In-Hospital Care Pathways for Stroke: A Cochrane Systematic Review
2003; Lippincott Williams & Wilkins; Volume: 34; Issue: 2 Linguagem: Inglês
10.1161/01.str.0000054673.28010.1b
ISSN1524-4628
AutoresJoseph Kwan, Peter Sandercock,
Tópico(s)Healthcare Systems and Practices
ResumoHomeStrokeVol. 34, No. 2In-Hospital Care Pathways for Stroke: A Cochrane Systematic Review Free AccessReview ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessReview ArticlePDF/EPUBIn-Hospital Care Pathways for Stroke: A Cochrane Systematic Review Joseph Kwan and Peter Sandercock Joseph KwanJoseph Kwan From the Department of Medicine for the Elderly (J.K.), Princess Margaret Hospital, Wiltshire, and the Department of Clinical Neurosciences (P.S.), Western General Hospital, Edinburgh, UK. and Peter SandercockPeter Sandercock From the Department of Medicine for the Elderly (J.K.), Princess Margaret Hospital, Wiltshire, and the Department of Clinical Neurosciences (P.S.), Western General Hospital, Edinburgh, UK. Originally published30 Jan 2003https://doi.org/10.1161/01.STR.0000054673.28010.1BStroke. 2003;34:587–588Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: January 30, 2003: Previous Version 1 Care of stroke patients varies significantly between hospitals.1,2 Implementation of a stroke care pathway may be a method of promoting organized and efficient patient care that is based on the best-available evidence and clinical guidelines. This, in turn, could reduce variations in stroke care.A care pathway can be defined as a plan of care that is developed and used by a multidisciplinary team, and is applicable to more than 1 aspect of care. It can be a printed document or an electronic program, and it usually forms all or part of the patient's case record. Care pathways are often used in conjunction with other tools such as case management, and they are intended to assist healthcare professionals in clinical decision-making.3,4 Care pathways are also known by other names such as clinical pathway, critical pathway, critical path method, care paths, and CareMaps. Despite the popularity of care pathways, the evidence to support their use is weak. This systematic review aims to assess the effects of care pathways, as compared with standard medical care, among patients admitted to hospital with acute stroke.5MethodsWe searched the Cochrane Stroke Group Specialized Trials Register (last searched in May 2001), the Cochrane Controlled Trials Register (Issue 4, 2000), MEDLINE (1975 to 2000), EMBASE (1980 to 2000), CINAHL (1982 to 2000), the Index to Scientific and Technical Proceedings (ISTP, May 2001), and HealthSTAR (May 2001). We also handsearched the Journal of Managed Care (1997 to 1998), which was later renamed the Journal of Integrated Care (1998 to 2001). The reference lists of the retrieved articles were also searched.We considered randomized controlled trials and nonrandomized studies (quasi-randomized trials, comparative studies, before and after studies, and interrupted time series) that compared care pathway care with standard medical care. One reviewer selected the studies for inclusion and the other independently checked the decisions. Two reviewers independently assessed the methodological quality of the studies. One reviewer then extracted the data and the other checked the extracted data. We found significant statistical heterogeneity in the analysis of 2 of the 24 outcomes studied (computed tomography [CT] brain scanning, length of stay).ResultsWe included 3 randomized controlled trials (total of 340 patients)6–8 and 7 nonrandomized studies (total of 1673 patients).9–15 We found no significant difference between care pathway and control groups in terms of death, dependency, or