In-Hospital Care Pathways for, Stroke
2005; Lippincott Williams & Wilkins; Volume: 36; Issue: 6 Linguagem: Inglês
10.1161/01.str.0000165900.79946.55
ISSN1524-4628
AutoresJoseph Kwan, Peter Sandercock,
Tópico(s)Biomedical Text Mining and Ontologies
ResumoHomeStrokeVol. 36, No. 6In-Hospital Care Pathways for, Stroke Free AccessReview ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessReview ArticlePDF/EPUBIn-Hospital Care Pathways for, StrokeAn Updated Systematic Review Joseph Kwan and Peter Sandercock Joseph KwanJoseph Kwan From the Elderly Care Research Unit (J.K.), University of Southampton, Southampton General Hospital, Southampton, UK; and the Department of Clinical Neurosciences (P.S.), University of Edinburgh, Western General Hospital, Edinburgh, UK. and Peter SandercockPeter Sandercock From the Elderly Care Research Unit (J.K.), University of Southampton, Southampton General Hospital, Southampton, UK; and the Department of Clinical Neurosciences (P.S.), University of Edinburgh, Western General Hospital, Edinburgh, UK. Originally published28 Apr 2005https://doi.org/10.1161/01.STR.0000165900.79946.55Stroke. 2005;36:1348–1349Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: April 28, 2005: Previous Version 1 Care pathways are structured care plans that are used by the different members of the multidisciplinary team and are usually implemented to manage more than one aspect of patient care (eg, diagnosis, investigation, acute stroke treatment). When used within a case management framework, care pathways can assist health care professionals with clinical decision-making, and they aim to promote organized and efficient patient care that is based on the best-available research evidence and clinical guidelines.1,2 A care pathway can take the form of a printed or electronic document, and it often replaces the patient's case record for the duration of the hospital stay. Many hospitals have adopted this tool, often as one of the components of a continuous quality improvement scheme, with an aim to improve the quality of stroke care, reduce variation of standards, minimize resource utilization, and educate health care staff.3,4 But is there sufficient evidence to support the use of care pathways for the management of stroke patients?The first Cochrane review of in-hospital care pathways for stroke found some evidence that care pathways may increase the use of certain investigations and reduce the likelihood of urinary tract infections and readmission to hospital.5 However, this benefit might be at the expense of a lower quality of life scores and patient satisfaction. The original Cochrane review has recently been updated with the inclusion of several more recent clinical studies. This article summarizes the findings of the updated Cochrane review.6Materials and MethodsWe searched the Cochrane Stroke Group Trials Register (last searched in June 2003), Cochrane Central Register of Controlled Trials (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, when it ceased to exist). We also hand-searched 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). We also checked the reference lists of articles retrieved from these searches. We considered all randomized and nonrandomized clinical studies that compared care pathway care with standard medical care.ResultsSince the original Cochrane review,5 5 new nonrandomized studies have been found and their findings are included.7–11 In total, we included 3 randomized controlled trials (total of 340 patients) and 12 nonrandomized studies (total of 4081 patients).2,3,7–19 Seven of the care pathways were implemented for acute stroke management, 3 were for stroke rehabilitation, and 5 were for combined acute stroke management and rehabilitation.There was significant statistical heterogeneity in the analysis of many of the outcomes. In summary, we found no significant difference between care pathway and control groups in terms of death or discharge destination. However, patients managed with a care pathway were more dependent at discharge (weighted mean