COLLABORATIVE SYSTEMATIC REVIEW OF THE RANDOMIZED TRIALS OF ORGANIZEDINPATIENT (STROKE UNIT) CARE AFTER STROKE

Objectives: To define the characteristics and determine the effectiven ess of organised inpatient (stroke unit) care compared with convention al care in reducing death, dependency, and the requirement for long te rm institutional care after stroke. Design: Systematic review of all r andomised trials which compared organised inpatient stroke care with t he contemporary conventional care. Specialist stroke unit intervention s were defined as either a ward or team exclusively managing stroke (d edicated stroke unit) or a ward or team specialising in the management of disabling illnesses, which include stroke (mixed assessment/rehabi litation unit). Conventional care was usually provided in a general me dical ward. Setting: 19 trials (of which three had two treatment arms) . 12 trials randomised a total of 2060 patients to a dedicated stroke unit or a general medical ward, six trials (647 patients) compared a m ixed assessment/rehabilitation unit with a general medical ward, and f our trials (542 patients) compared a dedicated stroke unit with a mixe d assessment/rehabilitation unit. Main outcome measures: Death, instit utionalisation, and dependency. Results: Organised inpatient (stroke u nit) care, when compared with conventional care, was best characterise d by coordinated multidisciplinary rehabilitation, programmes of educa tion and training in stroke, and specialisation of medical and nursing staff. The stroke unit care was usually housed in a geographically di screte ward. Stroke unit care was associated with a long term (median one year follow up) reduction of death (odds ratio 0.83, 95% confidenc e interval 0.69 to 0.98; P < 0.05) and of the combined poor outcomes o f death or dependency (0.69, 0.59 to 0.82; P < 0.0001) and death or in stitutionalisation (0.75, 0.65 to 0.87; P < 0.0001). Beneficial effect s were independent of patients' age, sex, or stroke severity and of va riations in stroke unit organisation. Length. of stay in a hospital or institution was reduced by 8% (95% confidence interval 3% to 13%) com pared with conventional care but there was considerable heterogeneity of results. Conclusions: Organised stroke unit care resulted in long t erm reductions in death, dependency, and the need for institutional ca re. The observed benefits were not restricted to any particular subgro up of patients or model of stroke unit care. No systematic increase in the use of resources (in terms of length of stay) was apparent.