(Stroke. 1999;30:1524-1527.)
© 1999 American Heart Association, Inc.
Original Contributions |
Stroke Unit Treatment
10-Year Follow-Up
From the Department of Medicine (B.I., F.B., S.A.S., R.R.,) University Hospital of Trondheim, and The Life Insurance Companies' Institute of Medical Statistics (L.L.H.), Ullevaal Hospital, Oslo, Norway. Correspondence to Dr Bent Indredavik, The Stroke Unit, Department of Medicine, University Hospital of Trondheim, N-7006 Trondheim, Norway.
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Abstract |
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 Top Abstract IntroductionSubjects and MethodsResultsDiscussionReferences |
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Background and Purpose—We have previously shown that treatment in our combined acute and rehabilitation stroke unit (SU) improves the outcome during the first 5 years after onset of stroke compared with that for stroke patients treated in general wards (GW). The aim of the present trial was to examine the effects of SU care after 10 years of follow-up.
Methods—In a randomized controlled trial, 110 patients with
symptoms and signs of an acute stroke were allocated to the SU and 110
to GW. No significant differences existed in baseline characteristics
between the groups. The outcome after 10 years was measured by the
proportion of patients at home, the proportion of patients in an
institution, the mortality, and the functional state as assessed by the
Barthel Index, in which a Barthel Index score of 
60 was classified as
independent or partly independent and a score of 95 was classified as
independent.
Results—After 10 years, 21 (19.1%) of the patients randomized to
the SU and 9 (8.2%) of the patients randomized to the GW were at home
(P=0.0184). Eighty-three (75.5%) of the patients from
the SU and 96 (87.3%) of the patients from the GW were dead
(P=0.0082), and 6 (5.4%) and 5 (4.5%), respectively,
were in an institution (eg, nursing home; NS). Twenty-two (20.0%) of
the SU patients and 9 (8.2%) of the GW patients had a Barthel Index
score of 60 (P=0.0118), and 14 (12.7%) and 6 (5.4%),
respectively, had a score of 95 (P=0.0606).
Conclusions—For the first time it has been shown that SU care improves survival and functional state and increases the proportion of patients able to live at home 10 years after their stroke. Treatment in combined acute and rehabilitation SU seems to have important long-term effects on outcome for stroke patients.
Key Words: randomized controlled trials • stroke management • stroke units • treatment outcome
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Introduction |
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TopAbstractIntroductionSubjects and MethodsResultsDiscussionReferences |
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Several trials have shown that treatment of stroke patients in stroke units (SU) improves the outcome compared with treatment in general wards (GW).1 2 3 4 5 6 7 8 9 Meta-analysis of all available randomized controlled trials has shown that care of stroke patients in SU reduces mortality, institutionalization, and dependency.10 11 Most SU trials have followed the patients only to discharge or 6 to 12 months after onset of the stroke. We have previously presented favorable results of SU care after 5 years' follow-up.12 The results showed that the better survival and functional outcome in the SU achieved during the first few weeks were still present after 5 years.12 A higher quality of life was also present in the SU group compared with the stroke patients treated in GW.13
The purpose of the present study was to test the hypothesis that the better outcome of the SU treatment compared with the GW was still present after 10 years' follow-up.
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Subjects and Methods |
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TopAbstractIntroductionSubjects and MethodsResultsDiscussionReferences |
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The SU, located in the Department of Medicine in our hospital, is a combined acute and rehabilitation SU. For management of acute stroke in our SU we have constructed an acute treatment program. The program is standardized with regard to diagnostic evaluation, observation, acute treatment, mobilization, and rehabilitation. We have a team approach to nursing and rehabilitation that emphasizes patient and family participation. Functional training and a modified motor relearning program are the basic rehabilitation approaches. The details of the treatment program have been previously published, as have the differences between the treatment in the SU and the GW.9 14
On admission to the hospital, 110 patients with symptoms and signs of acute stroke were randomly allocated to treatment in the SU and 110 to treatment in GW. Patients in deep coma on admission and patients living in nursing homes before the onset of the stroke were excluded before randomization. Otherwise, the patients represented an unselected hospitalized stroke population. Details regarding the method of randomization, inclusion criteria, and the study design have previously been described.9 There were no differences in baseline characteristics or severity of the stroke in the 2 groups.9 The maximum period of treatment in the SU was 42 days (average 16 days). Differences in treatment and care were present only during this period of a maximum of 6 weeks. For both groups, the family physicians were responsible for further treatment and follow-up after the first 6 weeks.12
We have previously reported the results of SU care up to 5 years after
the stroke.9 12 13 In the present study the patients
were reassessed 10 years±3 months after the onset of stroke, and the
end points were the following: proportion of patients at home,
proportion of patients in institutions, mortality, and functional
independence assessed by Barthel Index (BI).15 All
patients who died before 10 years and 3 months after the onset of
stroke were included in the mortality figures, whereas the functional
state (BI) was analyzed only for the patients who were alive at
this time. Patients with a BI score of 95 were classified as
independent, and patients with a BI score of 60 were classified as
independent or partly independent. A specially trained nurse who was
unaware of where the patients had been treated performed all the
assessments of the functional state (blinded testing). None of the
patients were lost from follow-up.
