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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). The different forms of rehabilitation services varied and included acute, intensive and semi-intensive models, comprehensive models, which combined acute and rehabilitation services, comprehensive stroke units that integrated Traditional Chinese Medicine, stroke rehabilitation units (with post-acute transfer to a separate unit or facility), mobile stroke units and mixed rehabilitation units, where patients with other neurological conditions are admitted. The majority of trials in this updated review compared stroke wards with general medical wards. Overall, 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.
In subgroup analysis of 3 trials that compared stroke rehabilitation units versus an alternative service, the odds of death at end of follow-up were reduced significantly (OR=0.51, 95% CI 0.29-0.90, p=0.019), while the odds of death or institutionalization dependency, death or dependency and hospital LOS, were not reduced. In another systematic review, Foley et al. (2007) examined the effectiveness of 3 different models of stroke rehabilitation including acute stroke unit care, comprehensive models and stroke rehabilitation units. Using data from the 5 studies that compared stroke rehabilitation unit care with either general medical ward or community-based care, post-acute rehabilitation stroke units were associated with reduced odds of death (OR=0.60, 95% CI 0.44 to 0.81, p<0.05) and death or dependency (OR=0.63, 95% CI 0.48 to 0.83, p<0.05), but without a significant reduction in hospital LOS.
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. In most cases, studies compared acute stroke units with conventional 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).