the results with the trialists who ran the organised stroke unit care more so than with those who ran the conventional care. At best, this represents a strictly factual account of service characteristics; at worst, it represents a consensus view of the trialists about which features of stroke unit care were effective.

 

Authors' conclusions

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. Feedback
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Index terms

 

Implications for practice

People with acute stroke are more likely to survive, return home and regain independence if they receive organised inpatient (stroke unit) care. This is typically provided by a co-ordinated multidisciplinary team operating within a discrete stroke ward that can offer a substantial period of rehabilitation if required. There are no firm grounds for restricting access according to a person's age, sex, stroke severity or pathological stroke type (that is ischaemic or haemorrhagic).

Since the original publication of this review, stroke services in many developed countries have undergone substantial reorganisation in line with national strategies and clinical practice guidelines to enable improvements in access to stroke unit care. More recently, stroke services in many countries have been further reorganised to reflect a two-tiered (or hub-and-spoke) model of care in which a central 'comprehensive stroke centre' (or 'hyper-acute stroke unit') is equipped with facilities for acute intravenous or intra-arterial treatments, intensive monitoring, advanced imaging and neurosurgery. These then serve a number of 'primary stroke centres' or stroke units within a hospital network or geographical location. Although this approach seems almost intuitive to many stroke clinicians, it has never been formally tested in randomised controlled trials. Until such trials are available, stroke services should ensure that every stroke patient receives the core service characteristics identified in the randomised trials.

 
Implications for research

Future trials should focus on examining the potentially important components of stroke unit care and direct comparisons of different models of organised stroke unit care, particularly with regard to the hyper-acute stroke unit model. In low-income healthcare settings, appropriately powered clinical trials could help define how barriers to the establishment of stroke units could be overcome (Langhorne 2012). Outcome measures should not only include the outcomes of death, dependency and institutionalisation, but also domains of patient satisfaction, quality of life and cost. Pre-planned collaboration between comparable trials could alleviate some of the problems of retrospective systematic reviews such as ensuring that similar variables and outcomes are recorded in any new trial.

Anyone carrying out a relevant randomised trial of a stroke service component is invited to contact Peter Langhorne regarding a future collaborative review.

 

Acknowledgements

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. Feedback
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Index terms

This review is dedicated to the memory of Peter Berman, Mona Britton and Richard Stevens.

 

Data and analyses

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. Feedback
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Index terms
Download statistical data

 
Comparison 1. Organised stroke unit care versus alternative service

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Death by the end of scheduled follow-up31Peto Odds Ratio (Peto, Fixed, 95% CI)Subtotals only

    1.1 Stroke ward versus general medical ward
153521Peto Odds Ratio (Peto, Fixed, 95% CI)0.75 [0.63, 0.90]

    1.2 Mixed rehabilitation ward versus general medical ward
6630Peto Odds Ratio (Peto, Fixed, 95% CI)0.91 [0.58, 1.42]

    1.3 Mobile stroke team versus general medical ward
2438Peto Odds Ratio (Peto, Fixed, 95% CI)1.08 [0.71, 1.65]

    1.4 Stroke ward versus mixed rehabilitation ward
4542Peto Odds Ratio (Peto, Fixed, 95% CI)0.82 [0.54, 1.24]

    1.5 Stroke ward versus mobile stroke team
1304Peto Odds Ratio (Peto, Fixed, 95% CI)0.35 [0.19, 0.65]

    1.6 Stroke ward versus stroke ward
154Peto Odds Ratio (Peto, Fixed, 95% CI)0.18 [0.04, 0.79]

    1.7 Stroke ward (plus TCM) versus stroke ward
2366Peto Odds Ratio (Peto, Fixed, 95% CI)0.54 [0.13, 2.22]

 2 Death or institutional care by the end of scheduled follow-up26Peto Odds Ratio (Peto, Fixed, 95% CI)Subtotals only

    2.1 Stroke ward versus general medical ward
132924Peto Odds Ratio (Peto, Fixed, 95% CI)0.74 [0.63, 0.87]

    2.2 Mixed rehabilitation ward versus general medical ward
5578Peto Odds Ratio (Peto, Fixed, 95% CI)0.71 [0.51, 0.99]

    2.3 Mobile stroke team versus general medical ward
2438Peto Odds Ratio (Peto, Fixed, 95% CI)1.27 [0.84, 1.93]

    2.4 Stroke ward versus mixed rehabilitation ward
4542Peto Odds Ratio (Peto, Fixed, 95% CI)0.90 [0.64, 1.27]

    2.5 Stroke ward versus mobile stroke team
1304Peto Odds Ratio (Peto, Fixed, 95% CI)0.40 [0.23, 0.68]

    2.6 Stroke ward versus stroke ward
154Peto Odds Ratio (Peto, Fixed, 95% CI)0.48 [0.16, 1.38]

 3 Death or dependency by the end of scheduled follow-up26Peto Odds Ratio (Peto, Fixed, 95% CI)Subtotals only

    3.1 Stroke ward versus general medical ward
122839Peto Odds Ratio (Peto, Fixed, 95% CI)0.75 [0.64, 0.88]

    3.2 Mixed rehabilitation ward versus general medical ward
6630Peto Odds Ratio (Peto, Fixed, 95% CI)0.65 [0.47, 0.90]

    3.3 Mobile stroke team versus general medical ward
2438Peto Odds Ratio (Peto, Fixed, 95% CI)0.80 [0.52, 1.22]

    3.4 Stroke ward versus mixed rehabilitation ward
4542Peto Odds Ratio (Peto, Fixed, 95% CI)1.01 [0.68, 1.50]

    3.5 Stroke ward versus mobile stroke team
1304Peto Odds Ratio (Peto, Fixed, 95% CI)0.73 [0.46, 1.14]

    3.6 Stroke ward versus stroke ward
154Peto Odds Ratio (Peto, Fixed, 95% CI)0.39 [0.13, 1.17]

 4 Length of stay (days) in a hospital or institution or both194115Std. Mean Difference (IV, Random, 95% CI)-0.15 [-0.32, 0.02]

    4.1 Stroke ward
163728Std. Mean Difference (IV, Random, 95% CI)-0.20 [-0.39, -0.00]

    4.2 Mixed rehabilitation ward
3387Std. Mean Difference (IV, Random, 95% CI)0.08 [-0.21, 0.37]

 5 Length of stay (days) in a hospital or hospital plus institution194115Std. Mean Difference (IV, Random, 95% CI)-0.15 [-0.32, 0.02]

    5.1 Acute hospital stay only
71817Std. Mean Difference (IV, Random, 95% CI)-0.23 [-0.50, 0.03]

    5.2 Hospital and institution stay
122298Std. Mean Difference (IV, Random, 95% CI)-0.09 [-0.33, 0.15]

 6 Death at 5-year follow-up31139Peto Odds Ratio (Peto, Fixed, 95% CI)0.74 [0.59, 0.94]

 7 Death or institutional care at 5-year follow-up2535Odds Ratio (M-H, Random, 95% CI)0.59 [0.33, 1.05]

 8 Death or dependency at 5-year follow-up2535Odds Ratio (M-H, Random, 95% CI)0.54 [0.22, 1.34]

 9 Death at 10-year follow-up31152Odds Ratio (M-H, Random, 95% CI)0.67 [0.43, 1.03]

 10 Death or institutional care at 10-year follow-up2535Peto Odds Ratio (Peto, Fixed, 95% CI)0.57 [0.37, 0.88]

 11 Death or dependency at 10-year follow-up2535Odds Ratio (M-H, Random, 95% CI)0.70 [0.27, 1.80]

 
Comparison 2. Organised stroke unit care versus general medical wards

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Death by the end of scheduled follow-up234591Peto Odds Ratio (Peto, Fixed, 95% CI)0.81 [0.69, 0.94]