Differences between groups in the proportion of patients at home and in
institutions were compared by the 
2 test.
Difference in survival during 10 years, presented graphically
by Kaplan-Meier survival curves, was estimated with the log-rank test.
The proportion of patients with BI 95(independent) or BI 60
(independent or partly independent) was also analyzed by the
2 test. All the analyses were
performed on an intention-to-treat basis.
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Results |
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TopAbstractIntroductionSubjects and MethodsResultsDiscussionReferences |
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As shown in Table 1
, the
proportion of patients at home was higher in the SU group after 10
years: 19.1% of the patients treated in the SU were at home compared
with 8.2% in the GW (P=0.0184). Both groups had a low
proportion of patients in institutions (eg, nursing homes) after 10
years, and there was no difference in institutional care between the 2
groups, with 5.4% in the SU group and 4.5% in the GW group in an
institution (NS; Table 1).
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A significant difference in survival was present 10 years after the
onset of the stroke. The death rate was 75.5% in the SU group and
87.3% in the GW group (P=0.0082) (Table 1
and the
Figure). Hence, 9 patients are needed to be treated to prevent 1 death
for a period of 10 years. The relative reduction in mortality
calculated by Cox proportional hazards regression analysis was
33% (RR 0.67, 95% CI 0.50 to 0.90).
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The differences in mortality occurred during the initial treatment
period of a maximum of 6 weeks (average 16 days), in which 8 (7.3%) of
the patients in the SU group and 19 (17.3%) of the patients in the GW
group died (P=0.027; (Table 2). The mortality rate during the period
from 6 weeks to 5 years was similar in the 2 groups: 57 patients
(51.8%) in the SU group and 59 patients (53.6%) in the GW group died
(NS; Table 2). There was no difference in mortality rates during
the period from 5 to 10 years, either: 18 patients in both groups
(16.3%) died. The average mortality rate per year during the period
from 1 to 5 years after stroke was 8.8% in the SU group and 9.6% in
the GW group, whereas the rate from 5 to 10 years was 3.3% in both
groups.
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The proportion of independent patients (BI 95) after 10 years'
follow-up was 12.7% in the SU group and 5.5% in the GW group
(P=0.0606; Table 3). The
proportion of patients who were independent or partly independent (BI
60) was 20.0% in the SU versus 8.2% in the GW group (Table 3; P=0.0118). The proportion of patients at home in
the 2 groups corresponded well with the proportion of patients with BI
60. In the SU group 21 (19.1%) of the patients were at home (Table 1) and 22 (20%) of the patients had a BI 60 (Table 3).
In the GW group 9 (8.2%) of the patients were at home (Table 1), and the same number of patients had a BI 60 (Table 3). In the SU group 1 patient with a BI score of <60 lived at
home, whereas 2 patients were institutionalized despite having a score
of 60. In the GW group all the patients at home had a BI 60, and
none with a BI 60 were in an institution. The proportion of patients
at home who received some kind of help after 10 years is shown in Table 4. No significant differences were
present.
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Discussion |
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TopAbstractIntroductionSubjects and MethodsResultsDiscussionReferences |
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For the first time it has been shown that stroke patients treated in SU have a better 10-year outcome than stroke patients treated in GW. A standardized systematic treatment and rehabilitation program in SU during the acute stage of stroke seems to improve 10-year survival and functional state and increase the proportion of patients able to live at home.
