Tableaux de données probantes et liste de référence
It is now well-established that patients who receive stroke unit care are more likely to survive, return home, and regain independence compared to patients who receive less organized forms of care. Stroke unit care is characterized by an experienced interdisciplinary stroke team, including physicians, nurses, physiotherapists, occupational therapists, speech therapists, among others, dedicated to the management of stroke patients, often located within a geographically defined space. Other features of stroke units include staff members who have an interest in stroke, routine team meetings, continuing education/training, and involvement of caregivers in the rehabilitation process. In an updated Cochrane Review, the Stroke Unit Trialists’ Collaboration (2013) identified 28 randomized and quasi-randomized trials (n=5,855) comparing stroke unit care with alternative, less organized care (e.g., an acute medical ward). Compared to less organized forms of care, stroke unit care was associated with a significant reduction in the odds of death (OR= 0.81, 95% CI 0.69 to 0.94, p = 0.005), death or institutionalization (OR=0.78, 95% CI 0.68 to 0.89, p = 0.0003), and death or dependency (OR= 0.79, 95% CI 0.68 to 0.90, p = 0.0007) at a median follow-up period of one year. Based on the results from a small number of trials, the authors also reported that the benefits of stroke unit care are maintained for periods up to 5 and 10 years post stroke. Moreover, subgroup analyses demonstrated benefits of stroke unit care regardless of sex, age, or stroke severity. Saposnik et al. (2011) investigated the differential impact of stroke unit care on four subtypes of ischemic stroke (cardioembolic, large artery disease, small vessel disease, or other) and reported that stroke unit care was associated with reduced 30-day mortality across all subtypes.
To determine if the benefits of stroke unit care demonstrated in clinical trials can be replicated in routine clinical practice, Seenan et al. (2007) conducted a systematic review of 25 observational studies (n=42,236) comparing stroke unit care to non-stroke unit care. Stroke unit care was associated with a reduction in the risk of death (OR=0.79, 95% CI 0.73 to 0.86, p<0.001) and of death or poor outcome (OR=0.87, 95% CI=0.80 to 0.95; p=0.002) within one-year of stroke. Similar findings were reported for the outcome of death at one year in a secondary analysis limited to multi-centered trials (OR=0.82, 95% CI 0.77 to 0.87, p<0.001).
Estimates of persons who experience a stroke while already hospitalized for other conditions range from 4% to 17% (as cited by Cumbler et al. 2014). Many of these patients have pre-existing stroke risk including hypertension, diabetes, cardiac diseases, and dyslipidemia (Vera et al. 2011). These in-hospital strokes often occur following cardiac and orthopedic procedures, usually within 7 days of surgery. There is evidence to suggest that, compared with persons who suffer a stroke in the community, patients who experience an in-hospital stroke have more severe strokes, worse outcomes and do not receive care in as timely a fashion. Of 15,815 consecutive patients included in the J-MUSIC registry, (Kimura et al 2006), 694 (4.4%) experienced an in-hospital ischemic stroke. The mean admission NIHSS score was significantly higher for patients with in-hospital stroke (14.6 vs. 8.1, p<0.0001). In-hospital stroke was an independent predictor of severe stroke, defined as NIHSS score ≥11 (OR=3.27, 95% CI 2.7-3.88, p<0.0001). Significantly more in-hospital stroke patients died both in hospital (19.2% vs. 6.8%, p<0.0001) and within 28 days (12.1% vs. 4.8%, p<0.0001). Farooq et al. (2008) compared the outcomes of 177 patients who experienced an in-hospital stroke and 2,566 who were admitted from the community to 15 hospitals in a single state over a 6-month period. In-hospital case fatality was significantly higher among in-hospital patients (14.6% vs. 6.9%, p=0.04). The distribution of mRS scores was shifter towards poorer outcomes for the in-hospital group (p<0.001) and fewer in-hospital stroke patients were discharged home (22.9% vs. 52.2%, p<0.01).
One of the largest studies to examine quality of care received and stroke outcome included 21,349 patients who experienced an in-hospital ischemic stroke and were admitted to 1,280 hospitals participating in the Get with the Guideline Stroke registry from 2006-2012, and 928,885 patients admitted to hospitals from the community during the same time frame (Cumbler et al. 2014). In-hospital stroke patients were significantly less likely to meet 7 achievement standards (t-PA within 3 hours, early antithrombotics, DVT prophylaxis, antithrombotics/anticoagulants on discharge, statin meds), and were less likely to receive a dysphagia screen or receive t-PA within 3.5-4.5 hours, but were more likely to receive a referral for rehabilitation and to receive intensive statin therapy. When quality/achievement measures were combined, in-hospital stroke patients were less likely to receive investigations/care for which they were eligible (82.6% vs. 92.8%, p<0.0001). In-hospital stroke patients also experienced worse outcomes. They were less likely to be independent in ambulation at discharge (adj OR=0.42, 95% CI 0.39-0.45, p<0.001), to be discharged home (adj OR=0.37, 95% CI 0.35-0.39, p<0.001) and the odds of in-hospital mortality were significantly higher (adj OR=2.72, 95% CI 2.57-2.88, p<0.001). Although a higher percentage of patients with in-hospital stroke received thrombolytic therapy with t-PA (11% vs. 6.6%), fewer received the treatment within 3-hours (31.6% vs. 73.4%, p<0.0001).