difference in functional independence measure −3.8; 95% confidence interval [CI], −7.3 to −0.2; P=0.04). Evidence from mainly nonrandomized studies suggested that patients managed with a care pathway might be: (1) less likely to have a urinary tract infection (odds ratio, 0.51; CI, 0.34 to 0.79); (2) less likely to be readmitted to hospital (odds ratio, 0.11; CI, 0.03 to 0.39); and (3) more likely to have a computed tomography brain scan (odds ratio, 2.42; CI, 1.12 to 5.25). Evidence from randomized 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). We also found that the quality of documentation (of hospital care) was significantly more comprehensive in the care pathway group.Six studies (2 randomized and 4 nonrandomized) assessed length of stay. The 2 randomized studies showed a non-significant trend toward a longer mean length of stay in care pathway group.14,19 By contrast, the 4 nonrandomized studies showed that mean length of stay was significantly shorter in the care pathway group.7,8,16,17 The aggregate result showed a nonsignificant trend toward shorter mean length of hospital stay in the care pathway group.Five studies (2 randomized and 3 nonrandomized) assessed hospitalization costs. One randomized study found no significant difference in hospitalization cost between the 2 groups,14 and another randomized study found a lower mean hospitalization cost in the care pathway group.18 Three nonrandomized studies found a fall in the mean hospitalization cost.12,13,16Lastly, no significant differences were found between the 2 groups in terms of: (1) therapy input; (2) other medical complications (eg, pneumonia, seizures, dehydration, deep vein thrombosis); (3) other investigations (eg, carotid duplex scanning, echocardiography); and (4) certain procedures (eg, use of intravenous fluids, urinary catheterization).ConclusionLike the original Cochrane review,5 this updated review has included both randomized and nonrandomized studies.6 Readers must therefore be extremely cautious when interpreting the results because of the potential for bias and confounding, and the significant statistical heterogeneity between the studies.In this updated review, we found no evidence that care pathway care provided significant additional benefit over standard medical care in terms of major clinical outcomes (death or discharge destination). In fact, there was some evidence from one randomized14 and one nonrandomized study8 that patients in the care pathway group were significantly more dependent on discharge. Nevertheless, there is weak evidence that care pathway might be associated with fewer urinary tract infections and readmissions, and more comprehensive use of computed tomography brain scans. The impact of care pathway care on length of stay and hospitalization costs remains unclear, and more detailed research in this area might be helpful.Impact on PracticeStudies have found advantages and disadvantages associated with this complex intervention. Because many of the results were derived from nonrandomized studies, they may be influenced by potential biases and confounding factors. In the meantime, the most important element of stroke management in hospital remains to be organized stroke unit care with rehabilitation. However, there is still insufficient high-quality evidence to support the routine implementation of care pathways for acute stroke or stroke rehabilitation.Note: The full text of this review is available in the Cochrane Library (for subscribers http://www3.interscience.wiley.com/cgi-bin/mrwhome/106568753/HOME). The full article should be cited as: Kwan J, Sandercock P. In-hospital care pathways for stroke. The Cochrane Database of Systematic Reviews 2004. Issue 4.FootnotesCorrespondence to Dr Joseph Kwan, Elderly Care Research Unit, Level E (MP 807), Southampton General Hospital, Tremona Road, Southampton, SO16 6YD, UK. E-mail [email protected] References 1 Lanska DJ. The role of clinical pathways in reducing the economic burden of stroke. Pharmacoeconomics. 