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?
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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