    1.1 Comprehensive stroke ward versus general medical ward
112988Peto Odds Ratio (Peto, Fixed, 95% CI)0.77 [0.63, 0.93]

    1.2 Rehabilitation stroke ward versus general medical ward
4535Peto Odds Ratio (Peto, Fixed, 95% CI)0.69 [0.46, 1.05]

    1.3 Mobile stroke team versus general medical ward
2438Peto Odds Ratio (Peto, Fixed, 95% CI)1.08 [0.71, 1.65]

    1.4 Mixed rehabilitation ward versus general medical ward
6630Peto Odds Ratio (Peto, Fixed, 95% CI)0.91 [0.58, 1.42]

 2 Death or institutional care by the end of scheduled follow-up203940Peto Odds Ratio (Peto, Fixed, 95% CI)0.78 [0.68, 0.89]

    2.1 Comprehensive stroke ward versus general medical ward
92391Peto Odds Ratio (Peto, Fixed, 95% CI)0.74 [0.62, 0.88]

    2.2 Rehabilitation stroke ward versus general medical ward
4533Peto Odds Ratio (Peto, Fixed, 95% CI)0.76 [0.52, 1.09]

    2.3 Mobile stroke team versus general medical ward
2438Peto Odds Ratio (Peto, Fixed, 95% CI)1.27 [0.84, 1.93]

    2.4 Mixed rehabilitation ward versus general medical ward
5578Peto Odds Ratio (Peto, Fixed, 95% CI)0.71 [0.51, 0.99]

 3 Death or dependency by the end of scheduled follow-up193510Peto Odds Ratio (Peto, Fixed, 95% CI)0.79 [0.68, 0.90]

    3.1 Comprehensive stroke ward versus general medical ward
71909Peto Odds Ratio (Peto, Fixed, 95% CI)0.82 [0.68, 0.98]

    3.2 Rehabilitation stroke ward versus general medical ward
4533Peto Odds Ratio (Peto, Fixed, 95% CI)0.83 [0.57, 1.23]

    3.3 Mobile stroke team versus general medical ward
2438Peto Odds Ratio (Peto, Fixed, 95% CI)0.80 [0.52, 1.22]

    3.4 Mixed rehabilitation ward versus general medical ward
6630Peto Odds Ratio (Peto, Fixed, 95% CI)0.65 [0.47, 0.90]

 4 Length of stay (days) in a hospital or institution132934Std. Mean Difference (IV, Random, 95% CI)-0.08 [-0.23, 0.06]

    4.1 Comprehensive stroke ward versus general medical ward
92373Std. Mean Difference (IV, Random, 95% CI)-0.18 [-0.34, -0.02]

    4.2 Rehabilitation stroke ward versus general medical ward
1174Std. Mean Difference (IV, Random, 95% CI)0.37 [0.07, 0.67]

   4.3 Mobile stroke team versus general medical ward
00Std. Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]

    4.4 Mixed rehabilitation ward versus general ward
3387Std. Mean Difference (IV, Random, 95% CI)0.08 [-0.21, 0.37]

 
Comparison 3. Different systems of organised care: acute stroke ward versus alternative service

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Death by the end of scheduled follow-up2265Odds Ratio (M-H, Random, 95% CI)0.49 [0.04, 5.92]

    1.1 Acute (semi-intensive) ward versus comprehensive ward
154Odds Ratio (M-H, Random, 95% CI)0.11 [0.01, 0.97]

    1.2 Acute (semi-intensive) ward versus mixed rehabilitation ward
1211Odds Ratio (M-H, Random, 95% CI)1.41 [0.76, 2.58]

 2 Death or institutional care by the end of scheduled follow-up2265Odds Ratio (M-H, Random, 95% CI)0.88 [0.32, 2.39]

    2.1 Acute (semi-intensive) ward versus comprehensive ward
154Odds Ratio (M-H, Random, 95% CI)0.46 [0.15, 1.39]

    2.2 Acute (semi-intensive) ward versus mixed rehabilitation ward
1211Odds Ratio (M-H, Random, 95% CI)1.32 [0.76, 2.30]

 3 Death or dependency by the end of scheduled follow-up2265Odds Ratio (M-H, Random, 95% CI)0.76 [0.24, 2.41]

    3.1 Acute (semi-intensive) ward versus comprehensive ward
154Odds Ratio (M-H, Random, 95% CI)0.38 [0.12, 1.18]

    3.2 Acute (semi-intensive) ward versus mixed rehabilitation ward
1211Odds Ratio (M-H, Random, 95% CI)1.24 [0.72, 2.14]

 4 Length of stay (days) in a hospital or institution2265Std. Mean Difference (IV, Random, 95% CI)-0.89 [-2.58, 0.79]

    4.1 Acute (semi-intensive) ward versus comprehensive ward
154Std. Mean Difference (IV, Random, 95% CI)-1.78 [-2.42, -1.14]

    4.2 Acute (semi-intensive) ward versus mixed rehabilitation ward
1211Std. Mean Difference (IV, Random, 95% CI)-0.06 [-0.33, 0.21]

 
Comparison 4. Different systems of organised care: comprehensive stroke ward versus alternative service

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Death by the end of scheduled follow-up1304Peto Odds Ratio (Peto, Fixed, 95% CI)0.35 [0.19, 0.65]

    1.1 Comprehensive stroke ward versus mobile stroke team
1304Peto Odds Ratio (Peto, Fixed, 95% CI)0.35 [0.19, 0.65]

 2 Death or institutional care by the end of scheduled follow-up1304Peto Odds Ratio (Peto, Fixed, 95% CI)0.40 [0.23, 0.68]

    2.1 Comprehensive stroke ward versus mobile stroke team
1304Peto Odds Ratio (Peto, Fixed, 95% CI)0.40 [0.23, 0.68]

 3 Death or dependency by the end of scheduled follow-up1304Peto Odds Ratio (Peto, Fixed, 95% CI)0.73 [0.46, 1.14]

    3.1 Comprehensive stroke ward versus mobile stroke team
1304Peto Odds Ratio (Peto, Fixed, 95% CI)0.73 [0.46, 1.14]

 4 Length of stay (days) in a hospital or institution1301Std. Mean Difference (IV, Random, 95% CI)0.07 [-0.16, 0.30]

    4.1 Comprehensive stroke ward versus mobile stroke team
1301Std. Mean Difference (IV, Random, 95% CI)0.07 [-0.16, 0.30]

 
Comparison 5. Different systems of organised care: rehabilitation stroke ward versus alternative service

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Death by the end of scheduled follow-up3331Peto Odds Ratio (Peto, Fixed, 95% CI)0.51 [0.29, 0.90]

    1.1 Rehabilitation stroke ward versus mixed rehabilitation ward
3331Peto Odds Ratio (Peto, Fixed, 95% CI)0.51 [0.29, 0.90]

 2 Death or institutional care by the end of scheduled follow-up3331Peto Odds Ratio (Peto, Fixed, 95% CI)0.71 [0.46, 1.09]

    2.1 Rehabilitation stroke ward versus mixed rehabilitation ward
3331Peto Odds Ratio (Peto, Fixed, 95% CI)0.71 [0.46, 1.09]

 3 Death or dependency by the end of scheduled follow-up3331Peto Odds Ratio (Peto, Fixed, 95% CI)0.80 [0.45, 1.42]

    3.1 Rehabilitation stroke ward versus mixed rehabilitation stroke ward
3331Peto Odds Ratio (Peto, Fixed, 95% CI)0.80 [0.45, 1.42]

 4 Length of stay (days) in a hospital or institution3331Std. Mean Difference (IV, Random, 95% CI)0.22 [-0.61, 1.05]

    4.1 Rehabilitation stroke ward versus mixed rehabilitation ward
3331Std. Mean Difference (IV, Random, 95% CI)0.22 [-0.61, 1.05]

 
Comparison 6. Different systems of organised care: stroke ward (plus TCM) versus stroke ward

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Death by the end of scheduled follow-up2366Peto Odds Ratio (Peto, Fixed, 95% CI)0.54 [0.13, 2.22]

    1.1 Stroke ward (plus TCM) versus stroke ward
2366Peto Odds Ratio (Peto, Fixed, 95% CI)0.54 [0.13, 2.22]

 

Appendices

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. Feedback
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Index terms
 

