In-hospital care pathways for stroke

 

Abstract

Background

Stroke care pathways have the potential to promote organised and efficient patient care that is based on best evidence and guidelines, but evidence to support their use is unclear.

Objectives

To assess the effects of care pathways, compared with standard medical care, among patients with acute stroke who had been admitted to hospital.

Search methods

We searched the Cochrane Stroke Group Trials Register (last searched in June 2003), the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 2, 2003), MEDLINE (1975 to June 2003), EMBASE (1980 to June 2003), CINAHL (1982 to June 2003), ISI Proceedings: Science & Technology (1990 to November 2003), and HealthSTAR (1994 to May 2001). We also handsearched the Journal of Integrated Care Pathways (2001 to 2003), formerly Journal of Managed Care (1997 to 1998) and Journal of Integrated Care (1998 to 2001). Reference lists of articles were searched.

Selection criteria

Randomised controlled trials and non-randomised studies that compared care pathway care with standard medical care.

Data collection and analysis

One reviewer selected studies for inclusion and the other independently checked the decisions. Two reviewers independently assessed the methodological quality of the studies. One reviewer extracted the data and the other checked the extracted data.

Main results

Three randomised controlled trials (340 patients) and 12 non-randomised studies (4081 patients) were included. There was significant statistical heterogeneity in the analysis of many of the outcomes. We found no significant difference between care pathway and control groups in terms of death or discharge destination. Patients managed with a care pathway were: (1) more dependent at discharge (P = 0.04); (2) less likely to suffer a urinary tract infection (Odds Ratio (OR) 0.51, 95% Confidence Interval (CI) 0.34 to 0.79); (3) less likely to be readmitted (OR 0.11, 95% CI 0.03 to 0.39); and (4) more likely to have neuroimaging (OR 2.42, 95% CI 1.12 to 5.25). Evidence from randomised trials suggested that patient satisfaction and quality of life were significantly lower in the care pathway group (P = 0.02 and P < 0.005 respectively).

Authors' conclusions

Use of stroke care pathways may be associated with positive and negative effects. Since most of the results have been derived from non-randomised studies, they are likely to be influenced by potential biases and confounding factors. There is currently insufficient supporting evidence to justify the routine implementation of care pathways for acute stroke management or stroke rehabilitation.

 

Plain language summary

In-hospital care pathways for stroke

The effects of using care pathways to manage people admitted to hospital with stroke are not clear. Care in a hospital stroke unit can reduce the risks of death and disability after stroke. Care pathways aim to promote organised and efficient patient care based on the best evidence and guidelines. The review found that patients treated within a care pathway may be less likely to suffer some complications (e.g. urine infections), and more likely to have certain tests (e.g. brain scans). However, the use of care pathways may also reduce the patient's likelihood of functioning independently when discharged from hospital, their quality of life, and their satisfaction with hospital care. Currently, there is not enough evidence to justify introducing care pathways for the routine care of all patients with stroke. Further research is needed to find out if care pathways for stroke do more good than harm.

 

摘要

背景

對於院內中風病人照顧路徑的計畫

基於最佳證據和指導方針的中風患者照顧路徑可能可以促進有組織和有效率的患者照顧，但證據支持他們的用途還不明朗。

目標

我們的目的是在評估照顧途徑與標準醫療照顧的效率，對象是急性腦中風的住院患者們。

搜尋策略

我們搜尋了the Cochrane Stroke Group Trials Register (最後到2003年6月的資料) he Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 2, 2003), MEDLINE (1975年到2003年6月) MBASE (1980年到2003年6月), CINAHL (1982年到2003年6月), ISI Proceedings: Science & echnology (1990年到2003年11月) nd HealthSTAR (1994年到2001年五月). 我們也手工檢索了the Journal of Integrated Care Pathways (2001年到 2003年), 原 Journal of Managed Care (1997 年到 1998年) and Journal of Integrated Care (1998年到2001年). 搜查了參考文獻目錄的文章

選擇標準

我們考慮了比較照顧途徑與標準的醫療護理照顧之隨機對照試驗和非隨機研究。

資料收集與分析

一位檢審者選擇要納入的研究，其他則獨立地檢查這些研究納入是否正確。兩名檢審者獨立地以評估這些研究的方法學品質。一位檢審者從研究中提取資料而其他則檢查提取的資料。

主要結論

三個隨機對照試驗(340位病人)和12個非隨機研究(4081位病人)包括在內。在許多結果分析中有顯著統計學異質性。 我們沒有發現照顧途徑與對照組之死亡或出院的結果有顯著性差異。病人由照顧路徑管理的表現是：(一)出院時更有依賴性(P = 0.04); (二)不太可能遭受尿路感染(比值比(OR)為0.51，95％可信區間(CI)為0.34到0.7); (三)不太可能發生再住院(OR為0.11，95％CI為0.03～0.39)和(d)更容易具有神經學影像(OR為2.42，95％CI為1.12到5.25)。隨機試驗的證據表明，病人滿意度和生活品質在照顧路徑組顯著較低(P = 0.02和P小於0.005)。

作者結論

使用中風照護路徑可能有正面和負面影響。由於大多數的結果是來自非隨機研究，他們可能會受到潛在的偏見和混雜因素影響。目前還沒有足夠證據支持在處理急性中風或中風復健上要常規執行照護途徑。

翻譯人

本摘要由奇美醫院黃志傑翻譯。

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。

總結

對於使用照護路徑來處理中風住院的病人的效果還不清楚。由醫院中風中心照護可以減低中風後死亡和失能的風險。照護途徑旨在以最佳的的證據和指導方針為基礎促進組織化和有效率的病人照護。檢審發現，在使用照護途徑處置的病人較不太可能受到一些併發症(如尿液感染)，以及更能接受一定的檢查(如腦部掃描)。然而，使用醫療途徑也可以減少從醫院出院時病人之獨立可能性，他們的生活品質以及他們的住院治療滿意度。目前，沒有足夠的證據支持實施照護途徑為所有腦中風的常規治療。還需要進一步研究來了解照護途徑對於中風是否利大於弊。