Hild Fjærtoft

Benefit of an extended stroke unit service with early supported discharge: A randomized, controlled trial.

Background and Purpose Several trials have shown that stroke unit care improves outcome for stroke patients. The aim of the present trial was to evaluate the effects of an extended stroke unit service (ESUS), with early supported discharge, cooperation with the primary healthcare system, and more emphasis on rehabilitation at home as essential elements. Methods In a randomized, controlled trial, 160 patients with acute stroke were allocated to the ESUS and 160 to the ordinary stroke unit service (OSUS). The primary outcome was the proportion of patients who were independent as assessed by the modified Rankin Scale (RS) (RS ≤2=global independence) and independent in activities of daily living (ADL) as assessed by Barthel Index (BI) (BI ≥95=independent in ADL) after 26 weeks. Secondary outcomes were RS and BI scores after 6 weeks; the proportion of patients at home, in institutions, and deceased after 6 and 26 weeks; and the length of stay in institutions. Results After 26 weeks, 65.0% in the ESUS versus 51.9% in the OSUS group showed global independence (RS ≤2) (P= 0.017) , while 60.0% in the ESUS versus 49.4% in the OSUS group were independent in ADL (BI ≥95) (P =0.056). The odds ratios for independence (ESUS versus OSUS) were as follows: RS, 1.72 (95% CI, 1.10 to 2.70); BI, 1.54 (95% CI, 0.99 to 2.39). At 6 weeks, 54.4% of the ESUS group and 45.6% of the OSUS group were independent according to RS (P =0.118), and 56.3% versus 48.8% were independent according to BI (P =0.179). The proportion of patients at home after 6 weeks was 74.4% for ESUS and 55.6% for OSUS (P =0.0004), and the proportion in institutions was 23.1% versus 40.0%, respectively (P =0.001). After 26 weeks, 78.8% in the ESUS group versus 73.1% in the OSUS were at home (P =0.239), while 13.1% versus 17.5% were in institutions (P =0.277). The mortality in the 2 groups did not differ. Average lengths of stay in an institution were 18.6 days in the ESUS and 31.1 days in the OSUS group (P =0.0324). Conclusions An ESUS with early supported discharge seems to improve functional outcome and to reduce the length of stay in institutions compared with traditional stroke unit care.

Stroke Unit Care Combined With Early Supported Discharge. Long-Term Follow-Up of a Randomized Controlled Trial

Background and Purpose— Early supported discharge from a stroke unit reduces the length of hospital stay. Evidence of a benefit for the patients is still unknown. The aim of this trial was to evaluate the long-term effects of an extended stroke unit service (ESUS), characterized by early supported discharge. The short-term effects were published previously. Methods— We performed a randomized controlled trial in which 320 acute stroke patients were allocated to either ordinary stroke unit service (OSUS) (160 patients) or stroke unit care with early supported discharge (160 patients). The ESUS consists of a mobile team that coordinates early supported discharge and further rehabilitation. Primary outcome was the proportion of patients who were independent as assessed by modified Rankin Scale (RS) (RS ≤2=global independence). Secondary outcomes measured at 52 weeks were performance on the Barthel Index (BI) (BI ≥95=independent in activities of daily living), differences in final residence, and analyses to identify patients who benefited most from an early supported discharge service. All assessments were blinded. Results— We found that 56.3% of the patients in the ESUS versus 45.0% in the OSUS were independent (RS ≤2) (P =0.045). The number needed to treat to achieve 1 independent patient in ESUS versus OSUS was 9. The odds ratio for independence was 1.56 (95% CI, 1.01 to 2.44). There were no significant differences in BI score and final residence. Patients with moderate to severe stroke benefited most from the ESUS. Conclusions— Stroke service based on treatment in a stroke unit combined with early supported discharge appears to improve the long-term clinical outcome compared with ordinary stroke unit care. Patients with moderate to severe stroke benefit most.

Acute stroke unit care combined with early supported discharge. Long-term effects on quality of life. A randomized controlled trial

Objectives: The aim of the present trial was to compare the effects of an extended stroke unit service (ESUS) with the effects of an ordinary stroke unit service (OSUS) on long-term quality of life (QoL). Design: One year follow-up of a randomized controlled trial with 320 acute stroke patients allocated either to OSUS (160 patients) or ESUS (160 patients) with early supported discharge and follow-up by a mobile team. The intervention was a mobile team and close co-operation with the primary health care service. All assessments were blinded. Main outcome measure: Primary outcome of QoL in this paper was measured by the Nottingham Health Profile (NHP) at 52 weeks. Secondary outcomes measured at 52 weeks were differences between the groups measured by the Frenchay Activity Index, Montgomery-A ° sberg Depression Scale, Mini-Mental State Score and the Caregivers Strain Index. Results: The ESUS group had a significantly better QoL (mean score 78.9) assessed by global NHP after one year than the OSUS group (mean score 75.2) (p -0.048). There were no significant differences between the groups in the secondary outcomes, but a trend in favour of ESUS. Caregivers Strain Index showed a mean score of 23.3 in the ESUS group and 22.6 in the OSUS group (p -0.089). Conclusion: It seems that stroke unit treatment combined with early supported discharge in addition to reducing the length of hospital stay can improve long-term QoL. However, similar trials are necessary to confirm the benefit of this type of service.