Appendix 1. MEDLINE search strategy

MEDLINE (Ovid) search strategy

1. cerebrovascular disorders/ or exp basal ganglia cerebrovascular disease/ or exp brain ischemia/ or exp carotid artery diseases/ or exp intracranial arterial diseases/ or exp "intracranial embolism and thrombosis"/ or exp intracranial hemorrhages/ or stroke/ or exp brain infarction/ or exp vertebral artery dissection/
2. (stroke or cerebrovasc$ or brain vasc$ or cerebral vasc$ or cva$ or apoplex$).tw.
3. ((brain$ or cerebr$ or cerebell$ or vertebrobasilar or hemispher$ or intracran$ or intracerebral or infratentorial or supratentorial or MCA or anterior circulation or posterior circulation or basal ganglia) adj5 (isch?emi$ or infarct$ or thrombo$ or emboli$)).tw.
4. ((brain$ or cerebr$ or cerebell$ or intracerebral or intracran$ or parenchymal or intraventricular or infratentorial or supratentorial or basal gangli$) adj5 (haemorrhage$ or hemorrhage$ or haematoma$ or hematoma$ or bleed$)).tw.
5. 1 or 2 or 3 or 4
6. hospital units/ or patient care team/
7. (stroke adj3 (unit or units or ward or wards or hospital or hospitals or centre$ or team or teams)).tw.
8. ((organi?ed or structured) adj3 care).tw.
9. (rehabilitation adj3 (unit or units or ward or wards or hospital or hospitals or centre$ or team or teams)).tw.
10. (multidisciplinary adj3 (team or teams or staff$ or care or rehabilitation or unit or units or ward or wards)).tw.
11. ((dedicated or discrete or comprehensive) adj5 (ward or wards or unit or units or stroke care)).tw.
12. ((specialist or specialized or specialised) adj5 (nurs$ or staff$ or care or unit or units or ward or wards)).tw.
13. (organi?ed adj3 (unit or units or ward or wards)).tw.
14. focus$ care.tw.
15. (package$ adj care).tw.
16. (intensive adj3 stroke adj3 care).tw.
17. Intensive Care Units/ or critical care/ or intensive care/
18. or/6-17
19. 5 and 18
20. Randomized Controlled Trials as Topic/
21. random allocation/
22. Controlled Clinical Trials as Topic/
23. control groups/
24. clinical trials as topic/
25. double-blind method/
26. single-blind method/
27. Research Design/
28. Program Evaluation/
29. randomised controlled trial.pt.
30. controlled clinical trial.pt.
31. clinical trial.pt.
32. random$.tw.
33. (controlled adj5 (trial$ or stud$)).tw.
34. (clinical$ adj5 trial$).tw.
35. ((control or treatment or experiment$ or intervention) adj5 (group$ or subject$ or patient$)).tw.
36. (quasi-random$ or quasi random$ or pseudo-random$ or pseudo random$).tw.
37. ((control or experiment$ or conservative) adj5 (treatment or therapy or procedure or manage$)).tw.
38. ((singl$ or doubl$ or tripl$ or trebl$) adj5 (blind$ or mask$)).tw.
39. (assign$ or allocat$).tw.
40. controls.tw.
41. trial.ti.
42. or/20-41
43. 19 and 42
44. exp animals/ not humans.sh.
45. 43 not 44
46. limit 45 to ed=20080101-20120904

 

Appendix 2. EMBASE search strategy

EMBASE (Ovid) search strategy

1. cerebrovascular disease/ or basal ganglion hemorrhage/ or exp brain hematoma/ or exp brain hemorrhage/ or exp brain infarction/ or exp brain ischemia/ or exp carotid artery disease/ or cerebral artery disease/ or cerebrovascular accident/ or exp intracranial aneurysm/ or exp occlusive cerebrovascular disease/ or stroke/
2. stroke patient/
3. (stroke or cerebrovasc$ or brain vasc$ or cerebral vasc$ or cva$ or apoplex$).tw.
4. ((brain$ or cerebr$ or cerebell$ or vertebrobasilar or hemispher$ or intracran$ or intracerebral or infratentorial or supratentorial or MCA or anterior circulation or posterior circulation or basal ganglia) adj5 (isch?emi$ or infarct$ or thrombo$ or emboli$)).tw.
5. ((brain$ or cerebr$ or cerebell$ or intracerebral or intracran$ or parenchymal or intraventricular or infratentorial or supratentorial or basal gangli$) adj5 (haemorrhage$ or hemorrhage$ or haematoma$ or hematoma$ or bleed$)).tw.
6. 1 or 2 or 3 or 4 or 5
7. "hospital subdivisions and components"/
8. ward/ or emergency ward/ or nursing unit/
9. intensive care unit/
10. exp intensive care/
11. (stroke adj3 (unit or units or ward or wards or hospital or hospitals or centre$ or team or teams)).tw.
12. ((organi?ed or structured) adj3 care).tw.
13. (rehabilitation adj3 (unit or units or ward or wards or hospital or hospitals or centre$ or team or teams)).tw.
14. (multidisciplinary adj3 (team or teams or staff$ or care or rehabilitation or unit or units or ward or wards)).tw.
15. ((dedicated or discrete or comprehensive) adj5 (ward or wards or unit or units or stroke care)).tw.
16. ((specialist or specialized or specialised) adj5 (nurs$ or staff$ or care or unit or units or ward or wards)).tw.
17. (organi?ed adj3 (unit or units or ward or wards)).tw.
18. focus$ care.tw.
19. (package$ adj care).tw.
20. (intensive adj3 stroke adj3 care).tw.
21. or/7-20
22. 6 and 21
23. stroke unit/
24. 22 or 23
25. Randomized Controlled Trial/
26. Randomization/
27. Controlled Study/
28. control group/
29. clinical trial/
30. Double Blind Procedure/
31. Single Blind Procedure/ or triple blind procedure/
32. Parallel Design/
33. random$.tw.
34. (controlled adj5 (trial$ or stud$)).tw.
35. (clinical$ adj5 trial$).tw.
36. ((control or treatment or experiment$ or intervention) adj5 (group$ or subject$ or patient$)).tw.
37. (quasi-random$ or quasi random$ or pseudo-random$ or pseudo random$).tw.
38. ((control or experiment$ or conservative) adj5 (treatment or therapy or procedure or manage$)).tw.
39. ((singl$ or doubl$ or tripl$ or trebl$) adj5 (blind$ or mask$)).tw.
40. (assign$ or alternate or allocat$ or counterbalance$ or multiple baseline).tw.
41. controls.tw.
42. trial.ti.
43. or/25-42
44. 24 and 43
45. heart stroke volume/ or heat stroke/ or stroke volume.tw. or heat stroke.tw.
46. 44 not 45
47. limit 46 to em=200801-201249
48. limit 47 to human

 

Appendix 3. CINAHL search strategy

CINAHL search strategy (1982 to September 2012)

