Elsevier

The Lancet

Volume 369, Issue 9558, 27 January–2 February 2007, Pages 299-305
The Lancet

Articles
Stroke-unit care for acute stroke patients: an observational follow-up study

https://doi.org/10.1016/S0140-6736(07)60152-4Get rights and content

Summary

Background

Large numbers of stroke patients arrive at hospital at a very early stage, and effective treatments for the acute phase of the disease are available. However, evidence that patients with acute stroke benefit from stroke-unit care is scarce. Our aim was to determine whether admission to a stroke unit, rather than a conventional ward, affected the outcome of patients with acute stroke.

Methods

We did an observational follow-up study of 11 572 acute stroke patients hospitalised within 48 h of the onset of symptoms either in a stroke unit (n=4936) or in a conventional ward (6636). Patients were identified retrospectively from discharge records from 260 Italian hospitals. The primary outcome was mortality or disability (Rankin score greater than two), assessed prospectively by independent, masked assessors 2 years after admission. Analyses were adjusted for patient characteristics and clustered at the hospital level.

Findings

Overall, 1576 patients died in hospital; 2169 died during the follow-up period. 347 patients were lost to follow-up. Compared with conventional-ward care, stroke-unit care was associated with a reduced probability of death or being disabled at the end of follow-up (odds ratio 0·81, 95% CI 0·72–0·91; p=0·0001). The potential benefit was significant across all age ranges and clinical characteristics, except for unconsciousness. No specific elements of setting, organisation, or process of care were associated with outcome.

Interpretation

Admission to a stroke-unit ward with dedicated beds and staff within 48 h of onset should be recommended for all patients with acute stroke.

Introduction

Several randomised controlled trials have been done in different countries and environments to assess the effective-ness of stroke-unit care for hospitalised stroke patients.1 The results of these studies were combined in a Cochrane systematic review, which definitively showed the benefit of stroke-unit care.1 However, there is still some delay in implementation of stroke-unit wards in European countries.2 The large-scale applicability of some of the complex interventions that were used experimentally on small, selected groups of patients included in the randomised trials is debatable. Guidelines differ about important aspects of stroke care—eg, acuteness for admission, patient selection, and care organisation.3 In North America there is even disagreement on the need to have a discrete, dedicated ward together with a dedicated stroke team.4, 5

The Italian National Ministry of Health has promoted a stroke-unit research project (Research Project on Stroke services in Italy, PROSIT) since 2000, which involves many institutions around the country. This project enabled us to do a large-scale controlled prospective trial to assess the effectiveness of stroke-unit care. Our aim was to determine whether all acute stroke patients admitted into stroke units have a better long-term outcome than those treated in conventional wards.

Section snippets

Participants and procedures

This study is an observational controlled follow-up study on acute stroke patients, done in hospitals in Italy between 2000 and 2004, to compare the long-term outcome of patients cared for in stroke units with those cared for in conventional wards. Seven Italian regions (Lombardia, Liguria, Veneto, Friuli-Venezia Giulia, Emilia-Romagna, Toscana, and Lazio), with a population of about 29 million and more than 50 000 acute stroke discharges every year, took part in the study.

The study was done in

Results

Figure 1 shows the trial profile. At baseline, data were available for 11 572 acute stroke patients from 424 units and 260 hospitals were studied. 16 hospitals had only stroke units and 230 only conventional wards; 14 hospitals had both types of ward. The number of cases for the three types of hospitals were 2502, 6260, and 2810, respectively. Table 1 shows the baseline characteristics for these patients. 90% of baseline data were complete.

Table 2 presents data on the follow-up status of

Discussion

This observational follow-up study, done in the clinical environment in Italy on a large sample of patients with acute stroke, shows that there is an association between stroke-unit care provided in the acute phase of the disease and improvement of stroke outcome. In this setting, stroke-unit care could reduce in-hospital case fatality and also increase the proportion of patients living independently about 2 years after discharge. The possible benefit is maintained over time and is evident both

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