Early Supported Discharge for Stroke Patients Improves Clinical Outcome. Does It Also Reduce Use of Health Services and Costs

Background: An early supported discharge service (ESD) appears to be a promising alternative to conventional care. The aim of this trial was to compare the use of health services and costs with traditional stroke care during a one-year follow-up. Methods: Three hundred and twenty patients were randomly allocated either to ordinary stroke unit care or stroke unit care combined with ESD which was coordinated by a mobile team. The use of all health services was recorded prospectively; its costs were measured as service costs and represent a combination of calculated average costs and tariffs. Hospital expenses were measured as costs per inpatient day and adjusted for the DRG. Results: There was a reduction in average number of inpatient days at 52 weeks in favour of the ESD group (p = 0.012), and a non-significant reduction in total mean service costs in the ESD group (EUR 18,937/EUR 21,824). ESD service seems to be most cost-effective for patients with a moderate stroke. Conclusion: Acute stroke unit care combined with an ESD programme may reduce the length of institutional stay without increasing the costs of outpatient rehabilitation compared with traditional stroke care.

Comparison of the validity of stroke diagnoses in a medical quality register and an administrative health register

Aims: Health registers are essential sources of data used in a wide range of stroke research, including epidemiological, clinical and healthcare studies. Regardless of the type of register, the data must be of high quality to be useful. In this study, we investigated and compared the correctness and completeness of the Norwegian Patient Register (an administrative health register) and the Norwegian Stroke Register (a medical quality register for acute stroke). Methods: We reviewed the medical records for 5192 admissions to hospital in 2012 and defined cases of stroke in the two registers as true positive, false positive, true negative or false negative. We calculated the sensitivity, specificity, positive predictive value (PPV) and negative predictive value with 95% confidence intervals assuming a normal approximation of the binomial distribution. Results: The Norwegian Stroke Register was highly correct and relatively complete (sensitivity 88.1%, specificity 100% and PPV 98.6%). The Norwegian Patient Register was more complete, but less correct, when we included both the main and secondary diagnoses of stroke (sensitivity 96.8%, specificity 99.6% and PPV 79.7%); restricting the analyses to the main diagnoses of stroke resulted in less complete and more correct registrations (sensitivity 86.1%, specificity 99.9% and PPV 93.5%). Conclusions: The Norwegian Stroke Register and the Norwegian Patient Register are adequately complete and correct to serve as valuable sources of data for epidemiological, clinical and healthcare studies, as well as for administrative purposes.

Validity and Reliability of Simple Questions in Assessing Short- and Long-Term Outcome in Norwegian Stroke Patients

The utility of simple questions for the assessment of stroke outcome in large-scale international studies has generally been approved, but their validity and reliability have not been evaluated in different cultures or at different intervals after a stroke. The study comprised 150 stroke patients who had been admitted consecutively to a stroke unit 6 weeks or 6 months earlier. Two weeks before the visit the patient received a postal questionnaire containing the simple ‘dependency’ question: ‘In the last 2 weeks, did you require help from another person for everyday activities?’ and the simple ‘recovery’ question: ‘Do you feel that you have made a complete recovery from your stroke?’. The visit was performed by trained personnel unaware of the patient’s or his carer’s replies, and comprised the same 2 questions administered by the personnel, the Barthel ADL Index (BI) and the modified Rankin Scale (mRS). The patients’ functional status was categorised as good or bad according to the chosen cutoff levels on BI and mRS. At 6 months the dependency question had an accuracy of 83 and 82% in identifying patients with good or bad outcome, defined as BI ≧95 or <95 and mRS <3 or ≧3, respectively, whereas the recovery question had an accuracy of 86% when compared with mRS = 0 or >0. There was no difference in accuracy of the simple questions at 6 weeks compared with 6 months, and there was no clinically important difference between responses from patients and carers. The agreement between the responses to the questionnaire and the interview was good to moderate (ĸ = 0.62 for the dependency question, and 0.55 for the recovery question). We conclude that the simple questions seem to be valid and reliable measures of stroke outcome when tested in Norwegian patients after 6 weeks or 6 months, which supports their continued use in large-scale multinational stroke studies at different intervals after stroke.

Effects of Cascade Apheresis in Patients with Psoriasis and Psoriatic Arthropathy

Eight patients with psoriasis, all with skin scales and 7 with disabling psoriatic arthritis, were subjected to cascade apheresis starting with three treatments per week for 2 weeks, followed by one treatment a week, comprising ten treatments in all. Six out of 7 patients (86%) with arthropathy and 3 out of 8 patients (38%) with scales experienced a beneficial effect. There was a large drop in the levels of circulating immune complexes (CIC) due to the treatment, and the removal of CIC was followed by reduced inflammatory activity in skin lesions and joints as evaluated by pain, morning stiffness, grip strength, plaque score, and PASI index. However, there was no correlation between the level of CIC, disease activity, or treatment response. From the present results it is concluded that CIC may play a more significant role regarding psoriatic arthropathy than in skin manifestations, and apheresis may be beneficial in patients not responding to conventional therapy.