S44 .S28 and S43
S43 .S29 or S30 or S31 or S32 or S33 or S34 or S35 or S36 or S38 or S39 or S40 or S41 or S42
S42 .TI trial
S41 .TI controls OR AB controls
S40 .TI ( assign* or allocat* ) OR AB ( assign* or allocat* )
S39 .TI ( (singl* or doubl* or tripl* or trebl*) N5 (blind* or mask*) ) OR AB ( (singl* or doubl* or tripl* or trebl*) N5 (blind* or mask*) )
S38 .TI ( (control or experiment* or conservative) N5 (treatment or therapy or procedure or manage*) ) OR AB ( (control or experiment* or conservative) N5 (treatment or therapy or procedure or manage*) )
S37 .TI ( quasi-random* or quasi random* or pseudo-random* or pseudo random* ) OR AB ( quasi-random* or quasi random* or pseudo-random* or pseudo random* )
S36 .TI ( (control or treatment or experiment* or intervention) N5 (group* or subject* or patient*) ) OR AB ( (control or treatment or experiment* or intervention) N5 (group* or subject* or patient*) )
S35 .TI clinical* N5 trial* OR AB clinical* N5 trial*
S34 .TI ( controlled N5 (trial* or stud*) ) OR AB ( controlled N5 (trial* or stud*) )
S33 .TI random* OR AB random*
S32 .(MH "Program Evaluation")
S31 .(MH "Random Assignment")
S30 .(ZT "clinical trial") or (ZT "randomised controlled trial")
S29 .(MH "Clinical Trials") OR (MH "Double-Blind Studies") OR (MH "Intervention Trials") OR (MH "Randomized Controlled Trials") OR (MH "Single-Blind Studies") OR (MH "Therapeutic Trials") OR (MH "Triple-Blind Studies")
S28 .S1 or S27
S27 .S11 and S26
S26 .S12 or S13 or S14 or S15 or S16 or S17 or S18 or S19 or S20 or S21 or S22 or S23 or S24 or S25
S25 .TI intensive N3 stroke N3 care OR AB intensive N3 stroke N3 care
S24 .TI package* N3 care OR AB package* N3 care
S23 .TI focus* care OR AB focus* care
S22 .TI ( organi?ed N3 (unit or units or ward or wards) ) OR AB ( organi?ed N3 (unit or units or ward or wards) )
S21 .TI ( (specialist or specialized or specialised) N5 (nurs* or staff* or care or unit or units or ward or wards) ) OR AB ( (specialist or specialized or specialised) N5 (nurs* or staff* or care or unit or units or ward or wards) )
S20 .TI ( (dedicated or discrete or comprehensive) N5 (ward or wards or unit or units or stroke care) ) OR AB ( (dedicated or discrete or comprehensive) N5 (ward or wards or unit or units or stroke care) )
S19 .TI ( multidisciplinary N3 (team or teams or staff* or care or rehabilitation or unit or units or ward or wards) ) OR AB ( multidisciplinary N3 (team or teams or staff* or care or rehabilitation or unit or units or ward or wards) )
S18 .TI ( rehabilitation N3 (unit or units or ward or wards or hospital or hospitals or centre* or team or teams) ) OR AB ( rehabilitation N3 (unit or units or ward or wards or hospital or hospitals or centre* or team or teams) )
S17 .TI ( (organi?ed or structured) N3 care ) OR AB ( (organi?ed or structured) N3 care )
S16 .TI ( stroke N3 (unit or units or ward or wards or hospital or hospitals or centre* or team or teams) ) OR AB ( stroke N3 (unit or units or ward or wards or hospital or hospitals or centre* or team or teams) )
S15 .(MH "Critical Care Nursing")
S14 .(MH "Critical Care")
S13 .(MH "Multidisciplinary Care Team")
S12 .(MH "Hospital Units") OR (MH "Intensive Care Units")
S11 .S2 or S3 or S4 or S7 or S10
S10 .S8 and S9
S9 .TI ( haemorrhage* or hemorrhage* or haematoma* or hematoma* or bleed* ) or AB ( haemorrhage* or hemorrhage* or haematoma* or hematoma* or bleed* )
S8 .TI ( brain brain* or cerebr* or cerebell* or intracerebral or intracran* or parenchymal or intraventricular or infratentorial or supratentorial or basal gangli* ) or AB (brain* or cerebr* or cerebell* or intracerebral or intracran* or parenchymal or intraventricular or infratentorial or supratentorial or basal gangli* )
S7 .S5 and S6
S6 .TI ( ischemi* or ischaemi* or infarct* or thrombo* or emboli* ) or AB ( ischemi* or ischaemi* or infarct* or thrombo* or emboli* )
S5 .TI (brain* or cerebr* or cerebell* or vertebrobasilar or hemispher* or intracran* or intracerebral or infratentorial or supratentorial or MCA or anterior circulation or posterior circulation or basal ganglia) or AB (brain* or cerebr* or cerebell* or vertebrobasilar or hemispher* or intracran* or intracerebral or infratentorial or supratentorial or MCA or anterior circulation or posterior circulation or basal ganglia )
S4 .TI (stroke or cerebrovasc* or brain vasc* or cerebral vasc* or cva* or apoplex*) or AB (stroke or cerebrovasc* or brain vasc* or cerebral vasc* or cva* or apoplex* )
S3 .(MH "Stroke Patients")
S2 .(MH "Cerebrovascular Disorders") OR (MH "Basal Ganglia Cerebrovascular Disease+") OR (MH "Carotid Artery Diseases+") OR (MH "Cerebral Ischemia+") OR (MH "Cerebral Vasospasm") OR (MH "Intracranial Arterial Diseases+") OR (MH "Intracranial Embolism and Thrombosis") OR (MH "Intracranial Hemorrhage+") OR (MH "Stroke") OR (MH "Vertebral Artery Dissections")
S1 .(MH "Stroke Units")

 

Feedback

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. Feedback
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Index terms
 

Patient subgroups

 

Summary

The 95% CI includes 1.0 for patients with mild stroke. I would conclude that for this subgroup, there is no significant benefit insofar as preventing death or institutional care. I certify that I have no affiliations with or involvement in any organisation or entity with a direct financial interest in the subject matter of my criticisms.
Don Hess 2000-09-12 16:05

Criticism editor summary
Regarding the outcome 'death or institutional care' for patients with mild stroke, the 95% CIs around the odds ratio suggest that stroke unit care is not beneficial in this subgroup of patients. This is not made clear in the review's abstract, results and discussion.

 

Reply

Thank you for your comment. The proper test in a subgroup analysis is not whether a subgroup result is statistically different from zero but whether there is statistically significant heterogeneity between the estimates of effect in each of the relevant subgroups. In our subgroup analysis the mild stroke patient group does indeed have CIs which include no effect (odds ratio = 1.0). However, we do not believe we can at present conclude that this subgroup of patients have a different result from the totality of patients. First, the statistical power of this analysis is limited because the mild stroke subgroup had relatively few outcome events (death or institutional care). Second, the mild stroke subgroup result is not significantly different from that of the moderate and severe subgroups. These analyses are explored in more detail in Stroke Unit Trialists' Collaboration. How do stroke units improve patient outcomes? A collaborative systematic review of the randomised trials. Stroke 1997;28:2139-44.

 

Contributors

Peter Langhorne 07/03/2001

 

Numerical error, 30 June 2014

 

Summary

Possible typo? The abstract states "... odds of death recorded at final (median one year) follow-up (odds ratio (OR) 0.87..." but text on page 15 (Comparisons 2.1, 2.2, 2.3 ...) and forest plot for 2.1 report OR = 0.81.

 

Reply

Dr Zekowski is correct. There appears to have been an error when updating the review. In the abstract the correct OR for death should be (OR 0.81, 95% CI 0.69 to 0.94; P = 0.005). This has now been corrected in the text.

 

Contributors

Feedback: Steven Zekowski MD

Response: Peter Langhorne

 

What's new

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. Feedback
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Index terms

Last assessed as up-to-date: 28 February 2013.


DateEventDescription

14 July 2014Feedback has been incorporatedFeedback added and numerical error in the Abstract has been corrected with no change to the conclusions.



 

History

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. Feedback
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Index terms

Protocol first published: Issue 1, 1995
Review first published: Issue 1, 1995


DateEventDescription

29 January 2013New citation required but conclusions have not changedThe conclusions of the review have not changed.

29 January 2013New search has been performedThis updated review identified four new trials (763 participants). We have excluded seven previously included quasi-randomised prospective controlled clinical trials. This review now incorporates an individual patient data meta-analysis of 28 randomised controlled trials (5855 participants). More recent stroke unit trials have addressed different ways of providing organised care. This update contains data from trials comparing stroke unit care with that given in general medical wards and comparing two different forms of organised (stroke unit) care.

9 September 2008AmendedConverted to new review format.

28 November 2006New search has been performedNew data on 2027 participants have become available from eight new trials (Athens, Beijing, Cape Town, Groningen, Joinville, Manchester, Osaka and Pavia). More recent stroke unit trials have addressed different ways of providing organised care. This update contains new information and data from trials comparing stroke unit care with general medical wards and comparing two different forms of organised (stroke unit) care.



 

Contributions of authors

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. Feedback
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Index terms

For this version of the review, Patricia Fearon performed the updated literature searches, reanalysed the data and redrafted the manuscript.

Peter Langhorne initiated and co-ordinated the review project, was principal grant holder and revised the updated report.

Peter Langhorne and Patricia Fearon formed the writing committee that was responsible for the re-drafting of the report.

