Paola Dey

Early supported discharge services for stroke patients: a meta-analysis of individual patients' data

BACKGROUND Stroke patients conventionally undergo a substantial part of their rehabilitation in hospital. Services have been developed that offer patients early discharge from hospital with rehabilitation at home (early supported discharge [ESD]). We have assessed the effects and costs of such services. METHODS We did a meta-analysis of data from individual patients who took part in randomised trials that recruited patients with stroke in hospital to receive either conventional care or any ESD service intervention that provided rehabilitation and support in a community setting with the aim of shortening the duration of hospital care. The primary outcome was death or dependency at the end of scheduled follow-up. FINDINGS Outcome data were available for 11 trials (1597 patients). ESD services were mostly provided by specialist multidisciplinary teams to a selected group (median 41%) of stroke patients admitted to hospital. There was a reduced risk of death or dependency equivalent to six (95% CI one to ten) fewer adverse outcomes for every 100 patients receiving an ESD service (p=0.02). The hospital stay was 8 days shorter for patients assigned ESD services than for those assigned conventional care (p<0.0001). There were also significant improvements in scores on the extended activities of daily living scale and in the odds of living at home and reporting satisfaction with services. The greatest benefits were seen in the trials evaluating a coordinated multidisciplinary ESD team and in stroke patients with mild to moderate disability. INTERPRETATION Appropriately resourced ESD services provided for a selected group of stroke patients can reduce long-term dependency and admission to institutional care as well as shortening hospital stays.

Costs and benefits of a one stop clinic compared with a dedicated breast clinic: randomised controlled trial

Abstract Objective: To determine the cost to the NHS and the impact on anxiety of a one stop clinic for assessing women with suspected breast cancer. Study design: Randomised controlled trial. Participants: Women aged 35 or over referred with a breast lump. Study setting: Teaching hospital, north west England. Interventions: Women were randomly allocated to attend a one stop clinic or a dedicated breast clinic. Outcome measures: Reduction in mean anxiety from baseline at 24 hours after the first visit and at 3 weeks and 3 months after diagnosis; mean cost per patient. Results: 670 women were randomised. Compared with women who attended the dedicated clinic, patients attending the one stop clinic were less anxious 24 hours after the visit (adjusted mean change in state anxiety −5.7 (95% confidence interval −8.4 to −3.0)) but not at 3 weeks or 3 months after diagnosis. The additional cost to the NHS of a one stop attendance was £32 per woman; this was largely explained by greater cytopathological and radiological staff costs. Conclusion: One stop clinics may not be justified in terms of a reduction in short term anxiety.

Stroke unit care benefits patients with intracerebral hemorrhage: systematic review and meta-analysis.

Background and Purpose— Patients with any type of stroke managed in organized inpatient (stroke unit) care are more likely to survive, return home, and regain independence. However, it is uncertain whether these benefits apply equally to patients with intracerebral hemorrhage and ischemic stroke. Methods— We conducted a secondary analysis of a systematic review of controlled clinical trials comparing stroke unit care with general ward care, including only trials published after 1990 that could separately report outcomes for patients with intracerebral hemorrhage and ischemic stroke. We performed random-effects meta-analyses and tested for subgroup interactions by stroke type. Results— We identified 13 trials (3570 patients) of modern stroke unit care that recruited patients with intracerebral hemorrhage and ischemic stroke, of which 8 trials provided data on 2657 patients. Stroke unit care reduced death or dependency (risk ratio [RR], 0.81; 95% confidence interval [CI], 0.471–0.92; P=0.0009; I2=60%) with no difference in benefits for patients with intracerebral hemorrhage (RR, 0.79; 95% CI, 0.61–1.00) than patients with ischemic stroke (RR, 0.82; 95% CI, 0.70–0.97; Pinteraction=0.77). Stroke unit care reduced death (RR, 0.79; 95% CI, 0.64–0.97; P=0.02; I2=49%) to a greater extent for patients with intracerebral hemorrhage (RR, 0.73; 95% CI, 0.54–0.97) than patients with ischemic stroke (RR, 0.82; 95%, CI 0.61–1.09), but this difference was not statistically significant (Pinteraction=0.58). Conclusions— Patients with intracerebral hemorrhage seem to benefit at least as much as patients with ischemic stroke from organized inpatient (stroke unit) care.

Breastfeeding expectations versus reality: A cluster randomised controlled trial

Objective  To evaluate the affect of an antenatal educational breastfeeding intervention on womens breastfeeding duration.

Adequacy of cervical cytology sampling with the Cervex brush and the Aylesbury spatula : a population based randomised controlled trial

Abstract Objective: To compare the adequacy of cervical cytology sampling with two sampling instruments commonly used in primary care—namely, the Aylesbury spatula and the Cervex brush. Design: Pair matched, population based randomised controlled trial. Setting: 86 general practices and family planning clinics in Greater Manchester. Subjects: 15 882 cervical smears taken from women aged 20-64 years as part of the national cervical screening programme. Interventions: Participating centres were allocated to sample with either the Cervex brush or the Aylesbury spatula. Main outcome measure: Inadequate smear rate. Results: 5.4% and 5.5% (433/8086 and 426/7796) of smears taken with the Cervex brush and the Aylesbury spatula respectively were reported as inadequate (odds ratio 0.95; 95% confidence interval 0.74 to 1.22). Conclusion: The Cervex brush offers no advantage over the Aylesbury spatula in reducing inadequate smear rates in the primary care setting. Key messages Cervical sampling instruments have rarely been formally evaluated in population based settings Group randomisation is useful when evaluating community based interventions but requires modified statistical techniques The Cervex brush offers no advantage over the Aylesbury spatula in reducing rates of inadequate smears when used in primary care