Does implementation of a standardized pathway of stroke care affect functional outcome after stroke?

 WRONG GOAL!  survivors want a pathway to recovery, NOT 'CARE' Do you not understand what stroke survivors want?

Does implementation of a standardized pathway of stroke care affect functional outcome after stroke?

Elin Bergh https://orcid.org/0000-0001-6947-9011 elin.josefina.bergh@ahus.no, Torunn Askim, […], Ole Morten Rønning https://orcid.org/0000-0001-5080-5788, Jurate Šaltyteė Benth, Hild Fjærtoft, and Bente Thommessen https://orcid.org/0000-0002-8665-1108, +3 -3View all authors and affiliations

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https://doi.org/10.1177/17474930221126592

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Abstract

Background:

A stroke care pathway (SCP) was introduced in Norway in 2018. The goal of the pathway was to avoid delay in treatment and diagnostics of acute stroke and to secure treatment according to national guidelines. In this study, we aimed to evaluate how the implementation of the SCP affects outcome after stroke.

Methods:

We performed a register-based study using data from the Norwegian Stroke Register that covers 87% of acute stroke patients in Norway. Patients included 1 year before and 1 year after the introduction of the care pathway were compared (2017 vs 2019). Change in functional outcome, the proportion of independent patients 90 days post-stroke, discharge destination, proportions admitted to stroke units and 90 days mortality were compared. Functional outcome was measured using modified Rankin Scale (mRS) and functional independence was defined as mRS 0–2.

Results:

In total, 11,009 patients with 90 days follow-up data were analyzed. Comparing the cohorts from 2017 and 2019, there was no change in demographics or stroke characteristics. No statistically significant differences in mRS, admission to thrombolysis time, or 90 days mortality were found. However, the proportion of patients discharged directly home and treated in a stroke unit increased from 2017 to 2019.

Conclusion:

The implementation of a standardized pathway of stroke care in Norway did not lead to improvement in functional outcome or a reduction in 90 days mortality. (Because you didn't set it up to deliver results! Just 'care'.)However, the proportion of patients discharged directly home increased, and more patients were treated in stroke units in 2019 compared with 2017.

Introduction

Clinical care pathways have been introduced in different healthcare settings for many years to organize and standardize care processes. They are primarily implemented to improve the quality and efficiency of evidence-based treatment and to improve patient safety and satisfaction. Their effect is hard to evaluate due to widely different settings, clinical heterogeneity, and the use of different outcome measures.^1–4

The use of clinical care pathways in stroke treatment was initiated in the 1990s. More efficient and improved quality of stroke care and reduced variations in stroke treatment are listed as reasons for their implementation. Previous studies, including a Cochrane review from 2005 and a cluster randomized controlled trial study from Italy, show that the evidence of their effect on patient outcome is highly inconclusive.^3,5,6

In 2017, the Norwegian health authorities decided to establish a national standardized pathway of stroke care based on national guidelines for stroke treatment and diagnostics.^7,8 The aim of the stroke care pathway (SCP) was to ensure that patients with acute stroke would receive well organized and predictable care without non-medical delay in assessment, diagnostics, or treatment. In addition, the SCP intended to reduce variations in stroke care throughout the country. Previous reports from the Norwegian Stroke Register (NSR) and studies from other countries show differences in care based on geography, urban-rural localization, and demographics. The SCP was implemented in 2018.^9–11

In the present study, we evaluate the period from suspicion of acute stroke to the patient is ready to be discharged from hospital. The pathway is organized in phases, and each phase has a recommended target time. The goal is to ensure compliance with the target times and to avoid delay in treatment of acute stroke. The SCP is centered on procedures with significant effect on stroke outcome such as reperfusion therapy and treatment in a stroke unit. As reperfusion therapy is highly time dependent and surgery of symptomatic carotid stenosis is recommended as early as possible and preferably within 2 weeks target times regarding these treatments are highlighted (see supplementary Table 1).^12–14

The aim of our study was to evaluate if the introduction of this SCP had an impact on functional outcomes and 90 days mortality after stroke. In addition, we aimed at comparing the proportion of patients admitted to a dedicated stroke unit and proportions discharged directly home in 2019 versus 2017.

Our primary hypothesis was that patients admitted to hospital with the diagnosis of acute stroke the year after the introduction of the pathway (2019) would have significantly better function compared with those admitted the year prior to the introduction (2017).

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