The following collaborators provided original data, advice and comment, and assisted with the redrafting of the report: C Blomstrand (Goteborg, Sweden); NL Cabral (Joinville, Brazil); A Cavallini (Pavia, Italy); P Dey (Manchester, England); E Hamrin (Uppsala, Sweden); G Hankey (Perth, Australia); B Indredavik (Trondheim, Norway); L Kalra (Orpington, England); M Kaste (Helsinki, Finland); SO Laursen (Svendborg, Denmark); RH Ma (Beijing, China); N Patel (Cape Town, South Africa); H Rodgers (Newcastle, England); MO Ronning (Akershus, Norway); J Sivenius (Kuopio, Finland); G Sulter (Groningen, Netherlands); A Svensson (Goteborg, Sweden); K Vemmos (Athens, Greece); S Wood-Dauphinee (Montreal, Canada); H Yagura (Osaka, Japan).

Previous versions of the review also received data, advice and comment from: K Asplund (Umea, Sweden); P Berman (Nottingham, England); M Britton (Stockholm, Sweden); J Douglas (Administrator); T Erila (Tampere, Finland); M Garraway (Edinburgh, Scotland); M Ilmavirta (Tampere, Finland); R Stevens (Dover, England); SP Stone (London, England); Brian Williams (Glasgow, Scotland).

Important contributions were also made by the following who supplied useful information and comment: D Deleo (Perth, Australia); A Drummond (Nottingham, England); R Fogelholm (Jyvaskyla, Finland); N Lincoln (Nottingham, England); H Palomaki (Helsinki, Finland); J Slattery (London, England); T Strand (Umea, Sweden); CP Warlow (Edinburgh, Scotland); L Wilhelmsen (Goteborg, Sweden).

 

Declarations of interest

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. Feedback
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Index terms

Most of the Stroke Unit Trialists Collaboration members carried out trials that are included in the review.

 

Sources of support

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. Feedback
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Index terms
 

Internal sources

  • University of Glasgow, UK.
  • University of Edinburgh, UK.

 

External sources

  • Chest, Heart and Stroke Scotland, UK.

