Pathways show better care for patients with stroke

Stroke occurs when the blood supply to the brain is cut off, resulting in cell damage and death due to lack of oxygen and nutrients. Facial weakness, arm weakness, difficulty with speech and time to call emergency services (FAST test) are the most common signs of stroke. A stroke can happen in two main ways: either when a blood vessel is blocked by a blood clot or plaque, termed ischemic stroke or when a blood vessel is ruptured, known as hemorrhagic stroke. A transient ischemic attack (TIA) or mini stroke is caused by a temporary blood clot and is indicative of a more serious risk of a future stroke.

Stroke is a major public health problem worldwide and the third leading cause of death in the United States. The incidence of stroke is high in EU  countries with a prevalence at 1.5% in Italy and 3% in the UK. The American Stroke Association (ASA), a division of the American Heart Association (AHA), published recommendations to promote coordinated systems that improve patient care in 2005. The Helsingborg Declaration 2006 on European Stroke Strategies reported on evidence-based care and evaluated different models of stroke services. Furthermore, in 2010 the Australian National Stroke Foundation published clinical guidelines that all stroke patients admitted to hospital be managed using a clinical pathway. These are structured, multidisciplinary plans of care designed to improve the continuity and co-ordination of care. However, there is little prospective data on their effectiveness.

A multicenter cluster randomized control trial published recently in BMC Medicine determined the impact of a program of structured care for patients with ischemic stroke. The Clinical Pathways for Effective and Appropriate Care (CPEAC) study compared 236 patients receiving clinical pathway directed care with 238 patients receiving usual care from 14 hospital units in several regions in Italy. The results showed that patients receiving clinical pathway based care had lower 7 day mortality and had a higher likelihood of returning to daily life, compared with those receiving usual care. Additionally, the 30-day mortality was lower in the patient group receiving the intervention compared with the control group but the difference did not reach significance.  Organized care and the variety of care was more frequently utilized by patients in the experimental group compared with those in the control group. Furthermore, compared with usual care the proportion of patients receiving organized care was significantly higher in the group on the intervention.

The findings from the study are in favor of clinical pathways that help provide a better, comprehensive and specialized care to patients affected by stroke. Patients’ satisfaction, quality of life, cost-effectiveness and the use of reperfusion therapy were not evaluated in the study. Thus further studies are required as suggested by the authors. Overall, clinical pathways were found to be more effective than usual care for treating stroke patients in hospital, providing prospective evidence for their usefulness.

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