Published online before print October 23, 2008, doi: 10.1161/STROKEAHA.108.523548
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(Stroke. 2009;40:10.)
© 2009 American Heart Association, Inc.
Original Contributions |
Stroke Unit Care in a Real-Life Setting
Can Results From Randomized Controlled Trials Be Translated Into Every-Day Clinical Practice? An Observational Study of Hospital Data in a Large Australian Population
From School of Public Health and Community Medicine (M.G.), The University of New South Wales & Centre for Research, Evidence Management and Surveillance, Division of Population Health, SSWAHS, Liverpool, New South Wales, Australia; Northern Beaches Area Stroke Unit (J.W.), Department of Neurology, Liverpool Health Service, Liverpool, New South Wales, Australia; School of Public Health and Community Medicine (B.J.), The University of New South Wales & Director, Centre for Research, Evidence Management and Surveillance, Division of Population Health, Liverpool, New South Wales, Australia; School of Public Health and Community Medicine (M.M.), The University of New South Wales Clinical Excellence Commission, Sydney, New South Wales, Australia.
Correspondence to Melina Gattellari, Senior Research Fellow, School of Public Health and Community Medicine, The University of New South Wales & Centre for Research, Evidence Management and Surveillance, Division of Population Health, SSWAHS, Locked Bag 7017, Liverpool, New South Wales, Australia 1871. E-mail Melina.Gattellari{at}sswahs.nsw.gov.au
Background and Purpose— In randomized trials, acute stroke units are associated with improved patient outcomes. However, it is unclear whether this evidence can be successfully translated into routine clinical practice. We aimed to determine the effect of a coordinated rollout of funding for 22 stroke units on patient outcomes in Australia.
Methods— A multicenter observational study was undertaken using health administrative data recording admissions for a primary diagnosis of ischemic stroke from July 2000 to June 2006. Analyses were stratified by hospital type (major principal referral, smaller nonprincipal referral hospitals).
Results— We analyzed 17 659 admissions for ischemic stroke. Among major principal referral hospitals with acute stroke units, the proportion of admissions resulting in death or discharge to home was unchanged after stroke unit rollout (10.7% vs 10.6% and 44.1% vs 45.0%, respectively; P=0.37). In contrast, significant differences in discharge destination were noted across time among smaller nonprincipal referral hospitals (P<0.001). Before the rollout of stroke units, 13.8% of admissions to smaller hospitals resulted in a death, decreasing to 10.5% after stroke units were implemented. Discharges to home increased from 38.8% to 44.5%. Discharges to nursing homes decreased from 6.3% to 4.9%. Differences across time remained significant when controlling for patient demographics, comorbidities, indicators of poor prognosis, and clustering of outcomes at hospital level. Improved outcomes were observed across all ages and among patients with indicators for a poor prognosis.
Conclusions— This multicenter analysis of a large Australian population of hospital stroke admissions demonstrates short-term benefits from implementing stroke units in nonprincipal referral hospitals.
Key Words: health services • mortality • stroke