* Indicates the major publication for the study

References

References to studies included in this review

  1. Top of page
  2. AbstractRésumé scientifiqueResumo
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. Feedback
  13. What's new
  14. History
  15. Contributions of authors
  16. Declarations of interest
  17. Sources of support
  18. Characteristics of studies
  19. References to studies included in this review
  20. References to studies excluded from this review
  21. References to studies awaiting assessment
  22. References to ongoing studies
  23. Additional references
  24. References to other published versions of this review
Athens 1995 {published and unpublished data}
  • Pappa T, Xynos K, Theodorakis M, Salliaris M, Kostopoulos K, Vemmos K. The impact of acute stroke unit treatment on long term survival. Cerebrovascular diseases 2007;23 Suppl 2:64.
  • Spengos K, Tsivgoulis G, Manios E, Papamichael C, Konstastinopoulou A, Vemmos K. Which patients benefit most from treatment in a stroke unit?. Stroke 2004; Vol. 35, issue 1:294.
  • Vemmos K, Takis K, Madelos D, Synetos A, Volotasiou V, Tzavellas H. Stroke unit treatment versus general medical wards: long term survival. Cerebrovascular Diseases 2001;11 Suppl 4:8.
Beijing 2004 {published data only}
  • Ma RH, Wang YJ, Qu H, Yang ZH. Assessment of the early effectiveness of a stroke unit in comparison to the general ward. Chinese Medical Journal 2004;117(6):852-5.
  • Ma RH, Wang YJ, Zhao XQ, Wang CX, Yang ZH, Qu H. The impact of stroke unit on early outcome of cerebral infarction patients. Zhonghua Nei Ke Za Zhi 2004;43(3):183-5.
Birmingham 1972 {published data only}
  • Peacock PB, Riley CHP, Lampton TD, Raffel SS, Walker JS. In: Stewart GT editor(s). Trends in Epidemiology: The Birmingham Stroke, Epidemiology and Rehabilitation Study. Springfield, Illinois: Thomas, 1972:231-345.
Dover 1984 {published and unpublished data}
Dover 1984 (GMW) {published and unpublished data}
  • Stevens RS, Ambler NR, Warren MD. A randomised controlled trial of a stroke rehabilitation ward. Age and Ageing 1984; Vol. 13:65-75.
Dover 1984 (MRW) {published and unpublished data}
  • Stevens RS, Ambler NR, Warren MD. A randomised controlled trial of a stroke rehabilitation ward. Age and Ageing 1984; Vol. 13:65-75.
Edinburgh 1980 {published and unpublished data}
  • Garraway WM, Akhtar AJ, Hockey L, Prescott RJ. Management of acute stroke in elderly: follow up of a controlled trial. British Medical Journal 1980;281:827-9.
Goteborg-Ostra 1988 {unpublished data only}
  • Svensson A, Harmsen P, Wilhelmsen L. Goteborg Ostra Stroke Unit Trial. Personal communication.
Goteborg-Sahlgren 1994 {published and unpublished data}
  • Claesson L, Gosman-Hedstrom G, Fagerberg B, Blomstrand C. Hospital re-admissions in relation to acute stroke unit care versus conventional care in elderly patients the first year after stroke: The Goteborg 70+ stroke study. Age and Ageing 2003;32:109-13.
  • Claesson L, Gosman-Hedstrom G, Johannesson M, Fagerberg B, Blomstrand C. Resource utilization and costs of stroke unit care integrated in a care continuum: A 1-year controlled, prospective, randomized study in elderly patients. The Goteborg 70+ stroke study. Stroke 2000;31:2569-77.
  • Claesson L, Gosman-Hedstrom G, Johannesson M, Fagerberg B, Blomstrand C. Stroke unit care - effects on ADL, health-related quality of life and health economy. Cerebrovascular Diseases 1999;9 Suppl 1:115.
  • Fagerberg B, Blomstrand C. Do stroke units save lives?. Lancet 1993; Vol. 342:992.
  • Fagerberg B, Claesson L, Gosman-Hedstrom G, Blomstrand C. Effect of acute stroke unit care integrated with care continuum versus conventional treatment: A randomized 1-year study of elderly patients. The Goteborg 70+ stroke study. Stroke 2000;31:2578-84.
Groningen 2003 {published data only}
  • Sulter G, Elting JW, Langedijik M, Maurits NM, De Keyser J. Admitting acute ischaemic stroke patients to a stroke care monitoring unit versus a conventional stroke unit; a randomized pilot study. Stroke 2003;34:101-4.
Guangdong 2008 {published data only}
  • Yang N, LI G, Zhang Z, Wang B. Clinical efficacy observing of the treatment in stroke unit of integrated TCM and western medicine on patients with ischaemic stroke in acute stage. Chinese Archives of Traditional Chinese Medicine 2008;26:2750-3.
Guangdong 2009 {published data only}
  • Yang N, Zheng L. Cost benefit and effect analysis for patients with ischaemic stroke on stroke unit of integration traditional Chinese and western medicine. Chinese Archives of Traditional Chinese Medicine 2009;27:1331-3.
Helsinki 1995 {published and unpublished data}
  • Kaste M, Palomaki H. By whom should elderly stroke patients be treated?. Stroke 1992;23(1):163.
  • Kaste M, Palomaki H. Who should treat elderly stroke patients?. Journal of Stroke and Cerebrovascular Diseases 1992;2 Suppl 1:S27.
  • Kaste M, Palomaki H, Sarna S. Where and how should elderly stroke patients be treated? A randomised trial. Stroke 1995;26:249-53.
Huaihua 2004 {published data only}
  • Liao Y, Zeng JS, Zhou J, Xie CM, Yang DY, Liu SX, et al. Pattern and superiority of stroke unit in treating patients with stroke. Chinese Journal of Clinical Rehabilitation 2004;8:6014-5.
Hunan 2007 {published data only}
  • Li X, Wu Q, Liu W. The effects of the treatment in stroke unit of integrated therapy TCM and WM on patients with stroke in acute stage. Journal of Emergency in Traditional Chinese Medicine 2007;16(4):381-3.
Illinois 1966 {published data only}
Joinville 2003 {published data only}
  • Cabral NL, Moro C, Silva GR, Scola RH, Werneck LC. Study comparing the stroke unit outcome and conventional ward treatment: A randomised study in Joinville, Brazil. Arquivos de Neuro-psiquatria 2003;61(2-A):188-93.
Kuopio 1985 {published and unpublished data}
  • Sivenius J, Pyorala K, Heinonen OP, Salonen JT, Reikkinen P. The significance of intensity of rehabilitation after stroke - a controlled trial. Stroke 1985;16:928-31.
Manchester 2003 {published and unpublished data}
  • Dey P, Woodman M, Gibbs A. Fast track assessment and rehabilitation for stroke patients (FASTAR). Report (Project number RD0/28/1/02) 2003.
  • Dey P, Woodman M, Gibbs A, Steele R, Stocks SJ, Wagstaff S, et al. Early assessment by a mobile stroke team: a randomised controlled trial. Age and Ageing 2005;34:331-8.
Montreal 1985 {published and unpublished data}
  • Wood-Dauphinee S, Shapiro S, Bass E, Fletcher C, Georges P, Hensby V, et al. A randomised trial of team care following stroke. Stroke 1984;5:864-72.
Newcastle 1993 {published and unpublished data}
  • Aitken PD, Rodgers H, French JM, Bates D, James OFW. General medical or geriatric unit care for acute stroke? A controlled trial. Age and Ageing 1993;22 Suppl 2:4-5.
New York 1962 {published data only}
  • Feldman DJ, Lee PR, Unterecker J, Lloyd K, Rusk HA, Toole A. A comparison of functionally orientated medical care and formal rehabilitation in the management of patients with hemiplegia due to cerebrovascular disease. Journal of Chronic Diseases 1962;15:297-310.
Nottingham 1996 {published and unpublished data}
  • Drummond A, Lincoln N, Juby L. Effects of stroke unit on knowledge of stroke and experiences in hospital. Age and Ageing 2001;30:129-33.
  • Drummond A, Pearson B, Lincoln NB, Berman P. Ten year follow up of a randomised controlled trial of care in a stroke rehabilitation unit. BMJ 2005;331:491-2.
  • Husbands SL, Lincoln NB, Drummond AER, Gladman J, Trescoli C. Five-year results of a randomized controlled trial of a stroke rehabilitation unit. Clinical Rehabilitation 1999;13(6):530-1.
  • Juby LC, Lincoln NB, Berman P. The effect of a stroke rehabilitation unit on functional and psychological outcome. A randomised controlled trial. Cerebrovascular Diseases 1996;6:106-10.
  • Lincoln NB, Husbands S, Trescoli C, Drummond AER, Gladman JRF, Berman P. Five year follow up of a randomised controlled trial of a stroke rehabilitation unit. BMJ 2000;320:549.
Nottingham 1996 (GMW) {published and unpublished data}
  • Juby LC, Lincoln NB, Berman P. The effect of a stroke rehabilitation unit on functional and psychological outcome. A randomised controlled trial. Cerebrovascular Diseases 1996;6:106-10.
Nottingham 1996 (MRW) {published and unpublished data}
  • Juby LC, Lincoln NB, Berman P. The effect of a stroke rehabilitation unit on functional and psychological outcome. A randomised controlled trial. Cerebrovascular Diseases 1996;6:106-10.
Orpington 1993 {published and unpublished data}
  • Kalra L. Inpatient rehabilitation for elderly stroke patients. Journal of the American Geriatrics Society 1994;42:1027.
  • Kalra L, Dale P, Crome P. Improving stroke rehabilitation: a controlled study. Stroke 1993;24:1462-7.
Orpington 1993 (GMW) {published and unpublished data}
  • Kalra L, Dale P, Crome P. Improving stroke rehabilitation: a controlled study. Stroke 1993;24:1462-7.
Orpington 1993 (MRW) {published and unpublished data}
  • Kalra L, Dale P, Crome P. Improving stroke rehabilitation: a controlled study. Stroke 1993;24:1462-7.
Orpington 1995 {published and unpublished data}
  • Kalra L, Eade J. Role of stroke rehabilitation units in managing severe disability after stroke. Stroke 1995;26:2031-4.
Orpington 2000 {published and unpublished data}
  • Evans A, Harraf F, Donaldson N, Kalra L. Randomised controlled study of stroke unit care versus stroke team care in different stroke subtypes. Stroke 2002;33:449-55.
  • Evans A, Perez I, Harraf H, Melbourn A, Steadman J, Donaldson N, et al. Can differences in management processes explain different outcomes between stroke unit and stroke team care?. Lancet 2001;358:1586-92.
  • Evans A, Perez I, Melbourn A, Steadman J, Kalra L. Alternative strategies in stroke: a randomised controlled trial of three strategies of stroke management and rehabilitation. Cerebrovascular Diseases 2000;10 Suppl 2:60.
  • Kalra LL, Evans A, Perez I, Knapp M, Donaldson N, Swift C. Alternative strategies for stroke: a prospective randomised controlled trial. Lancet 2000;356:894-9.
  • Patel A, Knapp M, Perez I, Evans A, Kalra L. Alternative strategies for stroke care: cost-effectiveness analysis from a prospective randomised controlled trial. Cerebrovascular Diseases 2003;16 Suppl 4:101.
Perth 1997 {published and unpublished data}
  • Hankey GJ, Deleo D, Stewart-Wynne EG. Stroke units: an Australian perspective. Australian and New Zealand Journal of Medicine 1997;27:437-8.
Svendborg 1995 {published data only}
  • Henriksen IO, Laursen SO. Acute stroke - treatment in a non-intensive stroke unit. Scandinavian Journal of Rehabilitation Medicine 1992;Suppl 26:153.
  • Laursen SO, Henriksen IO, Dons U, Jacobsen B, Gundertofte L. Intensive rehabilitation following stroke: controlled pilot study. Ugeskr Laeger 1995;157:1996-99.
Tampere 1993 {unpublished data only}
  • Ilmavirta M, Frey H, Erila T, Fogelholm R. Stroke outcome and outcome of brain infarction. A prospective randomised study comparing the outcome of patients with acute brain infarction treated in a stroke unit and in an ordinary neurological ward. Doctoral Thesis. Vol. 410; series A, Tampere: University of Tampere Faculty of Medicine, 1994.
Trondheim 1991 {published and unpublished data}
  • Indredavik B, Bakke F, Slordahl SA, Rokseth R, Haheim LL. Stroke unit treatment improves long-term quality of life: a randomized controlled trial. Stroke 1998;29:895-99.
  • Indredavik B, Bakke F, Slordahl SA, Rokseth R, Haheim LL. Stroke unit treatment: 10 year follow-up. Stroke 1999;30:1524-7.
  • Indredavik B, Bakke F, Slordahl SA, Rokseth R, Haheim LL. Treatment in a combined acute and rehabilitation stroke unit. Which aspects are important?. Stroke 1999;30:917-23.
  • Indredavik B, Bakke F, Solberg R, Rokseth R, Haahein LL, Home I. Benefit of stroke unit: a randomised controlled trial. Stroke 1991;22:1026-31.
  • Indredavik B, Fjaertoft H, Ekeberg RN, Loge A, Morch B. Benefit of an extended stroke unit service with early supported discharge. A randomised control trial. Stroke 2000;31:2989-94.
  • Indredavik B, Slordahl SA, Bakke F. Stroke unit treatment - 10 years follow-up. Cerebrovascular Diseases 1999;9 Suppl 1:122.
  • Indredavik B, Slordahl SA, Bakke F, Rokseth R, Haheim LL. Stroke unit treatment: long-term effects. Stroke 1997;28:1861-66.

