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. 2020 Apr 23;4(4):CD000197.
doi: 10.1002/14651858.CD000197.pub4.

Organised inpatient (stroke unit) care for stroke: network meta-analysis

Peter Langhorne  1 , Samantha Ramachandra  2 ; Stroke Unit Trialists' Collaboration  1
Affiliations

Organised inpatient (stroke unit) care for stroke: network meta-analysis

Peter Langhorne et al. Cochrane Database Syst Rev. .

Abstract

Background: Organised inpatient (stroke unit) care is provided by multi-disciplinary teams that manage stroke patients. This can been provided in a ward dedicated to stroke patients (stroke ward), with a peripatetic stroke team (mobile stroke team), or within a generic disability service (mixed rehabilitation ward). Team members aim to provide co-ordinated multi-disciplinary care using standard approaches to manage common post-stroke problems.

Objectives: • To assess the effects of organised inpatient (stroke unit) care compared with an alternative service. • To use a network meta-analysis (NMA) approach to assess different types of organised inpatient (stroke unit) care for people admitted to hospital after a stroke (the standard comparator was care in a general ward). Originally, we conducted this systematic review to clarify: • The characteristic features of organised inpatient (stroke unit) care? • Whether organised inpatient (stroke unit) care provide better patient outcomes than alternative forms of care? • If benefits are apparent across a range of patient groups and across different approaches to delivering organised stroke unit care? Within the current version, we wished to establish whether previous conclusions were altered by the inclusion of new outcome data from recent trials and further analysis via NMA.

Search methods: We searched the Cochrane Stroke Group Trials Register (2 April 2019); the Cochrane Central Register of Controlled Trials (CENTRAL; 2019, Issue 4), in the Cochrane Library (searched 2 April 2019); MEDLINE Ovid (1946 to 1 April 2019); Embase Ovid (1974 to 1 April 2019); and the Cumulative Index to Nursing and Allied Health Literature (CINAHL; 1982 to 2 April 2019). In an effort to identify further published, unpublished, and ongoing trials, we searched seven trial registries (2 April 2019). We also performed citation tracking of included studies, checked reference lists of relevant articles, and contacted trialists.

Selection criteria: Randomised controlled clinical trials comparing organised inpatient stroke unit care with an alternative service (typically contemporary conventional care), including comparing different types of organised inpatient (stroke unit) care for people with stroke who are admitted to hospital.

Data collection and analysis: Two review authors assessed eligibility and trial quality. We checked descriptive details and trial data with co-ordinators of the original trials, assessed risk of bias, and applied GRADE. The primary outcome was poor outcome (death or dependency (Rankin score 3 to 5) or requiring institutional care) at the end of scheduled follow-up. Secondary outcomes included death, institutional care, dependency, subjective health status, satisfaction, and length of stay. We used direct (pairwise) comparisons to compare organised inpatient (stroke unit) care with an alternative service. We used an NMA to confirm the relative effects of different approaches.

Main results: We included 29 trials (5902 participants) that compared organised inpatient (stroke unit) care with an alternative service: 20 trials (4127 participants) compared organised (stroke unit) care with a general ward, six trials (982 participants) compared different forms of organised (stroke unit) care, and three trials (793 participants) incorporated more than one comparison. Compared with the alternative service, organised inpatient (stroke unit) care was associated with improved outcomes at the end of scheduled follow-up (median one year): poor outcome (odds ratio (OR) 0.77, 95% confidence interval (CI) 0.69 to 0.87; moderate-quality evidence), death (OR 0.76, 95% CI 0.66 to 0.88; moderate-quality evidence), death or institutional care (OR 0.76, 95% CI 0.67 to 0.85; moderate-quality evidence), and death or dependency (OR 0.75, 95% CI 0.66 to 0.85; moderate-quality evidence). Evidence was of very low quality for subjective health status and was not available for patient satisfaction. Analysis of length of stay was complicated by variations in definition and measurement plus substantial statistical heterogeneity (I² = 85%). There was no indication that organised stroke unit care resulted in a longer hospital stay. Sensitivity analyses indicated that observed benefits remained when the analysis was restricted to securely randomised trials that used unequivocally blinded outcome assessment with a fixed period of follow-up. Outcomes appeared to be independent of patient age, sex, initial stroke severity, stroke type, and duration of follow-up. When calculated as the absolute risk difference for every 100 participants receiving stroke unit care, this equates to two extra survivors, six more living at home, and six more living independently. The analysis of different types of organised (stroke unit) care used both direct pairwise comparisons and NMA. Direct comparison of stroke ward versus general ward: 15 trials (3523 participants) compared care in a stroke ward with care in general wards. Stroke ward care showed a reduction in the odds of a poor outcome at the end of follow-up (OR 0.78, 95% CI 0.68 to 0.91; moderate-quality evidence). Direct comparison of mobile stroke team versus general ward: two trials (438 participants) compared care from a mobile stroke team with care in general wards. Stroke team care may result in little difference in the odds of a poor outcome at the end of follow-up (OR 0.80, 95% CI 0.52 to 1.22; low-quality evidence). Direct comparison of mixed rehabilitation ward versus general ward: six trials (630 participants) compared care in a mixed rehabilitation ward with care in general wards. Mixed rehabilitation ward care showed a reduction in the odds of a poor outcome at the end of follow-up (OR 0.65, 95% CI 0.47 to 0.90; moderate-quality evidence). In a NMA using care in a general ward as the comparator, the odds of a poor outcome were as follows: stroke ward - OR 0.74, 95% CI 0.62 to 0.89, moderate-quality evidence; mobile stroke team - OR 0.88, 95% CI 0.58 to 1.34, low-quality evidence; mixed rehabilitation ward - OR 0.70, 95% CI 0.52 to 0.95, low-quality evidence.

