Ruth Dobson

Randomized Controlled Trial of a Comprehensive Stroke Education Program for Patients and Caregivers

BACKGROUND AND PURPOSE We report the findings of a randomized controlled trial to determine the effectiveness of a multidisciplinary Stroke Education Program (SEP) for patients and their informal carers. METHODS Two hundred four patients admitted with acute stroke and their 176 informal carers were randomized to receive an invitation to the SEP or to receive conventional stroke unit care. The SEP consisted of one 1-hour small group educational session for inpatients followed by six 1-hour sessions after discharge. The primary outcome measure was patient- and carer-perceived health status (SF-36) at 6 months after stroke. Knowledge of stroke, satisfaction with services, emotional outcome, disability, and handicap and were secondary outcome measures. RESULTS Only 51 of 108 (47%) surviving patients randomized to the SEP completed the program, as did 20 of 93 (22%) informal carers of surviving patients. Perceived health status (Short Form 36 [SF-36] health survey) scores were similar for SEP patients and controls. Informal carers in the control group scored better on the social functioning component of the SF-36 than the SEP group (P=0.04). Patients and informal carers in the SEP group scored higher on the stroke knowledge scale than controls (patients, P=0.02; carers, P=0. 01). Patients in the SEP group were more satisfied with the information that they had received about stroke (P=0.004). There were no differences in emotional or functional outcomes between groups. CONCLUSIONS Although the SEP improved patient and informal carer knowledge about stroke and patient satisfaction with some components of stroke services, this was not associated with an improvement in their perceived health status. Indeed, the social functioning of informal carers randomized to the SEP was less than in the control group.

Early supported hospital discharge following acute stroke: pilot study results

Objective: To establish the feasibility and method of evaluation of an early supported hospital discharge policy for patients with acute stroke. Design: A randomized controlled trial comparing an early supported discharge service to conventional care. Setting: Three acute hospitals in Newcastle upon Tyne. Subjects: Ninety-two eligible patients with acute stroke admitted between 1 February 1995 and 31 January 1996. Main outcome measures: Placement, length of stay, readmission rates, mortality, functional ability (Nottingham Extended Activities of Daily Living (ADL) Scale), handicap (Oxford Handicap Scale), global health status (Dartmouth Coop Function Charts) and carer stress (General Health Questionnaire 30 item). Results: The median length of stay for patients randomized to early supported discharge was 13 days compared to 22 days in the conventional care group (p = 0.02). The median Barthel ADL Index at seven days post stroke of patients randomized to early supported discharge was 15, and 13 for those randomized to conventional care (NS). At three months post stroke the median Nottingham EADL score of patients randomized to early supported discharge was 10 compared to 7 for those who received conventional care (NS). There were no statistically significant differences in the global health status of patients or carer stress. Conclusion: An early supported discharge service following acute stroke with individualized rehabilitation in the community is feasible and can be evaluated by a randomized controlled trial but a larger multicentre trial is needed before such a service is widely adopted.

A Regional Collaborative Audit of the Practice and Outcome of Carotid Endarterectomy in the United Kingdom

Objectives to evaluate performance and outcome of carotid endarterectomy (CEA) against agreed audit standards within one English health region. Design a prospective collaborative audit over twelve months (November 1994 to October 1995) involving all surgeons undertaking CEA within one English health region. Methods audit standards were agreed by all participating surgeons at the outset based on existing national guidelines. Data were abstracted from clinical notes. Outcomes were reviewed by clinicians 30 days post-surgery. A confidential individualised report of the results was provided to each surgeon. A survey of participating surgeons sought to evaluate the audit process. Results ten surgeons performed 139 CEAs on 134 individuals (64% men). Median per surgeon was 12 (range 1–44). Audit standards were generally achieved: 114 (82%) patients had symptomatic carotid stenosis of 70–99%, 14 (10%) were asymptomatic. The median time from first referral to hospital to operation was 4.8 months (interquartile range 3.0–7.3). The rate of disabling stroke or death at 30 days was 2.2% (95% confidence interval (CI) 0.4–6.4%). Surgeons valued the audit.Conclusions the study showed that in the study area CEA was performed predominantly on high-risk patients with low subsequent surgical mortality.

Regular ArticleA Regional Collaborative Audit of the Practice and Outcome of Carotid Endarterectomy in the United Kingdom

Objectives to evaluate performance and outcome of carotid endarterectomy (CEA) against agreed audit standards within one English health region. Design a prospective collaborative audit over twelve months (November 1994 to October 1995) involving all surgeons undertaking CEA within one English health region. Methods audit standards were agreed by all participating surgeons at the outset based on existing national guidelines. Data were abstracted from clinical notes. Outcomes were reviewed by clinicians 30 days post-surgery. A confidential individualised report of the results was provided to each surgeon. A survey of participating surgeons sought to evaluate the audit process. Results ten surgeons performed 139 CEAs on 134 individuals (64% men). Median per surgeon was 12 (range 1–44). Audit standards were generally achieved: 114 (82%) patients had symptomatic carotid stenosis of 70–99%, 14 (10%) were asymptomatic. The median time from first referral to hospital to operation was 4.8 months (interquartile range 3.0–7.3). The rate of disabling stroke or death at 30 days was 2.2% (95% confidence interval (CI) 0.4–6.4%). Surgeons valued the audit.Conclusions the study showed that in the study area CEA was performed predominantly on high-risk patients with low subsequent surgical mortality.