Stroke units in their natural habitat - Can results of randomized trials be reproduced in routine clinical practice?

Purpose-Meta-analyses of randomized controlled trials of acute stroke care have shown care in stroke units (SUs) to be superior to that in conventiona l general medical, neurological, or geriatric wards, with reductions in ear ly case fatality, functional outcome, and the need for long-term institutio nalization. This study examined whether these results can be reproduced in clinical practice. Methods-A multicenter observational study of procedures and outcomes in acu te stroke patients admitted to designated SUs or general medical or neurolo gical wards (GWs), the study included patients of all ages with acute strok e excluding those with subarachnoid hemorrhage, who were entered into the R iks-Stroke (Swedish national quality assessment) database during 1996 (14 3 08 patients in 80 hospitals). Results-Patients admitted to SUs who had lived independently and who were f ully conscious on admission to the hospital had a lower case fatality than those cared for in GWs (relative risk [RR] for death, 0.87; 95% confidence interval [CI], 0.79 to 0.96) and at 3 months (RR, 0.91; 95% CI, 0.85 to 0.9 8). A greater proportion of patients cared for in an SU could be discharged home (RR, 1.06; 95% CI, 1.03 to 1.10), and fewer were in long-term institu tional care 3 months after the stroke (RR, 0.94; 95% CI, 0.89 to 0,99). No difference was seen in outcome in patients cared for in SUs or GWs if they had impaired consciousness on admission. Conclusions-The improvement in outcomes after stroke care in SUs compared w ith care in GWs can be reproduced in the routine clinical setting, but the magnitude of the benefit appears smaller than that reported from meta-analy ses.