1998; 14: 151–158.CrossrefMedlineGoogle Scholar2 Baker CM, Miller I, Sitterding M, Hajewski CJ. Acute stroke patients comparing outcomes with and without case management. Nurs Case Manag. 1998; 3: 196–203.MedlineGoogle Scholar3 Pasquarello MA. Measuring the impact of an acute stroke program on patient outcomes. J Neurosci Nurs. 1990; 22: 76–82.CrossrefMedlineGoogle Scholar4 Every NR, Hochman J, Becker R, Kopecky S, Cannon CP. Critical pathways. Circulation. 2000; 101: 461–465.CrossrefMedlineGoogle Scholar5 Kwan J, Sandercock P. In-hospital care pathways for stroke: a Cochrane systematic review. Stroke. 2003; 34: 587–588.LinkGoogle Scholar6 Kwan J, Sandercock P. In-hospital care pathways for stroke (Cochrane Review). Cochrane Database Syst Rev. Chichester, UK: John Wiley & Sons, Ltd. 2004;Issue 4.Google Scholar7 Kwan J, Hand P, Dennis M, Sandercock P. Effects of introducing an integrated care pathway in an acute stroke unit. Age Ageing. 2004; 33: 362–367.CrossrefMedlineGoogle Scholar8 Mosimaneotsile B, Raun K, Tokishi C. Stroke patient outcomes: does an integrated delivery model of care make a difference? Physical and Occupational Therapy in Geriatrics. 2000; 17: 67–82.CrossrefGoogle Scholar9 Wee AS, Cooper WB, Chatham RK, Cobb AB, Murphy T. The development of a stroke clinical pathway: an experience in a medium-sized community hospital. J Miss State Med Assoc. 2000; 41: 648–653.MedlineGoogle Scholar10 Widjaja LS, Chan BP, Chen H, Ong BKC, Pang YT. Variance analysis applied to a stroke pathway: how this can improve efficiency of healthcare delivery. Ann Acad Med Singapore. 2002; 31: 425–430.MedlineGoogle Scholar11 Wilkinson G, Parcell M, McDonald A. Finalist: ACHS Quality Improvement Award. Cerebrovascular accident clinical pathway. J Qual Clin Pract. 2000; 20: 109–112.CrossrefMedlineGoogle Scholar12 Bowen J, Yaste C. Effect of a stroke protocol on hospital costs of stroke patients. Neurology. 1994; 44: 1961–1964.CrossrefMedlineGoogle Scholar13 Crawley WD. Case management: improving outcomes of care for ischaemic stroke patients. Medsurg Nurs. 1996; 5: 239–244.MedlineGoogle Scholar14 Falconer JA, Roth EJ, Sutin JA, Strasser DC, Chang RW. The critical path method in stroke rehabilitation: lessons from an experiment in cost containment and outcome improvement. Qual Rev Bull. 1993; 19: 8–16.CrossrefMedlineGoogle Scholar15 Hamrin EKF, Lindmark B. The effect of systematic care planning after acute stroke in general hospital medical wards. J Advanced Nurs. 1990; 15: 1146–1153.CrossrefMedlineGoogle Scholar16 Odderson IR, McKenna BS. A model for management of patients with stroke during the acute phase. Outcome and economic implications. Stroke. 1993; 24: 1823–1827.CrossrefMedlineGoogle Scholar17 Ross G, Johnson D, Kobernick M. Evaluation of a critical pathway for stroke. J Am Osteopath Assoc. 1997; 97: 269–266.CrossrefMedlineGoogle Scholar18 Schull DE, Tosch P, Wood M. Clinical nurse specialists as collaborative care managers. Nurs Manage. 1992; 23: 30–33.Google Scholar19 Sulch D, Perez I, Melbourn A, Kalra L. Randomized controlled trial of integrated (managed) care pathway for stroke rehabilitation. Stroke. 2000; 31: 1929–1934.CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Holt K, Niazi I, Amjad I, Kumari N, Rashid U, Duehr J, Navid M, Shafique M and Haavik H (2021) The Effects of 4 Weeks of Chiropractic Spinal Adjustments on Motor Function in People with Stroke: A Randomized Controlled Trial, Brain Sciences, 10.3390/brainsci11060676, 11:6, (676) Wilhelm H, Bullinger B and Chromik J (2019) White Coats at the Coalface: The Standardizing Work of Professionals at the Frontline, Organization Studies, 10.1177/0170840619862833, 41:8, (1169-1200), Online publication date: 1-Aug-2020. 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June 2005Vol 36, Issue 6 Advertisement Article InformationMetrics https://doi.org/10.1161/01.STR.0000165900.79946.55 Manuscript receivedOctober 9, 2004Manuscript acceptedOctober 13, 2004Originally publishedApril 28, 2005 PDF download Advertisement
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