The differences of treatment in this trial were limited to the first 6 weeks. We have carefully examined the information and records of treatment of every patient and found no differences in treatment, prophylaxis, or follow-up between the 2 groups in the period from 6 weeks to 10 years.12 Hence, if the better 10-year outcome in the SU group was a consequence of treatment, it has to be caused by the initial treatment and rehabilitation in the SU.
A completely blinded assessment is not possible in a trial like ours. The nurse who performed all the assessments was, however, not informed of where the patients had been treated. Hence, the assessments were blinded as far as possible.
The present analysis shows the same results in favor of SU
treatment as the 5-year follow-up analysis.12 The
proportion of patients at home was 1.9 times higher in the SU group
after 5 years12 than in the GW group, and it was even
higher (2.3 times) in the SU group after 10 years (SU 19.1% versus GW
8.2%; Table 1).
As noticed also in the 5-year follow up,12 the number of
patients with help from home care was similar in the 2 groups (Table 4). We found no indication of more support from relatives or
help from the healthcare system in the SU group (Table 4). The
higher proportion of patients at home in the SU group was therefore
probably due to a better functional outcome.
We used the BI for evaluation of activity of daily living in our SU
trial.9 12 13 14 15 The higher proportion of patients who were
independent or partly independent (BI score 60) after 10 years in the
SU group compared with the GW group is probably the reason for the
higher proportion of patients at home in the SU group (Table 1,
Table 3). It seems, at least in our country, that BI 60 is the
functional level needed for long-term ability to live at home for
stroke patients.
The proportion of patients living in institutions was low after 10 years. The explanation may be that the patients who were long-term survivors were the most independent stroke patients.
In previous studies we have shown that our SU treatment reduced the initial mortality (after 6 weeks) and that this reduction was still present after 5 years.9 12 However, the mortality rate between 6 weeks and 5 years was similar between the 2 groups.12 The 10-year follow-up results show no difference in death rate between the 2 groups in the period from 6 weeks to 10 years, but the initial difference in mortality during the first 6 weeks was still present. It is worth noting that the mortality rate seems to decrease in both groups if we compare the death rate from 1 to 5 years with the rate from 5 to 10 years. We do not know the reason for this decline, but it is probably the healthiest stroke patients who survive for 5 years. This particular group might then have a good prognosis for a long life.
Altogether, there was a high 10-year mortality. Some of the explanations might be that the average age at inclusion was about 73 years.9 During the 10-year follow-up many patients reached a very old age, and this fact may explain some of the high death rates. However, the high death rates should also be a challenge for better follow-up and better secondary prophylaxis, because most of the deaths probably were caused by such vascular diseases as myocardial infarction and stroke.12 16
The lack of difference in death rates between the SU- and GW groups in the period from 6 weeks to 10 years supports the evidence of no difference in treatment/secondary prophylaxis after the first 6 weeks between the groups.12
Consequently, it is hard to find any other explanation for the better outcome in the SU group after 10 years other than that the differences were caused by the effect of the acute treatment and early rehabilitation in our SU.
The reasons that SU treatment seems to improve long-term outcome are not known. We have in a previous article14 identified some factors that seemed to be important for the better outcome after 6 weeks. The factors identified were mainly the same that have proved to be effective in other SU.10 11 17 The factors most frequently present in SU trials have been team care, focus on rehabilitation, and participation of patients and relatives in the treatment and rehabilitation process.10 11 17 18
Most of the controlled SU trials have emphasized rehabilitation, but unlike most trials we have a very strong focus on the very early mobilization/rehabilitation, starting within 24 hours after admission.9 We have previously presented some data14 supporting the theory that this very early mobilization may have been important for the results in our trial. Compared with most of the other SU trials, we have also placed somewhat more emphasis on the very acute treatment. One of the most important elements in our acute treatment program has been the extensive use of intravenous saline solutions during the first 12 hours after admission. The aim of this hydration program was to avoid dehydration and low blood pressures and to stabilize blood pressure.14 Some results exist which indicate that low blood pressure during the acute stage of a stroke might be harmful.19 20 A systematic observation of fever and reduction of temperature >38°C was also part of the standard treatment program in our SU.9 14 These factors might also have contributed to the better outcome in the SU group.14 21 22
However, we believe that the combination of strong and early rehabilitation efforts and the standardized acute medical treatment program are responsible for the somewhat better results we have achieved compared with most of the trials from other units.9 10 11 Acute stroke patients need both acute care and acute rehabilitation. A unit dedicated to both of these elements might be more effective than units that focus only on acute treatment23 or only on rehabilitation.3 4 5 With only 220 patients, our trial alone cannot prove this assumption, but it gives some support to such a view. However, we need trials in which we can directly compare different SU models and treatment programs before we really know whether this combined SU model is superior to others.
