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Meta-Analysis
. 2004 Oct 18;2004(4):CD002924.
doi: 10.1002/14651858.CD002924.pub2.

In-hospital care pathways for stroke

J Kwan  1 , P Sandercock
Affiliations
Meta-Analysis

In-hospital care pathways for stroke

J Kwan et al. Cochrane Database Syst Rev. .

Abstract

Background: Stroke care pathways have the potential to promote organised and efficient patient care that is based on best evidence and guidelines, but evidence to support their use is unclear.

Objectives: We aimed to assess the effects of care pathways, compared with standard medical care, among patients with acute stroke who had been admitted to hospital.

Search strategy: We searched the Cochrane Stroke Group Trials Register (last searched in June 2003), the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 2, 2003), MEDLINE (1975 to June 2003), EMBASE (1980 to June 2003), CINAHL (1982 to June 2003), ISI Proceedings: Science & Technology (1990 to November 2003), and HealthSTAR (1994 to May 2001). We also handsearched the Journal of Integrated Care Pathways (2001 to 2003), formerly Journal of Managed Care (1997 to 1998) and Journal of Integrated Care (1998 to 2001). Reference lists of articles were searched.

Selection criteria: We considered randomised controlled trials and non-randomised studies that compared care pathway care with standard medical care.

Data collection and analysis: One reviewer selected studies for inclusion and the other independently checked the decisions. Two reviewers independently assessed the methodological quality of the studies. One reviewer extracted the data and the other checked the extracted data.

Main results: Three randomised controlled trials (340 patients) and 12 non-randomised studies (4081 patients) were included. There was significant statistical heterogeneity in the analysis of many of the outcomes. We found no significant difference between care pathway and control groups in terms of death or discharge destination. Patients managed with a care pathway were: (a) more dependent at discharge (P = 0.04); (b) less likely to suffer a urinary tract infection (Odds Ratio (OR) 0.51, 95% Confidence Interval (CI) 0.34 to 0.79); (c) less likely to be readmitted (OR 0.11, 95% CI 0.03 to 0.39); and (d) more likely to have neuroimaging (OR 2.42, 95% CI 1.12 to 5.25). Evidence from randomised trials suggested that patient satisfaction and quality of life were significantly lower in the care pathway group (P = 0.02 and P < 0.005 respectively).

Reviewers' conclusions: Use of stroke care pathways may be associated with positive and negative effects. Since most of the results have been derived from non-randomised studies, they are likely to be influenced by potential biases and confounding factors. There is currently insufficient supporting evidence to justify the routine implementation of care pathways for acute stroke management or stroke rehabilitation.

PubMed Disclaimer

Conflict of interest statement

The contact reviewer (JK) is also the author of one of the included non‐randomised studies (Kwan 2004).

Figures

1.1
1.1. Analysis
Comparison 1 Care pathway care versus standard care, Outcome 1 Death by the end of follow‐up.
1.2
1.2. Analysis
Comparison 1 Care pathway care versus standard care, Outcome 2 Death in hospital.
1.3
1.3. Analysis
Comparison 1 Care pathway care versus standard care, Outcome 3 Dependency at discharge (mean Functional Indepedence Measure).
1.4
1.4. Analysis
Comparison 1 Care pathway care versus standard care, Outcome 4 Dead or dependent (modified Rankin Score >2) by the end of follow‐up.
1.5
1.5. Analysis
Comparison 1 Care pathway care versus standard care, Outcome 5 Discharged to Institutional care.
1.6
1.6. Analysis
Comparison 1 Care pathway care versus standard care, Outcome 6 Death in hospital or discharged to institutional care.
1.7
1.7. Analysis
Comparison 1 Care pathway care versus standard care, Outcome 7 Discharged to home.
1.8
1.8. Analysis
Comparison 1 Care pathway care versus standard care, Outcome 8 Complication: Pneumonia.
1.9
1.9. Analysis
Comparison 1 Care pathway care versus standard care, Outcome 9 Complication: Urinary tract infection.
1.10
1.10. Analysis
Comparison 1 Care pathway care versus standard care, Outcome 10 Complication: Deep vein thrombosis.
1.11
1.11. Analysis
Comparison 1 Care pathway care versus standard care, Outcome 11 Complication: Pressure sores.
1.12
1.12. Analysis
Comparison 1 Care pathway care versus standard care, Outcome 12 Complication: Dehydration.
1.13
1.13. Analysis
Comparison 1 Care pathway care versus standard care, Outcome 13 Complication: Fluid and electrolyte imbalance.
1.14
1.14. Analysis
Comparison 1 Care pathway care versus standard care, Outcome 14 Complication: Fever (all causes).
1.15
1.15. Analysis
Comparison 1 Care pathway care versus standard care, Outcome 15 Complication: Seizures.
1.16
1.16. Analysis
Comparison 1 Care pathway care versus standard care, Outcome 16 Complication: Falls or fractures.
1.17
1.17. Analysis
Comparison 1 Care pathway care versus standard care, Outcome 17 Complication: Constipation.
1.18
1.18. Analysis
Comparison 1 Care pathway care versus standard care, Outcome 18 Complication: Myocardial infarction.
1.19
1.19. Analysis
Comparison 1 Care pathway care versus standard care, Outcome 19 Investigation: First or second computed tomography brain scan.
1.20
1.20. Analysis
Comparison 1 Care pathway care versus standard care, Outcome 20 Investigation: Computed tomography brain scan within 24 hours.
1.21
1.21. Analysis
Comparison 1 Care pathway care versus standard care, Outcome 21 Investigation: Carotid duplex study.
1.22
1.22. Analysis
Comparison 1 Care pathway care versus standard care, Outcome 22 Investigation: Echocardiography.
1.23
1.23. Analysis
Comparison 1 Care pathway care versus standard care, Outcome 23 Investigation: Electrocardiography.
1.24
1.24. Analysis
Comparison 1 Care pathway care versus standard care, Outcome 24 Investigation: Chest x‐ray.
1.25
1.25. Analysis
Comparison 1 Care pathway care versus standard care, Outcome 25 Investigation: Cerebral angiography (catheter or MR angiography).
1.26
1.26. Analysis
Comparison 1 Care pathway care versus standard care, Outcome 26 Medication: Use of heparin (subcutaneous or intravenous) in acute period.
1.27
1.27. Analysis
Comparison 1 Care pathway care versus standard care, Outcome 27 Medication: Use of new antihypertensive therapy in the acute period.
1.28
1.28. Analysis
Comparison 1 Care pathway care versus standard care, Outcome 28 Medication: Use of intravenous fluids.
1.29
1.29. Analysis
Comparison 1 Care pathway care versus standard care, Outcome 29 Procedure: Urinary catheterisation for patients with incontinence.
1.30
1.30. Analysis
Comparison 1 Care pathway care versus standard care, Outcome 30 Procedure: Use of thrombo‐embolism deterrent stockings.
1.31
1.31. Analysis
Comparison 1 Care pathway care versus standard care, Outcome 31 Patient satisfaction.
1.32
1.32. Analysis
Comparison 1 Care pathway care versus standard care, Outcome 32 Duration of hospital stay.
1.33
1.33. Analysis
Comparison 1 Care pathway care versus standard care, Outcome 33 Readmission or emergency department attendance after discharge.
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Update of

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