discharge destination. Evidence from mainly nonrandomized studies suggests that stroke patients managed using a care pathway may be (a) less likely to suffer a urinary tract infection (OR 0.38, CI 0.18 to 0.79); (b) less likely to be readmitted to hospital (OR 0.11, CI 0.03 to 0.39); and (c) more likely to have a CT brain scan (OR 3.66, CI 1.45 to 9.27) or carotid duplex study (OR 2.45, CI 1.3 to 4.61). Evidence from randomized trials suggests that patient satisfaction and quality of life may be significantly lower in the care pathway group (P=0.02 and P<0.005 respectively). There was no significant difference in the length of stay between the 2 groups.DiscussionThe results of this review should be interpreted with caution because nonrandomized studies, which are highly susceptible to bias, have been included. Sources of biases include selection of patients; retrospective data collection; inclusion of nonconsecutive cases; lack of blinding of the investigators who assessed the outcomes; tendency for investigators to report only positive results; and publication bias. Factors that limited the reliability of the results of this review include variations in the definition and components of the intervention; the small number of studies included in data analysis; and presence of significant heterogeneity between the studies.Data, chiefly from nonrandomized studies, provided weak evidence that care pathways may improve the process of care, hence leading to fewer complications (urinary tract infections and hospital readmissions) and more thorough investigations (more CT brain scans and carotid duplex studies). However, care pathway care may be associated with lower patient satisfaction and quality of life. The reasons for these adverse effects are unclear, but if the aim of the care pathways in these studies was to shorten the length of stay in hospital, then there may be pressure on the staff to discharge the patients as soon as possible, which could be before they were ready for discharge.In this review, 4 studies7,10,12,15 reported a reduction in the mean hospital cost, and 1 study found no significant difference in cost.6 Only 1 study reported the items of costs and their individual values.6 Without knowing the cost of the individual items for these 5 studies, it was impossible to perform quantitative meta-analysis of the cost data.In this brief summary, it is not possible to give the full details of the analyses on the 24 outcomes studied, or to include any graphs. Full details and all the graphical plots are available in the version of this review published in the Cochrane Library.5 Many hospital and university libraries now provide free online access to the Cochrane Library; subscription details are available at http://www.update-software.com/Cochrane/and reprints of the full article can be obtained from the Update Software document delivery service (http://www.updateusa.com/document_delivery/Doc-delivery.html).Implications for PracticeThe use of care pathways to manage stroke patients in hospital may be associated with both positive and negative effects on the process of care and clinical outcomes. Since most of the results have been derived from nonrandomized studies, they are likely to be influenced by potential biases and confounding factors. There is currently insufficient supporting evidence to justify routine implementation of care pathways for acute stroke management or stroke rehabilitation in hospital.Implications for ResearchFurther research is necessary before widespread implementation of stroke care pathways is recommended. In particular, well-conducted randomized and nonrandomized studies should be undertaken. More information is needed on the effects of