Current issues of ACP Journal Club are published in Annals of Internal Medicine


Therapeutics

Stroke units for rehabilitation after acute care reduced death and dependence

ACP J Club. 1998 Sep-Oct;129:29. doi:10.7326/ACPJC-1998-129-2-029


Source Citation

Rønning OM, Guldvog B. Outcome of subacute stroke rehabilitation. A randomized controlled trial. Stroke. 1998 Apr;29:779-84.


Abstract

Question

For patients in the subacute phase of rehabilitation after a stroke, is hospital rehabilitation in a stroke unit (SU) as effective as municipality-based health care for reducing death and dependence and increasing health-related quality of life?

Design

Randomized controlled trial with 7-month follow-up.

Setting

A 6-bed SU in a catchment area of 20 municipalities in Norway with a total population of 291 905.

Patients

550 patients with confirmed acute stroke were screened, and 251 were studied. Inclusion criteria were age ≥ 60 years, Scandinavian Stroke Scale (SSS) score between 12 and 52, hospitalization within 24 hours of stroke, being conscious on admission, and ability to participate in the rehabilitation program. Patients admitted from nursing homes were excluded.

Intervention

All patients received acute stroke care in an SU or general medical ward. 127 patients were then allocated to rehabilitation care in an SU that provided multidisciplinary care, planning, and education for patient and family from a team of nurses; physical, occupational, and speech therapists; a social worker; and a neurologist. The remaining 124 patients were allocated to municipality-based care that provided nursing home rehabilitation with inpatient or day-patient care and further home rehabilitation from nurses and physical and speech therapists.

Main outcome measures

Death, need for long-term care, and number of disabled patients (Barthel Index [BI] score < 75). Secondary outcomes were neurologic deficits, functional disability, and quality of life.

Main results

Fewer patients in the SU group were dependent or dead at 7 months than in the municipal care group (P = 0.01) (Table). The groups did not differ for death (9.4% for the hospital group vs 16.1% for the municipal group, P = 0.11), need for long-term care (12.6% vs 10.5%, P = 0.6), dependence (14.8% vs 25.0%, P = 0.07), or quality of life. Subgroup analysis showed that SU patients with a BI score < 50 at baseline had lower rates of dependence (21% vs 50%, P = 0.005) and dependence or death (32% vs 62%, P = 0.002). More SU patients with a BI score ≥ 50 at baseline needed long-term care (11% vs 1.5%, P = 0.02).

Conclusions

Patients who received rehabilitation after stroke in a hospital-based, multi-disciplinary stroke unit had a lower rate of death or dependence at 7 months. Subgroup analysis showed that patients with moderate or severe stroke had greater benefits.

Source of funding: National Association for Heart and Vascular Diseases.

For correspondence: Dr. O.M. Rønning, Department of Neurology, Central Hospital of Akershus, 1474 Nordbyhagen, Norway. FAX 47-67-92-94-69.


Table. Stroke unit rehabilitation program vs municipality-based care for stroke*

Outcome at 7 mo Stroke unit Municipal care RRR (95% CI) NNT (CI)
Death or dependence 23.3% 38.4% 39.2% (9.8 to 59.4) 7 (4 to 31)

*Abbreviations defined in Glossary; RRR, NNT, and CI calculated from data in article.


Commentary

Dedicated acute SUs improve survival and functional outcome compared with general medical wards (1). Rønning and Guldvog examined whether continued hospital rehabilitation led to better outcomes than municipality-based care. In particular, patients with more disability (BI score < 50) generally have more medical complications and a lower rate of death or dependence when treated in the hospital. This justifies the use of coordinated hospital-based interdisciplinary care for these patients.

Although patients who received hospital-based rehabilitation had better outcomes in this trial, a subgroup with higher BI scores at admission required long-term care more often than did the control group. These inconsistent results are difficult to interpret because the control group received widely varied treatments at different intensities and in different settings. A more consistent control intervention would have facilitated interpretation of the study findings.

The various hospital settings used for stroke rehabilitation are not easily comparable among countries. Therapeutic intensity (the amount of time spent with therapists) is a more comparable independent variable. Subacute rehabilitation in this study constituted hospital-based rehabilitation care after acute medical and neurologic management. In the United States, "subacute" rehabilitation refers to coordinated rehabilitation care (< 3 h/d) in a skilled nursing facility, whereas "acute" rehabilitation (≥ 3 h/d) occurs in medical or free-standing hospitals. A recent prospective study indicated that for patients with stroke, acute rehabilitation results in better functional outcome than subacute rehabilitation (2). Additional clinical studies are needed to define and control the intensity of rehabilitation, nursing, and medical care to clarify what constitutes cost-effective rehabilitation for patients with stroke.

Richard L. Harvey, MD
The Rehabilitation Institute of ChicagoChicago, Illinois, USA


References

1. Stroke Unit Trialists' Collaboration. Collaborative systematic review of the randomised trials of organised inpatient (stroke unit) care after stroke. BMJ. 1997;314:1151-9.

2. Kramer AM, Steiner JF, Schlenker RE, et al. Outcomes and costs after hip fracture and stroke. A comparison of rehabilitation settings. JAMA. 1997;277:396-404.