References to studies excluded from this review

  1. Top of page
  2. AbstractRésumé scientifiqueResumo
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. Feedback
  13. What's new
  14. History
  15. Contributions of authors
  16. Declarations of interest
  17. Sources of support
  18. Characteristics of studies
  19. References to studies included in this review
  20. References to studies excluded from this review
  21. References to studies awaiting assessment
  22. References to ongoing studies
  23. Additional references
  24. References to other published versions of this review
Abissi 1995 {published data only}
  • Abissi CJ, Sepe E, Patiak C, Davis JN. Cerebral infarction: comparison of a care with case-management to traditional care. Neurology 1995;45 Suppl 4:A240.
Asplund 2000 {published data only}
  • Asplund K, Gustafson Y, Jacobsson C, Bucht G, Wahlin A, Peterson J, et al. Geriatric-based general wards for older acute medical patients: a randomized comparison of outcomes and use of resources. Journal of the American Geriatrics Society 2000;48(11):1381-8.
Cavallini 2003 {published and unpublished data}
  • Cavallini A, Micieli G, Marcheselli S, Quaglini S. Role of monitoring in the management of acute ischaemic stroke patients. Stroke 2003;34(11):2599-603.
  • Cavallini A, Micieli G, Zambrelli E, Quaglini S, Rogoni C. Role of continuous physiological monitoring in the acute phase of stroke. Cerebrovascular Diseases 2001;11 Suppl 4:117.
Davis 2000 {published data only}
  • Davis M, Chambers B, Birschel P. A pilot study of monitoring in acute stroke. Stroke 2000;31(11):2869.
  • Davis M, Hollymann C, McGiven M, Chambers I, Egbuji J, Barer D. Physiological monitoring in acute stroke. Age and Ageing 1999;28 Suppl 1:45.
Diagana 2008 {published data only}
  • Diagana M, Ould Abdallahi Salem B, N'Diaye M, LeCornet C, Quet F, et al. Impact of acute unit care improving post-stroke functionality outcomes in Noukachott, Mauritania. African Journal of Neurological Sciences 2008;27:38-46.
Di Lauro 2003 {published data only}
  • Di Lauro A, Pellegrino L, Savastano G, Ferraro C, Fusco M, Balzarano F, et al. A randomised trial on the efficacy of intensive rehabilitation in the acute phase of ischemic stroke. Journal of Neurology 2003;250(10):1206-8.
Durastanti 2005 {published data only}
  • Durastanti L, Puca E, Angelantonio E, Di Lorenzano S, Falcou A, Gori MC, et al. Efficacy of acute ischemic stroke patients management in an emergency department stroke unit (EDSU). Cerebrovascular Diseases 2005;19 Suppl 2:57.
HAMLET 2009 {published data only}
  • Hofmeijer J, van den Worp HB, Amelink GJ, Algra A, van Gijn J, Kapelle LJ. HAMLET hemicraniectomy after MCA infarction with life-threatening oedema trial (Abstract 11). Proceedings of the European Stroke Conference, 21-24 May, Valencia, Spain. 2003.
Hamrin 1982 {published and unpublished data}
Koton 2005 {published data only}
  • Koton S, Schwammenthal Y, Merzeliak O, Philips T, Tsabari R, Bruk B, et al. Effectiveness of establishing a dedicated acute stroke unit in routine clinical practice in Israel. Israel Medical Association Journal 2005;7:688-93.
  • Koton S, Schwammenthal Y, Merzeliak O, Philips T, Tsabari R, Bruk B, et al. Management and outcome of acute stroke: differences between organised short-term acute stroke unit and general medical wards. Cerebrovacular Diseases 2005;19 Suppl 2:58.
Langhorne 2001 {published data only}
  • Langhorne P, Fraser P, Wright F, Shields M, MacIntosh G, Stott D. Evaluation of an acute care protocol for stroke patients: a controlled clinical trial. Cerebrovascular Diseases 2001;11 Suppl 4:35.
Middleton 2006 {published data only}
  • Middelton S. An outcomes approach to stroke care; the importance of teamwork and evidence-based nursing care. International Journal of Stroke 2012;7:224-6.
  • Middleton S, Levi C, Griffiths R, Grimshaw J, Ward J. Quality in Acute Stroke Care project: protocol for a cluster randomised control trial to evaluate the management of fever, sugar and swallowing after stroke. Journal of Internal Medicine 2006;36:A1-A14.
  • Middleton S, Levi C, Ward J, Grimshaw J, Griffiths R, D'Este C, et al. Fever, hyperglycaemia and swallowing dysfunction management in acute stroke: a cluster randomised controlled trial of knowledge transfer. Implementation Science 2009;4:16.
  • Middleton S, McElduff P, Ward J, Grimshaw J, Dale S, D'Este C, et al. Implementation of evidence-based treatment protocols to manage fever, hyperglycaemia and swallowing dysfunction in acute stroke (QASC): a cluster randomised control trial. Lancet 2011;378:1699-706.
Moloney 1999 {published data only}
  • Moloney A, Critchlow B, Jones K. A multi-disciplinary care pathway in stroke - does it improve care?. Age and Ageing 1999;28 Suppl 1:42-3.
Pappa 2009 {published data only}
  • Pappa T, Spengos K, Skoufi M, Zafiriou I, Barbaressou Z, Peppa K, et al. Acute stroke unit improves long-term survival in very old stroke patients. Cerebrovascular Diseases 2009;27 Suppl 6:13.
Patel 2000 {unpublished data only}
  • Patel N, Louw S, Zwarenstein M. Organised care of acute stroke at Groot Schuur Hospital (MPhil in Epidemiology). Cape Town: University of Cape Town, 2000.
Pearson 1988 {published data only}
  • Pearson A, Durand I, Punton S. Effects of admission to a nursing unit. Australian Journal of Advanced Nursing 1988;6(1):38-42.
Ricauda 2004 {published data only}
Ronning 1998 {published and unpublished data}
  • Ronning OM, Guldvog B. Stroke units versus general medical wards, II: neurological deficits and activities of daily living: a quasi-randomised controlled trial. Stroke 1998;29:586-90.
  • Ronning OM, Guldvog B, Stavem K. The benefit of an acute stroke unit in patients with intracerebral haemorrhage: a controlled trial. Journal of Neurology Neurosurgery and Psychiatry 2001;70:631-4.
  • Stavem K, Ronning OM. Survival over 12 years following acute stroke: initial treatment in a stroke unit versus general medical ward. Acta Neurologica Scandinavica 2011;124(6):429-433.
Ronning 1998a {published data only}
  • Ronning OM, Guldvog B. Stroke units versus general medical wards, I: twelve- and eighteen-month survival. A randomized controlled trial. Stroke 1998;29:58-62.
Ronning 1998b {published data only}
  • Ronning OM, Guldvog B. Outcome of subacute stroke rehabilitation. A randomized controlled trial. Stroke 1998;29:779-84.
Shiraishi 2004 {published data only}
  • Shirashi N, Mizutani C, Menjho M, Deguchi A, Takase K, Hamaguchi H, et al. Comparison of daily living for a convalescent rehabilitation ward and general ward for stroke patients. Japanese Journal of Geriatrics 2004;41:646-52.
Silva 2004 {published data only}
  • Silva Y, Piugdemont M, Castellanos M, Serena J, Suner RM, Davalos A. Semi-intensive monitoring in acute stroke and long term outcome. Stroke 2002; Vol. 33, issue 1:411.
  • Silva Y, Puigdemont M, Castellanos M, Serena J, Suner RM, Garcia MM, et al. Semi-intensive monitoring in acute stroke and long term outcome. Cerebrovascular Diseases 2005;19(1):23-30.
  • Silva Y, Serena J, Castellanos M, Ramio L, Osuna T, Davalos A. Stroke units: the effect of continuous monitoring on clinical outcome. Cerebrovascular Diseases 2001;11 Suppl 4:122.
Stone 1998 {unpublished data only}
  • Stone SP. A trial of stroke unit (SU) versus comprehensive geriatric service (CGS) management of all stroke patients. Neurorehabilitation and Neural Repair 1999;13(1):13.
Strand 1985 {published and unpublished data}
  • Strand T, Asplund K, Eriksson S, Hagg E, Lithner F, Wester PO. A non-intensive stroke unit reduced functional disability and the need for long-term hospitalisation. Stroke 1985;16:29-34.
  • Strand T, Asplund K, Eriksson S, Hagg E, Lithner F, Wester PO. Stroke unit care - who benefits? Comparisons with general medical care in relation to prognostic indicators on admission. Stroke 1986;17:377-81.
von Arbin 1980 {published data only}
Walter 2005 {published data only}
  • Walter A, Seidel G, Thie A, Raspe HH, for the SSSH Study Group. German stroke units versus conventional care in acute ischemic stroke and TIA - a prospective study. Cerebrovascular Diseases 2005;19 Suppl 2:30.
Wang 2004 {published data only}
  • Wang YJ, Gao XL, Ma RH, Wu D. Beijing Organized Stroke Care Study (BOSS). Proceedings of the 29th International Stroke Conference, San Diego, California, USA. 5-7 February 2004.
Yagura 2005 {published data only}