In conclusion, the results of this trial show that care of patients with acute stroke in a combined acute treatment and rehabilitation SU improves 10-year survival and functional state and increases the proportion of patients able to live at home 10 years after the stroke. No other SU trial or no other treatment for stroke has shown such promising long-term results. Hence, treatment in a combined acute treatment and rehabilitation SU is a treatment modality for acute stroke that has the strongest evidence of effectiveness. The combined SU, which focuses on both acute care and acute rehabilitation, seems to be very important for a favorable short- and long-term outcome for stroke patients.
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Acknowledgments |
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This study was supported by grants from the Norwegian Council on Cardiovascular Diseases, The Fund of Cardiovascular Research, and the Stroke Unit's Fund of Stroke Research, University Hospital of Trondheim, Trondheim, Norway. The authors wish to extend their gratitude to research nurse John Bjørn Storvold for a very careful and systematic blind assessment of all the patients alive after 10 years, to our secretary Margareth Ibenfeldt for help in preparation of the paper, and to Tove Wendel for the linguistic revision. We also wish to thank all the members of the staff in our Stroke Unit for their help and support in the performance of this study.
Received March 25, 1999; revision received May 3, 1999; accepted May 10, 1999.
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References |
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|
TopAbstractIntroductionSubjects and MethodsResultsDiscussionReferences |
|---|
1. Garraway WM, Akthar AJ, Hockey L, Presscott RJ. Management of acute stroke in the elderly: preliminary results of a controlled trial. BMJ.. 1980;280:1040–1044.
2.
Strand T, Asplund K, Eriksson S, Hegg E, Lithner F,
Wester PO. A non-intensive stroke unit reduces functional disability
and the need for long-term hospitalization. Stroke.. 1985;16:29–34.
3.
Stevens RS, Ambler NR, Warren MD. A randomised
controlled trial of a stroke rehabilitation ward. Age
Ageing.. 1984;13:65–75.
4.
Kalra L, Dale P, Crome P. Improving stroke
rehabilitation: a controlled study. Stroke.. 1993;24:1462–1467.
5.
Kaste M, Palmomaki H, Sarna S. Where and how should
elderly stroke patients be treated? A randomized trial.
Stroke. 1995;26:249–253.
6. Aitken PD, Rodgers H, French JM, Bates D, James OFW. General medical or geriatric unit care for acute stroke? A controlled trial. Age Ageing. 1993;22(suppl 2):4–5.
7. Juby LC, Lincoln NB, Berman P. The effect of a stroke rehabilitation unit on functional and psychological outcome: a randomised controlled trial. Cerebrovasc Dis. 1996;6:106–110.
8.
Jørgensen HS, Nakayama H, Raaschou HO, Larsen K,
Hubbe P, Skyhøj Olsen T. The effect of a stroke unit: reductions in
mortality, discharge rate to nursing home, length of hospital stay, and
cost. Stroke.. 1995;26:1178–1182.
9.
Indredavik B, Bakke F, Solberg R, Rokseth R, Håheim
LL, Holme I. Benefit of a stroke unit: a randomized controlled trial.
Stroke.. 1991;22:1026–1031.
10. Langhorne P, Williams BO, Gilchrist W, Howie K. Do stroke units save lives? Lancet.. 1993;342:395–398.[Medline] [Order article via Infotrieve]
11.
The Stroke Unit Trialists' Collaboration.
Collaborative systematic review of the randomised trials of organised
inpatient (stroke unit) care after stroke. BMJ.. 1997;314:1151–1159.
12.
Indredavik B, Slørdahl S. A. Bakke F, Rokseth R,
Håheim LL. Stroke unit treatment: long-term effects.
Stroke.. 1997;28:1861–1866.
13.
Indredavik B, Bakke F, Slørdahl S. A, Rokseth R,
Håheim L. L. Stroke unit treatment improves long-term quality of
life: a randomized controlled trial. Stroke.. 1998;29:895–899.
14.