Authors' conclusions: We found moderate-quality evidence that stroke patients who receive organised inpatient (stroke unit) care are more likely to be alive, independent, and living at home one year after the stroke. The apparent benefits were independent of patient age, sex, initial stroke severity, or stroke type, and were most obvious in units based in a discrete stroke ward. We observed no systematic increase in the length of inpatient stay, but these findings had considerable uncertainty.

Trial registration: ClinicalTrials.gov NCT00544622 NCT00843765.

PubMed Disclaimer

Conflict of interest statement

Most of the Stroke Unit Trialists Collaboration members carried out trials that are included in the review.

Peter Langhorne: none known.

Samantha Ramachandra: none known.

Figures

1
1
Flow diagram illustrating the results of updated searches.
2
2
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
3
3
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
4
4
Subgroup analysis by patient characteristics: poor outcome at the end of scheduled follow‐up. Analyses used the generic inverse variance approach. P values relate to the subgroup interaction.
5
5
Network meta‐analysis plot for different types of organised care. The nodes show the service groups (GMW: general medical ward; MRW: mixed rehabilitation ward; MST: mobile stroke team; SW: stroke ward), with care in a GMW as the reference.
6
6
Network meta‐analysis plot for different types or organised care. The outcome is poor outcome at the end of scheduled follow‐up. The treatment column shows the service groups (GMW: general medical ward; MRW: mixed rehabilitation ward; MST: mobile stroke team; SW: stroke ward). The results are the odds ratio (95% confidence interval) for the odds of a poor outcome, with care in a GMW as the reference (OR = 1.0).
7
7
Network meta‐analysis plot for different types of organised care. The outcome is death at the end of scheduled follow‐up. The treatment column shows the service groups (GMW: general medical ward; MRW: mixed rehabilitation ward; MST: mobile stroke team; SW: stroke ward). The results are the odds ratio (95% confidence interval) for the odds of a poor outcome, with care in a GMW as the reference (OR = 1.0).
8
8
Network meta‐analysis plot for different types or organised care. The outcome is death or institutional care at the end of scheduled follow‐up. The treatment column shows the service groups (GMW: general medical ward; MRW: mixed rehabilitation ward; MST: mobile stroke team; SW: stroke ward). The results are the odds ratio (95% confidence interval) for the odds of a poor outcome, with care in a GMW as the reference (OR = 1.0).
9
9
Network meta‐analysis plot for different types of organised care. The outcome is death or dependency at the end of scheduled follow‐up. The treatment column shows the service groups (GMW: general medical ward; MRW: mixed rehabilitation ward; MST: mobile stroke team; SW: stroke ward). The results are the odds ratio (95% confidence interval) for the odds of a poor outcome, with care in a GMW as the reference (OR = 1.0).
1.1
1.1. Analysis
Comparison 1: Organised stroke care versus alternative service, Outcome 1: Poor outcome by the end of scheduled follow‐up
1.2
1.2. Analysis
Comparison 1: Organised stroke care versus alternative service, Outcome 2: Death by the end of scheduled follow‐up
1.3
1.3. Analysis
Comparison 1: Organised stroke care versus alternative service, Outcome 3: Death or institutional care by the end of scheduled follow‐up
1.4
1.4. Analysis
Comparison 1: Organised stroke care versus alternative service, Outcome 4: Death or dependency by the end of scheduled follow‐up
1.5
1.5. Analysis
Comparison 1: Organised stroke care versus alternative service, Outcome 5: Length of stay (days) in a hospital or institution or both
1.6
1.6. Analysis
Comparison 1: Organised stroke care versus alternative service, Outcome 6: Length of stay (days) in a hospital or hospital plus institution
1.7
1.7. Analysis
