Key message: people who have a stroke are more likely to be alive, be at home and be independent after a year if they are cared for in a stroke unit
We probably all know someone who’s had a stroke, which is now the second leading cause of death and the third most common cause of disability worldwide. Many of us have followed broadcaster Andrew Marr’s progress in the wake of the stroke he had, aged 53, earlier this year and his wife, Jackie Ashley, caught the attention of many with her recent Guardian blog on their experience of this devastating event. She deemed the NHS to be “wonderful, wonderful, wonderful” and paid tribute to the health professionals who helped get her husband back on his feet, but pointed to the void in support offered by community services after intensive and generally excellent care in hospital. Not all hospital care is equal either, of course, and the type of care offered in hospital after acute stroke can make all the difference to whether, and how well, the person recovers.
A review from the Cochrane Stroke Group on organised inpatient (stroke unit) care has been updated and not only includes four new randomized controlled trials (RCTs) but also an individual patient data meta-analysis of all 28 RCTs with almost 6000 people. Organised care for people after stroke has undergone significant change over the years in many developed countries and the more recent trials have explored different types of provision. 21 RCTs (3994 people) compared stroke unit care with care given in general wards. There are various models of stroke unit care but the core characteristic of this approach was co-ordinated care by a multi-disciplinary team of medical, nursing and therapy staff (usually physiotherapists, speech therapists and social workers) who met at least once a week. Stroke unit care may be offered in a dedicated stroke ward, mixed rehabilitation ward or through a mobile stroke team.
What did they find?
A year after having a stroke, people cared for in stroke units were
- more likely to be alive
- more likely to be independent
- more likely to be at home
- not in hospital for longer
These outcomes were independent of age, sex, severity of stroke and stroke type. The benefits were most apparent when stroke units were based in a discrete ward. The three trials which followed people up for five to ten years found a lasting benefit for people treated in stroke units.
How good was the evidence?
- Some trials were judged to be at high risk of bias; when the analysis was limited to the seven low risk trials the improvement in survival associated with stroke unit care was no longer statistically significant so this effect may have been overestimated
- Most trials were performed in high income countries so the results may not apply to different settings
Here in the UK, the National Institute for Health and Care Excellence (NICE) recently issued a new guideline on rehabilitation after stroke, which cites this and four other Cochrane reviews. Among the key priorities for implementation, as highlighted in the press release, is that ‘people with residual disability after stroke should receive rehabilitation in a dedicated stroke inpatient rehabilitation unit and subsequently from a specialist stroke team within the community’. The review is also one of 32 Cochrane reviews which have informed the Scottish Intercollegiate Guidelines Network (SIGN) guideline on stroke management and rehabilitation. You can find both guidelines from the links below.
Andrew Marr himself has been full of praise for the NHS and the treatment he received. It’s good to have the further evidence this review update offers that specialist stroke unit care really does aid recovery. What we need to know now is just how stroke units may improve patient outcomes as this is something the review can’t explain. Possibilities include staff expertise, better nursing care or more effective rehabilitation procedures, for example. Let’s hope future research will explore which are the important components so that care for people after stroke can get better and better.
Stroke Unit Trialists’ Collaboration. Organised inpatient (stroke unit) care for stroke. Cochrane Database of Systematic Reviews 2013, Issue 9. Art. No.: CD000197. DOI: 10.1002/14651858.CD000197.pub3.
Jackie Ashley. Caring for my stroke victim husband Andrew Marr changed my life. The Guardian, 1 August 2013.
Andrew Marr, after the stroke: “I’m going to be sweeter all round”. The Observer, 4 August 2013.
National Clinical Guideline Centre; National Institute for Health and Care Excellence (commissioner). Stroke rehabilitation: long term rehabilitation after stroke. London: National Clinical Guideline Centre, Royal College of Physicians; 2013 (NICE CG162). [Issued June 2013]. Available from URL: http://guidance.nice.org.uk/CG162
Scottish Intercollegiate Guidelines Network (SIGN). Management of patients with stroke: rehabilitation, prevention and management of complications, and discharge planning. Edinburgh: SIGN; 2010. (SIGN publication no. 118). [cited June 2010]. Available from URL: http://www.sign.ac.uk/guidelines/fulltext/118/index.html