care pathways on functional outcomes; process of care; quality of life; patient and carer satisfaction; implementation of evidence-based practice; and hospital cost. Qualitative research may also provide information on the best method of design, implementation, and evaluation of care pathways.Section Editor: Graeme J. Hankey, MD, FRACPFootnotesCorrespondence to Dr Joseph Kwan, Department of Medicine for the Elderly, Princess Margaret Hospital, Okus Road, Swindon, Wiltshire, SN1 4JU, UK. E-mail: [email protected] References 1 Ebrahim S, Redfern J. Stroke care: a matter of chance: a national survey of stroke services. London: The Stroke Association; 1999.Google Scholar2 Rudd AG, Irwin P, Rutledge Z, Lowe D, Wade D, Morris R, Pearson MG. The national sentinel audit for stroke: a tool for raising standards of care. J R Coll Physicians Lond. 1999; 33: 460–464.MedlineGoogle Scholar3 Hydo B. Designing an effective clinical pathway for stroke. Am J Nurs. 1995; 95: 44–50.Google Scholar4 Lanska DJ. The role of clinical pathways in reducing the economic burden of stroke. Pharmacoeconomics. 1998; 14: 151–158.CrossrefMedlineGoogle Scholar5 Kwan J, Sandercock P. In-hospital care pathways for stroke (Cochrane systematic review). In: The Cochrane Library, Issue 2, 2002. Oxford: Update Software; 2002.Google Scholar6 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 Scholar7 Schull DE, Tosch P, Wood M. Clinical nurse specialists as collaborative care managers. Nurs Manage. 1992; 23: 30–33.Google Scholar8 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 Scholar9 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 Scholar10 Bowen J, Yaste C. Effect of a stroke protocol on hospital costs of stroke patients. Neurology. 1994; 44: 1961–1964.CrossrefMedlineGoogle Scholar11 Hamrin EKF, Lindmark B. The effect of systematic care planning after acute stroke in general hospital medical wards. J Adv Nurs. 1990; 15: 1146–1153.CrossrefMedlineGoogle Scholar12 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 Scholar13 Pasquarello MA. Measuring the impact of an acute stroke program on patient outcomes. J Neurosci Nurs. 1990; 22: 76–82.CrossrefMedlineGoogle Scholar14 Ross G, Johnson D, Kobernick M. Evaluation of a critical pathway for stroke. J Am Osteopath Assoc. 1997; 97: 269–272, 275–276.CrossrefMedlineGoogle Scholar15 Crawley WD. Case management: improving outcomes of care for ischemic stroke patients. Medsurg Nurs. 1996; 5: 239–244.MedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Lavin J, Corboy J, Katsogridakis Y, Pham O, Brinson D and Krug S (2023) Electronic medical record based tools: Not a panacea in the diagnosis of coin-shaped foreign bodies, International Journal of Pediatric Otorhinolaryngology, 10.1016/j.ijporl.2022.111410, 164, (111410), Online publication date: 1-Jan-2023. Rattray N, Damush T, Myers L, Perkins A, Homoya B, Knefelkamp C, Fleming B, Kingsolver A, Boldt A, Ferguson J, Zillich A and Bravata D (2022) Pharmacy program to improve care for veterans with transient ischaemic attack: a pilot implementation evaluation, BMJ Open Quality, 10.1136/bmjoq-2022-001863, 11:3, (e001863), Online publication date: 1-Sep-2022. Studer A, Billings K, Thompson D, Ida J, Rastatter J, Patel M, Huetteman P, Hoeman E, Duggan S, Mudahar S, Birmingham P, King M and Lavin J (2020) Standardized Order Set Exhibits Surgeon Adherence to Pain Protocol in Pediatric Adenotonsillectomy, The Laryngoscope, 10.1002/lary.29314, 131:7, Online publication date: 1-Jul-2021. CECCHI F, DIVERIO M, ARIENTI C, CORBELLA E, MARRAZZO F, SPERANZA G, DEL ZOTTO E, POGGIANTI G, GIGLIOTTI F, POLCARO P, ZINGONI M, ANTONIOLI D, AVILA L, BARILLI M, ROMANO E, LANDUCCI PELLEGRINI L, GAMBINI M, VERDESCA S, BERTOLUCCI