Comparison 1: Organised stroke care versus alternative service, Outcome 7: Poor outcome at 5‐year follow‐up
1.8
1.8. Analysis
Comparison 1: Organised stroke care versus alternative service, Outcome 8: Death at 5‐year follow‐up
1.9
1.9. Analysis
Comparison 1: Organised stroke care versus alternative service, Outcome 9: Death or institutional care at 5‐year follow‐up
1.10
1.10. Analysis
Comparison 1: Organised stroke care versus alternative service, Outcome 10: Death or dependency at 5‐year follow‐up
1.11
1.11. Analysis
Comparison 1: Organised stroke care versus alternative service, Outcome 11: Poor outcome at 10‐year follow‐up
1.12
1.12. Analysis
Comparison 1: Organised stroke care versus alternative service, Outcome 12: Death at 10‐year follow‐up
1.13
1.13. Analysis
Comparison 1: Organised stroke care versus alternative service, Outcome 13: Death or institutional care at 10‐year follow‐up
1.14
1.14. Analysis
Comparison 1: Organised stroke care versus alternative service, Outcome 14: Death or dependency at 10‐year follow‐up
2.1
2.1. Analysis
Comparison 2: Stroke ward versus general medical ward, Outcome 1: Poor outcome by the end of scheduled follow‐up
2.2
2.2. Analysis
Comparison 2: Stroke ward versus general medical ward, Outcome 2: Death by the end of scheduled follow‐up
2.3
2.3. Analysis
Comparison 2: Stroke ward versus general medical ward, Outcome 3: Death or institutional care by the end of scheduled follow‐up
2.4
2.4. Analysis
Comparison 2: Stroke ward versus general medical ward, Outcome 4: Death or dependency by the end of scheduled follow‐up
2.5
2.5. Analysis
Comparison 2: Stroke ward versus general medical ward, Outcome 5: Length of stay (days) in a hospital or institution
3.1
3.1. Analysis
Comparison 3: Mobile stroke team versus general medical ward, Outcome 1: Poor outcome by the end of scheduled follow‐up
3.2
3.2. Analysis
Comparison 3: Mobile stroke team versus general medical ward, Outcome 2: Death by the end of scheduled follow‐up
3.3
3.3. Analysis
Comparison 3: Mobile stroke team versus general medical ward, Outcome 3: Death or institutional care by the end of scheduled follow‐up
3.4
3.4. Analysis
Comparison 3: Mobile stroke team versus general medical ward, Outcome 4: Death or dependency by the end of scheduled follow‐up
3.5
3.5. Analysis
Comparison 3: Mobile stroke team versus general medical ward, Outcome 5: Length of stay (days) in a hospital or institution
4.1
4.1. Analysis
Comparison 4: Mixed rehabilitation ward versus general medical ward, Outcome 1: Poor outcome by the end of scheduled follow‐up
4.2
4.2. Analysis
Comparison 4: Mixed rehabilitation ward versus general medical ward, Outcome 2: Death by the end of scheduled follow‐up
4.3
4.3. Analysis
Comparison 4: Mixed rehabilitation ward versus general medical ward, Outcome 3: Death or institutional care by the end of scheduled follow‐up
4.4
4.4. Analysis
Comparison 4: Mixed rehabilitation ward versus general medical ward, Outcome 4: Death or dependency by the end of scheduled follow‐up
4.5
4.5. Analysis
Comparison 4: Mixed rehabilitation ward versus general medical ward, Outcome 5: Length of stay (days) in a hospital or institution
5.1
5.1. Analysis
Comparison 5: Different systems of organised care: stroke ward versus alternative organised care, Outcome 1: Poor outcome by the end of scheduled follow‐up
5.2
5.2. Analysis
Comparison 5: Different systems of organised care: stroke ward versus alternative organised care, Outcome 2: Death by the end of scheduled follow‐up
5.3
5.3. Analysis
Comparison 5: Different systems of organised care: stroke ward versus alternative organised care, Outcome 3: Death or institutional care by the end of scheduled follow‐up
5.4
5.4. Analysis
Comparison 5: Different systems of organised care: stroke ward versus alternative organised care, Outcome 4: Death or dependency by the end of scheduled follow‐up
5.5
5.5. Analysis
Comparison 5: Different systems of organised care: stroke ward versus alternative organised care, Outcome 5: Length of stay (days) in a hospital or institution
See this image and copyright information in PMC

