Stroke Units An evidence based approach

by Langhorne, Peter; Dennis, Martin

• ISBN13: 9780727912114
• ISBN10: 0727912119
• Edition: 1st
• Format: Paperback
• Copyright: 1998-05-08
• Publisher: BMJ Books

Summary

Based on systematic reviews carried out by the international Stroke Unit Trialists' Collaboration, this book discusses the place of the in-patient stroke unit in the present day mangement of stroke patients. The analysis discusses both their methodology and results in terms of effectiveness of the stroke unit - reduction of mortality, benefit to patients, and resource implications. The wider issues are addressed in chapters considering other alternatives and situations where less evidence is available.

Author Biography

Peter Langhorne and Martin Dennis have written most chapters and take editorial responsibility for the content and opinions expressed in this book. Additional contributions (Chapter 5 and Appendix) have been made by invited authors. However, many other individuals have contributed to the project and the main body of data, descriptive information, and useful advice and comment have been provided by members of a collaborative review group (the Stroke Unit Trialists’ Collaboration - see list below). Therefore individual chapters of the book should be cited as follows: 1, 2, 3, 4, 6 and 7 - Langhorne and Dennis on behalf of the Stroke Unit Trialists’ Collaboration; 5 - Major and Walker; Appendix - Perth unit: Hankey and colleagues, Trondheim unit; Indredavik and colleagues, Orpington unit: Kalra, Nottingham unit: Berman and colleagues.

Table of Contents

Authorship	ix
Contributors	xi
Foreword	xiii
Iain Chalmers
Preface	xv
The stroke unit story	1	(7)
History of stroke unit care and its evaluation	1	(5)
Early studies	2	(1)
Definitions of a stroke unit	3	(1)
Stroke intensive care units	4	(1)
Later developments	4	(2)
The demands of evidence based practice	6	(2)
How should we evaluate our interventions?	8	(12)
Levels of evidence	8	(2)
Sources of error	10	(3)
Systematic error (bias)	10	(3)
Random error	13	(1)
Design of a reliable stroke unit trial	13	(1)
Why randomised trials may not be enough	14	(1)
Systematic reviews of randomised trials	15	(5)
Conduct of systematic reviews	15	(2)
Sources of bias in systematic reviews	17	(1)
Interpretation of systematic reviews	18	(2)
Assembling evidence about stroke units	20	(13)
Formulating the stroke unit question	20	(3)
Defining the intervention	20	(1)
Defining the patient group	21	(1)
Defining the context	22	(1)
Defining the outcomes	22	(1)
Identifying the relevant trials	23	(1)
Locating information from relevant trials	23	(1)
The stroke unit trials	24	(9)
General comments	24	(1)
Stroke unit characteristics	24	(5)
Characteristics of different models of stroke unit	29	(4)
Effectiveness of organised (stroke unit) care	33	(23)
Conventions of meta-analysis	33	(3)
What is meta-analysis?	33	(1)
What is an odds ratio?	34	(1)
Presentation of results	35	(1)
Coping with different types of outcome	36	(1)
Meta-analysis of the stroke unit trials	36	(20)
Can the risk of death be reduced?	36	(2)
Why were deaths reduced?	38	(2)
Preventing death at the expense of increased dependency among survivors?	40	(1)
Is the need for institutional care reduced?	41	(1)
Is dependency (disability) among survivors reduced?	42	(3)
Is quality of life among survivors improved?	45	(1)
What are the absolute benefits of stroke unit care?	45	(1)
Subgroup analysis	46	(2)
Which patients benefit?	48	(1)
What kind of stroke unit is effective?	49	(1)
Exploring the diversity of stroke unit trials	50	(1)
What general policies should be applied?	51	(5)
Economics of stroke unit care	56	(10)
Economic analysis	56	(1)
Methods of economic analysis	56	(1)
Terminology	57	(1)
Sources of data for economic analysis	57	(1)
Costs of stroke	57	(2)
Identifying potential costs and benefits	59	(1)
Cost effectiveness analysis	59	(1)
Potential benefits	59	(1)
Potential costs	59	(1)
Measuring costs and benefits	60	(2)
Economic interpretation of results	62	(4)
Economic ``balance sheet''	62	(2)
Factors missing from the analysis	64	(1)
Implications of the analysis	64	(2)
Implications for planning stroke services	66	(14)
Evidence based stroke care	66	(1)
Comprehensive stroke services	67	(1)
What kind of stroke unit?	68	(2)
Stroke patients only or mixed rehabilitation service?	68	(1)
Stroke ward or mobile stroke team?	68	(1)
Acute or rehabilitation unit?	69	(1)
Staffing of the stroke unit	70	(2)
In which department should the unit be established?	70	(1)
What staff are needed?	71	(1)
Stroke unit policies	72	(2)
Stroke unit size	72	(1)
Patient selection criteria	73	(1)
Duration of stay	73	(1)
Practices and procedures	74	(4)
Communication: Multidisciplinary team	74	(1)
Communication: Carers	75	(1)
Care pathways	75	(3)
Education, training, and beliefs	78	(1)
Overcoming resistance to change	78	(2)
Implications for future research	80	(4)
Current state of knowledge	80	(1)
Outstanding questions	81	(3)
Appendix: Descriptions of stroke unit care	84	(9)
Glossary of terms	93	(7)
References	100	(9)
Index	109