F, MOSCA I, GEMIGNANI P, PAPERINI A, CASTAGNOLI C, HOCHLEITNER I, LUISI M, LUCIDI G, HAKIKI B, GABRIELLI M, FRUZZETTI M, BRUZZI A, BACCI BONOTTI E, PANCANI S, GALERI S, MACCHI C and APRILE I Development and implementation of a stroke rehabilitation integrated care pathway in an Italian no profit institution: an observational study, European Journal of Physical and Rehabilitation Medicine, 10.23736/S1973-9087.20.06195-X, 56:6 Ng S, Rahman N, Ang I, Sridharan S, Ramachandran S, Wang D, Tan C, Toh S and Tan X (2019) Characterization of high healthcare utilizer groups using administrative data from an electronic medical record database, BMC Health Services Research, 10.1186/s12913-019-4239-2, 19:1, Online publication date: 1-Dec-2019. Steigleder T, Kollmar R and Ostgathe C (2019) Palliative Care for Stroke Patients and Their Families: Barriers for Implementation, Frontiers in Neurology, 10.3389/fneur.2019.00164, 10 Lavin J, Wiedermann J, Sals A, Kato K, Brinson D, Nytko A, Katsogridakis Y, Krug S and Ida J (2018) Electronic medical record-based tools aid in timely triage of disc-shaped foreign body ingestions, The Laryngoscope, 10.1002/lary.27279, 128:12, (2697-2701), Online publication date: 1-Dec-2018. Quadri S, Huynh T, Cappelen-Smith C, Wijesuriya N, Mamun A, Beran R, McDougall A and Cordato D (2018) Reflection on stroke deaths and end-of-life stroke care, Internal Medicine Journal, 10.1111/imj.13619, 48:3, (330-334), Online publication date: 1-Mar-2018. Sullivan D, Mannix M and Timmons S (2017) Integrated Care Pathways and Care Bundles for Dementia in Acute Care: Concept Versus Evidence, American Journal of Alzheimer's Disease & Other Dementiasr, 10.1177/1533317517698791, 32:4, (189-193), Online publication date: 1-Jun-2017. Inoue A, Kohno K, Iwata S, Ohue S, Ozaki S, Ninomiya S, Tomita H, Kamogawa K, Okamoto K, Fukumoto S, Ichikawa H, Onoue S, Nakamura Y and Okuda B (2017) Efficacy of Early Superficial Temporal Artery–Middle Cerebral Artery Double Anastomoses for Atherosclerotic Occlusion in Patients with Progressing Stroke, Journal of Stroke and Cerebrovascular Diseases, 10.1016/j.jstrokecerebrovasdis.2016.10.009, 26:4, (741-748), Online publication date: 1-Apr-2017. Hussain Z, Lim M and Stojkovic S (2017) Role of clinical pathway in improving the quality of care for patients with faecal incontinence: A randomised trial, World Journal of Gastrointestinal Pharmacology and Therapeutics, 10.4292/wjgpt.v8.i1.81, 8:1, (81), . Nakibuuka J, Sajatovic M, Nankabirwa J, Ssendikadiwa C, Kalema N, Kwizera A, Byakika-Tusiime J, Furlan A, Kayima J, Ddumba E, Katabira E and Quinn T (2016) Effect of a 72 Hour Stroke Care Bundle on Early Outcomes after Acute Stroke: A Non Randomised Controlled Study, PLOS ONE, 10.1371/journal.pone.0154333, 11:5, (e0154333) Deng Y, Jiao Y, Hu R, Wang Y, Wang Y and Zhao X (2014) Reduction of Length of Stay and Costs Through the Implementation of Clinical Pathways for Stroke Management in China, Stroke, 45:5, (e81-e83), Online publication date: 1-May-2014. Singh R, Venkateshwara G, Batterley J and Bruce S (2013) Early Rehabilitation in Head Injury; Can We Improve The Outcomes?, Archives of Trauma Research, 10.5812/atr.13665, 2:3 Lee S, Huh P, Kim D, Yoo D, Lee T and Cho K (2013) Early superficial temporal artery to middle cerebral artery bypass in acute ischemic stroke, Clinical Neurology and Neurosurgery, 10.1016/j.clineuro.2012.11.022, 115:8, (1238-1244), Online publication date: 1-Aug-2013. Singh R, Venkateshwara G, Kirkland J, Batterley J and Bruce S (2011) Clinical pathways in head injury: improving the quality of care with early rehabilitation, Disability and Rehabilitation, 10.3109/09638288.2011.608146, 34:5, (439-442), Online publication date: 