Update of

Comment in

References

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Felix 2016 {published data only}
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Fu 2006 {published data only}
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HAMLET 2009 {published data only}
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Hamrin 1982 {published and unpublished data}
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Moloney 1999 {published data only}
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Pappa 2009 {published data only}
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Patel 2000 {unpublished data only}
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Pearson 1988 {published data only}
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Strand 1985 {published and unpublished data}
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References to studies awaiting assessment

Anhui 2008 {published data only}
    1. Ni C, Li C, Han R, Chen J, Sun H, Liu S. A randomised controlled trial of standardised tertiary rehabilitation after stroke. Journal of Rehabilitation Medicine 2008;Suppl 46:71.
China (Hao) 2010 {published data only}
    1. Hao JJ. Effect of comprehensive stroke unit on patients with pneumonia after acute stroke. Chinese Journal of Cerebrovascular Diseases 2010;7:120-3.
China (Pei) 2011 {published data only}
    1. Pei Z. Clinical research of organised stroke care model with integrated Chinese traditional and Western medicine in primary hospital. Chinese Journal of Contemporary Neurology and Neurosurgery 2011;11:221-5.
China (Wang) 2008 {published data only}
    1. Wang ZM, Wang P, Chen J, Luo DH, Shen WM. Application of stroke rehabilitation in municipal hospitals during the acute phase of cerebral infarction. Chinese Journal of Epidemiology 2008;29:724-5. - PubMed
China (Wu) 2007 {published data only}
    1. Wu WL, Lu XL, Zheng MY, Liang W, Yao XL, Hu ZL. Impact of organised stroke unit on the therapeutic effect in stroke patients. Journal of Southern Medical University 2010;30:555-6. - PubMed
Haikou 2007 {published data only}
    1. Su Q, Lin T, Wu Y, Cai M, Chen Z. Benefit of an extended stroke unit to acute cerebral infarction. Cerebrovascular Diseases 2007;24:490.
Shanghai 2006 {published data only}
    1. Hu YS. Standardized tertiary rehabilitation (STR) for stroke patients with hemiplegia in promoting the neurological function. Neurorehabilitation and Neural Repair 2006;20:163.
    1. Hu YS. Standarized tertiary rehabilitation (STR) for patients with cerebral strokes accompanied by hemiplegia. Neurorehabilitation and Neural Repair 2006;20:163.
    1. Jiang CY, Hu YS, Wang Q, Wu Y, Zhu YL. The cost-effectiveness analysis of early rehabilitation for stroke patients. Neurorehabilitation and Neural Repair 2006;20:205.
    1. Sun LM, Hu YS, Wu Y, Zhu YL, Fan WK. Effect of standardized tertiary rehabilitation on the motor function in patients with cerebral stroke accompanied by hemiplegia. Neurorehabilitation and Neural Repair 2006;20:163.

References to ongoing studies

ChiCTR‐OCH‐09000335 {unpublished data only}
    1. ChiCTR-OCH-09000335. A study of the stroke unit of traditional Chinese and western medicine in the treatment of ischemic stroke. http://www.chictr.org.cn/showprojen.aspx?proj=9196 (first posted 22 February 2009).
China (Wang) 2015 {published data only}
    1. Wang Y, Li Z, Xian Y, Zhao X, Li H, Shen H, GOLDEN BRIDGE-AIS investigators. Rationale and design of a cluster-randomized multifaceted intervention trial to improve stroke care quality in China: the GOLDEN BRIDGE-Acute Ischemic Stroke. American Heart Journal 2015;169(6):767-74. - PubMed
NCT00544622 {unpublished data only}
    1. NCT00544622. Structured stroke management improves outcome at 6 months. https://clinicaltrials.gov/ct2/show/NCT00544622 (first posted 16 October 2007).
NCT00843765 {unpublished data only}
    1. NCT00843765. Efficiency study of traditional Chinese medicine (TCM) versus Western medicine (WM) on ischemic stroke. https://clinicaltrials.gov/ct2/show/NCT00843765 (first posted 13 February 2009).
Russia 2017 {published data only}
    1. Ivanova G, Melnikova E, Shmonin A, Shamalov N, Khasanova D, Bodrova R, et al. Preliminary results of large clinical trial 'development of medical rehabilitation in Russia' (DOME): rehabilitation in stroke units and rehabilitation centers. European Stroke Journal 2017;2(1 Suppl 1):177-8.
    1. Ivanova G, Shamalov N, Melnikova E, Belkin A, Khasanova D, Prokopenko S, et al. Results of large clinical trial 'development of medical rehabilitation in Russia': patient-oriented, multidisciplinary and problem-focused model of rehabilitation patients with stroke or cerebral hemorrhage. European Stroke Journal 2018;3(1 Suppl 1):54.

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Publication types

Associated data