Indredavik B, Bakke F, Slørdahl S. A, Rokseth R,
Håheim L. L. Treatment in a combined acute and rehabilitation
stroke unit: which aspects are most important? Stroke.. 1999;30:917–923.
15. Mahoney FI, Barthel DW. Functional evaluation: the Barthel Index. Md State Med J.. 1965;14:61–65.[Medline] [Order article via Infotrieve]
16.
Dennis MS, Burn JPS, Sandercock PAG, Bamford JK, Wade
DT, Warlow CP. Long-term survival after first-ever stroke: the
Oxfordshire Community Stroke Project. Stroke.. 1993;24:796–800.
17.
The Stroke Unit Trialists' Collaboration. How do
stroke units improve patient outcomes? A collaborative review of the
randomized trials. Stroke.. 1997;28:2139–2144.
18. Langhorne P, Dennis M, eds. Stroke Units: An Evidence-Based Approach to Stroke Care. London, UK: BMJ Books; 1998.
19. Jørgensen HS, Nakayama H, Raaschou HO, Olsen TS. Effects of blood pressure and diabetes on stroke in progression. Lancet. 1994:344:156–159.
20. Wahlgren NG, MacMahon DG, De Keyser J, Indredavik B, Ryman T. Intravenous Nimodipine West European Stroke Trial (INWEST) of nimodipine in the treatment of acute ischemic stroke. Cerebrovasc Dis.. 1994;4:204–210.
21. Busto R, Dietrich WD, Globus MY-T. Small differences in intra ischemic brain temperature critically determine the extent of ischemic injury. J Cereb Blood Flow Metab.. 1987;7:729–738.[Medline] [Order article via Infotrieve]
22. Reith J, Joergensen HS, Pedersen PM. Body temperature in acute stroke: relation to stroke severity, infarct size, mortality, and outcome. Lancet.. 1996;347:422–425.[Medline] [Order article via Infotrieve]
23. Hacke W, Schwab S, De Georgia M. Intensive care of acute ischemic stroke. Cerebrovasc Dis.. 1994;4:385–392.
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 I. M Proot, H. H. Abu-Saad, G. G. Van Oorsouw, and J. J. Stevens Autonomy in Stroke Rehabilitation: the perceptions of care providers in nursing homes Nursing Ethics, January 1, 2002; 9(1): 36 - 50. [Abstract] [PDF]
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E.-L. Glader, B. Stegmayr, L. Johansson, K. Hulter-Asberg, and P. O. Wester Differences in Long-Term Outcome Between Patients Treated in Stroke Units and in General Wards: A 2-Year Follow-Up of Stroke Patients in Sweden Stroke, September 1, 2001; 32(9): 2124 - 2130. [Abstract] [Full Text] [PDF]
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H. Bronnum-Hansen, M. Davidsen, and P. Thorvaldsen Long-Term Survival and Causes of Death After Stroke Stroke, September 1, 2001; 32(9): 2131 - 2136. [Abstract] [Full Text] [PDF]
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 C. Fieschi and A. Falcou Keynote address Neurology, September 1, 2001; 57(90002): S82 - 86. [Abstract] [Full Text]
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 M. Shaw Integrated care pathway based rehabilitation for acute stroke did not reduce length of hospital stay Evid. Based Nurs., April 1, 2001; 4(2): 53 - 53. [Full Text]
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S. Recent advances: Geriatric BMJ, January 13, 2001; 322(7278): 86 - 89. [Full Text] [PDF]
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B. Indredavik, H. Fjartoft, G. Ekeberg, A. D. Loge, and B. Morch Benefit of an Extended Stroke Unit Service With Early Supported Discharge : A Randomized, Controlled Trial Stroke, December 1, 2000; 31(12): 2989 - 2994. [Abstract] [Full Text] [PDF]
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 T. Brott and J. Bogousslavsky Treatment of Acute Ischemic Stroke N. Engl. J. Med., September 7, 2000; 343(10): 710 - 722. [Full Text] [PDF]
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M. Shaw Stroke unit care decreased mortality and increased the number of patients who were living at home 10 years after stroke Evid. Based Nurs., April 1, 2000; 3(2): 55 - 55. [Full Text]
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Y. Yoshimoto, K. Yamashita, S. Kashiwagi, and S. Kato Treatment for Ruptured Aneurysms and Screening for Unruptured Aneurysms • Response Stroke, December 1, 1999; 30 (12): 2759 - 2768. [Full Text] [PDF]
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