1-Mar-2012. Lopez G, Afshinnik A and Samuels O (2011) Care of the Stroke Patient: Routine Management to Lifesaving Treatment Options, Neurotherapeutics, 10.1007/s13311-011-0061-1, 8:3, (414-424), Online publication date: 1-Jul-2011. Venketasubramanian N, Pwee K and Chen C (2011) Singapore Ministry of Health Clinical Practice Guidelines on Stroke and Transient Ischemic Attacks, International Journal of Stroke, 10.1111/j.1747-4949.2011.00602.x, 6:3, (251-258), Online publication date: 1-Jun-2011. Tsui E, Yamazaki T, Ikeda M and Umemoto K (2011) Enhancement of healthcare quality using clinical‐pathways activities, VINE, 10.1108/03055721111115557, 41:1, (63-75), Online publication date: 15-Feb-2011. Ringleb P, Bousser M, Ford G, Bath P, Brainin M, Caso V, Cervera Á, Chamorro A, Cordonnier C, Csiba L, Davalos A, Diener H, Ferro J, Hacke W, Hennerici M, Kaste M, Langhorne P, Lees K, Leys D, Lodder J, Markus H, Mas J, Mattle H, Muir K, Norrving B, Obach V, Paolucci S, Ringelstein E, Schellinger P, Sivenius J, Skvortsova V, Sunnerhagen K, Thomassen L, Toni D, Kummer R, Wahlgren N, Walker M and Wardlaw J (2010) Ischaemic Stroke and Transient Ischaemic Attack European Handbook of Neurological Management, 10.1002/9781444328394.ch9, (101-158) Ferrero E, Ferri M, Viazzo A, Gaggiano A, Ferrero M, Maggio D, Berardi G, Pecchio A, Piazza S, Cumbo P and Nessi F (2010) Early Carotid Surgery in Patients After Acute Ischemic Stroke: Is it Safe? A Retrospective Analysis in a Single Center Between Early and Delayed/Deferred Carotid Surgery on 285 Patients, Annals of Vascular Surgery, 10.1016/j.avsg.2010.03.014, 24:7, (890-899), Online publication date: 1-Oct-2010. Ferrero E, Ferri M, Viazzo A, Gaggiano A, Ferrero M, Maggio D, Berardi G, Pecchio A, Piazza S, Cumbo P and Nessi F (2010) Chirurgie carotidienne précoce chez des patients présentant un accident ischémique cérébral aigu : est-elle sûre? Une analyse rétrospective monocentrique comparant la chirurgie carotidienne précoce et retardée/différée chez 285 Patients, Annales de Chirurgie Vasculaire, 10.1016/j.acvfr.2011.05.013, 24:7, (968-977), Online publication date: 1-Oct-2010. Micieli G, Cavallini A, Quaglini S, Fontana G and Duè M (2010) The Lombardia Stroke Unit Registry: 1-year experience of a web-based hospital stroke registry, Neurological Sciences, 10.1007/s10072-010-0249-x, 31:5, (555-564), Online publication date: 1-Oct-2010. Yamazaki T and Umemoto K (2011) Knowledge Management of Healthcare by Clinical-Pathways, Journal of Information & Knowledge Management, 10.1142/S0219649210002577, 09:02, (119-125), Online publication date: 1-Jun-2010. Scott I (2009) What are the most effective strategies for improving quality and safety of health care?, Internal Medicine Journal, 10.1111/j.1445-5994.2008.01798.x, 39:6, (389-400), Online publication date: 1-Jun-2009. Fuentes B and Diez-Tejedor E (2009) Stroke Units: Many Questions, Some Answers, International Journal of Stroke, 10.1111/j.1747-4949.2009.00244.x, 4:1, (28-37), Online publication date: 1-Feb-2009. (2009) Geriatrische Rehabilitation Medizin des Alterns und des alten Menschen, 10.1007/978-3-7985-1727-1_15, (185-196), . Cameron J, Tsoi C and Marsella A (2008) Optimizing Stroke Systems of Care by Enhancing Transitions Across Care Environments, Stroke, 39:9, (2637-2643), Online publication date: 1-Sep-2008. Ringleb P, Schellinger P and Hacke W (2008) Leitlinien zum Management von Patienten mit akutem Hirninfarkt oder TIA der Europäischen Schlaganfallorganisation 2008European Stroke Organisation 2008 guidelines for managing acute cerebral infarction or transient ischemic attack, Der Nervenarzt, 10.1007/s00115-008-2531-1, 79:8, (936-957), Online publication date: 1-Aug-2008. Jinghua