References to studies awaiting assessment

  1. Top of page
  2. AbstractRésumé scientifiqueResumo
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. Feedback
  13. What's new
  14. History
  15. Contributions of authors
  16. Declarations of interest
  17. Sources of support
  18. Characteristics of studies
  19. References to studies included in this review
  20. References to studies excluded from this review
  21. References to studies awaiting assessment
  22. References to ongoing studies
  23. Additional references
  24. References to other published versions of this review
Anhui 2008 {published data only}
  • Ni C, Li C, Han R, Chen J, Sun H, Liu S. A randomised controlled trial of standardised tertiary rehabilitation after stroke. Journal of Rehabilitation Medicine 2008;Suppl 46:71.
China (Hao) 2010 {published data only}
  • Hao JJ. Effect of comprehensive stroke unit on patients with pneumonia after acute stroke. Chinese Journal of Cerebrovascular Diseases 2010;7:120-3.
China (Pei) 2011 {published data only}
  • Pei Z. Clinical research of organised stroke care model with integrated Chinese traditional and Western medicine in primary hospital. Chinese Journal of Contemporary Neurology and Neurosurgery 2011;11:221-5.
China (Wang) 2008 {published data only}
  • Wang ZM, Wang P, Chen J, Luo DH, Shen WM. Application of stroke rehabilitation in municipal hospitals during the acute phase of cerebral infarction. Chinese Journal of Epidemiology 2008;29:724-5.
China (Wu) 2007 {published data only}
  • Wu WL, Lu XL, Zheng MY, Liang W, Yao XL, Hu ZL. Imapct of organised stroke unit on the therapeutic effect in stroke patients. Journal of Southern Medical University 2010;30:555-6.
Haikou 2007 {published data only}
  • Su Q, Lin T, Wu Y, Cai M, Chen Z. Benefit of an extended stroke unit to acute cerebral infarction. Cerebrovascular Diseases 2007;24:490.
Shanghai 2006 {published data only}
  • Hu YS. Standardized tertiary rehabilitation (STR) for stroke patients with hemiplegia in promoting the neurological function. Neurorehabilitation and Neural Repair 2006;20:163.
  • Hu YS. Standarized tertiary rehabilitation (STR) for patients with cerebral strokes accompanied by hemiplegia. Neurorehabilitation and Neural Repair 2006;20:163.
  • Jiang CY, Hu YS, Wang Q, Wu Y, Zhu YL. The cost-effectiveness analysis of early rehabilitation for stroke patients. Neurorehabilitation and Neural Repair 2006;20:205.
  • Sun LM, Hu YS, Wu Y, Zhu YL, Fan WK. Effect of standardized tertiary rehabilitation on the motor function in patients with cerebral stroke accompanied by hemiplegia. Neurorehabilitation and Neural Repair 2006;20:163.

References to ongoing studies

  1. Top of page
  2. AbstractRésumé scientifiqueResumo
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. Feedback
  13. What's new
  14. History
  15. Contributions of authors
  16. Declarations of interest
  17. Sources of support
  18. Characteristics of studies
  19. References to studies included in this review
  20. References to studies excluded from this review
  21. References to studies awaiting assessment
  22. References to ongoing studies
  23. Additional references
  24. References to other published versions of this review
Baden 2007 {unpublished data only}
  • Structured stroke management improves outcomes at 6 months. Ongoing study -.
Beijing 2009 {unpublished data only}
  • Efficiency study of traditional Chinese medicine (TCM) versus western medicine (WM) on ischaemic stroke. Ongoing study -.
Shanghai 2009 {unpublished data only}
  • A study of the stroke unit of traditional Chinese and western medicine in the treatment of ischaemic stroke. Ongoing study -.

Additional references

  1. Top of page
  2. AbstractRésumé scientifiqueResumo
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. Feedback
  13. What's new
  14. History
  15. Contributions of authors
  16. Declarations of interest
  17. Sources of support
  18. Characteristics of studies
  19. References to studies included in this review
  20. References to studies excluded from this review
  21. References to studies awaiting assessment
  22. References to ongoing studies
  23. Additional references
  24. References to other published versions of this review
Barer 1993
  • Barer D, Gibson OP, Ellul J and the "GUESS" Group. Outcome of hospital care for stroke in 12 centres. Proceedings of the British Geriatrics Society, Spring Meeting, Glasgow. April 15-17, 1993.
Ebrahim 1990
  • Ebrahim S. Clinical Epidemiology of Stroke. 1st Edition. Oxford: Oxford University Press (Medical Publications), 1990.
Garraway 1985
  • Garraway WM. Stroke rehabilitation units: concepts, evaluation, and unresolved issues. Stroke 1985;16:178-81.
Higgins 2011
  • Higgins JPT, Green S (editors). Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 [updated March 2011]. The Cochrane Collaboration, 2011. Available from www.cochrane-handbook.org.
Langhorne 2012
  • Langhorne P, de Villiers L, Pandian JD. Applicability of stroke-unit care to low-income and middle-income countries. Lancet Neurology 2012;11:341-48.
Lozano 2012
  • Lozano R, Naghavi M, Foreman K, Lim S, Shibuya K, Aboyans V, et al. Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 2012;380:2095-128.
Murray 2012
  • Murray CJL, Vos T, Lozano R, Naghavi M, Flaxman AD, Michaud C, et al. Disability-adjusted life years (DALYs) for 291 diseases and injuries in 21 regions, 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 2012;380:2197-223.
RevMan 2012
  • The Nordic Cochrane Centre, The Cochrane Collaboration. Review Manager (RevMan). 5.2. Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, 2012.
Seenan 2007
Strong 2007
Wade 1992
  • Wade D. Measurement in Neurological Rehabilitation. 1st Edition. Oxford: Oxford University Press, 1992.
Warlow 2008
  • Warlow C, Van Gijn J, Dennis M, Wardlaw J, Bamford J, Hankey G, et al. Stroke: Practical Management. 3rd Edition. Oxford: Blackwell Publishing, 2008.

References to other published versions of this review

  1. Top of page
  2. AbstractRésumé scientifiqueResumo
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. Feedback
  13. What's new
  14. History
  15. Contributions of authors
  16. Declarations of interest
  17. Sources of support
  18. Characteristics of studies
  19. References to studies included in this review
  20. References to studies excluded from this review
  21. References to studies awaiting assessment
  22. References to ongoing studies
  23. Additional references
  24. References to other published versions of this review
Langhorne 1993
Langhorne 1998
  • Langhorne P, Dennis MS, on behalf of the Stroke Unit Trialists' Collaboration. Stroke Units: An Evidence Based Approach. London: BMJ Books, 1998.
Major 1998
  • Major K, Walker A. Economics of stroke unit care. In: Langhorne P, Dennis MS editor(s). Stroke Units: An Evidence Based Approach. London: BMJ Books, 1998.
SUTC 1997a
  • Stroke Unit Trialists' Collaboration. Collaborative systematic review of the randomised trials of organised inpatient (stroke unit) care after stroke. BMJ 1997;314:1151-9.
SUTC 1997b
  • Stroke Unit Trialists' Collaboration. How do stroke units improve patient outcomes? A collaborative systematic review of the randomized trials. Stroke 1997;28:2139-44.
SUTC 2001
  • Stroke Unit Trialists' Collaboration. Organised inpatient (stroke unit) care for stroke. Cochrane Database of Systematic Reviews 2001, Issue 3. [DOI: 10.1002/14651858.CD000197]
SUTC 2007
  • Stroke Unit Trialists’ Collaboration. Organised inpatient (stroke unit) care for stroke. Cochrane Database of Systematic Reviews 2007, Issue 4. [DOI: 10.1002/14651858.CD000197]