Shi , Qiang Su and Zhongsheng Zhao (2008) Critical factors for the effectiveness of clinical pathway in improving care outcomes 2008 International Conference on Service Systems and Service Management (ICSSSM 2008), 10.1109/ICSSSM.2008.4598529, 978-1-4244-1671-4, (1-6) Guidelines for Management of Ischaemic Stroke and Transient Ischaemic Attack 2008, Cerebrovascular Diseases, 10.1159/000131083, 25:5, (457-507) Hankey G (2008) Chapter 19 Costs and health care system issues Stroke, 10.1016/S0072-9752(08)01919-2, (373-388), . HAMA S, YAMASHITA H, SHIGENOBU M, WATANABE A, HIRAMOTO K, TAKIMOTO Y, ARAKAWA R, KURISU K, YAMAWAKI S and KITAOKA T (2007) Sitting balance as an early predictor of functional improvement in association with depressive symptoms in stroke patients, Psychiatry and Clinical Neurosciences, 10.1111/j.1440-1819.2007.01705.x, 61:5, (543-551), Online publication date: 1-Oct-2007. El Baz N, Middel B, van Dijk J, Oosterhof A, Boonstra P and Reijneveld S (2007) Are the outcomes of clinical pathways evidence-based? A critical appraisal of clinical pathway evaluation research, Journal of Evaluation in Clinical Practice, 10.1111/j.1365-2753.2006.00774.x, 0:0, (070821070410002-???) Dobesh P, Bosso J, Wortman S, Dager W, Karpiuk E, Ma Q and Zarowitz B (2006) Critical Pathways: The Role of Pharmacy Today and Tomorrow, Pharmacotherapy, 10.1592/phco.26.9.1358, 26:9, (1358-1368), Online publication date: 1-Sep-2006. Kwan J and Sandercock P (2005) In-Hospital Care Pathways for, Stroke, Stroke, 36:6, (1348-1349), Online publication date: 1-Jun-2005. Dy S, Garg P, Nyberg D, Dawson P, Pronovost P, Morlock L, Rubin H and Wu A (2005) Critical Pathway Effectiveness: Assessing the Impact of Patient, Hospital Care, and Pathway Characteristics Using Qualitative Comparative Analysis, Health Services Research, 10.1111/j.1475-6773.2005.0r370.x, 40:2, (499-516) Schwamm L, Pancioli A, Acker J, Goldstein L, Zorowitz R, Shephard T, Moyer P, Gorman M, Johnston S, Duncan P, Gorelick P, Frank J, Stranne S, Smith R, Federspiel W, Horton K, Magnis E and Adams R (2005) Recommendations for the Establishment of Stroke Systems of Care, Stroke, 36:3, (690-703), Online publication date: 1-Mar-2005.Schwamm L, Pancioli A, Acker J, Goldstein L, Zorowitz R, Shephard T, Moyer P, Gorman M, Johnston S, Duncan P, Gorelick P, Frank J, Stranne S, Smith R, Federspiel W, Horton K, Magnis E and Adams R (2005) Recommendations for the Establishment of Stroke Systems of Care, Circulation, 111:8, (1078-1091), Online publication date: 1-Mar-2005.Goldstein L and Amarenco P (2005) Prevention and Health Services Delivery, Stroke, 36:2, (222-224), Online publication date: 1-Feb-2005. Kwan J and Sandercock P (2004) In-hospital care pathways for stroke, Cochrane Database of Systematic Reviews, 10.1002/14651858.CD002924.pub2 Rudd A and Matchar D (2004) Health Policy and Outcome Research in Stroke, Stroke, 35:2, (397-400), Online publication date: 1-Feb-2004. Suzuki M, Imai A, Honda M, Kobayashi K and Ohtsuka S (2004) Role of a critical pathway for door-to-CT-completion interval in the management of acute ischemic stroke patients in the emergency room, The Keio Journal of Medicine, 10.2302/kjm.53.247, 53:4, (247-250), . Mirallas Martínez J (2004) Avances en la rehabilitación del paciente con enfermedad cerebrovascular, Rehabilitación, 10.1016/S0048-7120(04)73432-5, 38:2, (78-85), Online publication date: 1-Jan-2004. February 2003Vol 34, Issue 2 Advertisement Article InformationMetrics https://doi.org/10.1161/01.STR.0000054673.28010.1BPMID: 12574581 Manuscript receivedJune 20, 2002Manuscript acceptedJuly 5, 2002Originally publishedJanuary 30, 2003 PDF download Advertisement
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