Health service management study for stroke : A randomized controlled trial to evaluate two models of stroke care

Background: The most effective and efficient model for providing organized stroke care remains uncertain. This study aimed to compare the effect of two models in a randomized controlled trial. Methods: Patients with acute stroke were randomized on day one of admission to combined, co-located acute/rehabilitation stroke care or traditionally separated acute/rehabilitation stroke care. Outcomes measured at baseline and 90 days post-discharge included functional independence measure, length of hospital stay, and functional independence measure efficiency (change in functional independence measure score ÷ total length of hospital stay). Results: Among 41 patients randomized, 20 were allocated co-located acute/rehabilitation stroke care and 21 traditionally separated acute/rehabilitation stroke care. Baseline measurements showed no significant difference. There was no significant difference in functional independence measure scores between the two groups at discharge and again at 90 days postdischarge (co-located acute/rehabilitation stroke care: 103·6 ± 22·2 vs. traditionally separated acute/rehabilitation stroke care: 99·5 ± 27·7; P = 0·77 at discharge; co-located acute/rehabilitation stroke care: 109·5 ± 21·7 vs. traditionally separated acute/rehabilitation stroke care: 104·4 ± 27·9; P= 0·8875 at 90 days post-discharge). Total length of hospital stay was 5·28 days less in co-located acute/rehabilitation stroke care compared with traditionally separated acute/rehabilitation stroke care (24·15 ± 3·18 vs. 29·42 ± 4·5, P = 0·35). There was significant improvement in functional independence measure efficiency score among participants assigned to co-located acute/rehabilitation stroke care compared with traditionally separated acute/rehabilitation stroke care (co-located acute/rehabilitation stroke care: median 1·60, interquartile range: 0·87–2·81; traditionally separated acute/rehabilitation stroke care: median 0·82, interquartile range: 0·27–1·57, P = 0·0393). Linear regression analysis revealed a high inverse correlation (R2 = 0·89) between functional independence measure efficiency and time spent in the acute stroke unit. Conclusion: This proof-of-concept study has shown that co-located acute/rehabilitation stroke care was just as effective as traditionally separated acute/rehabilitation stroke care as reflected in functional independence measure scores, but significantly more efficient as shown in greater functional independence measure efficiency. Co-located acute/rehabilitation stroke care has potential for significantly improved hospital bed utilization with no patient disadvantage

Safety and efficacy of fluoxetine on functional outcome after acute stroke (AFFINITY): a randomised, double-blind, placebo-controlled trial

Background Trials of fluoxetine for recovery after stroke report conflicting results. The Assessment oF FluoxetINe In sTroke recoverY (AFFINITY) trial aimed to show if daily oral fluoxetine for 6 months after stroke improves functional outcome in an ethnically diverse population. Methods AFFINITY was a randomised, parallel-group, double-blind, placebo-controlled trial done in 43 hospital stroke units in Australia (n=29), New Zealand (four), and Vietnam (ten). Eligible patients were adults (aged ≥18 years) with a clinical diagnosis of acute stroke in the previous 2–15 days, brain imaging consistent with ischaemic or haemorrhagic stroke, and a persisting neurological deficit that produced a modified Rankin Scale (mRS) score of 1 or more. Patients were randomly assigned 1:1 via a web-based system using a minimisation algorithm to once daily, oral fluoxetine 20 mg capsules or matching placebo for 6 months. Patients, carers, investigators, and outcome assessors were masked to the treatment allocation. The primary outcome was functional status, measured by the mRS, at 6 months. The primary analysis was an ordinal logistic regression of the mRS at 6 months, adjusted for minimisation variables. Primary and safety analyses were done according to the patient's treatment allocation. The trial is registered with the Australian New Zealand Clinical Trials Registry, ACTRN12611000774921. Findings Between Jan 11, 2013, and June 30, 2019, 1280 patients were recruited in Australia (n=532), New Zealand (n=42), and Vietnam (n=706), of whom 642 were randomly assigned to fluoxetine and 638 were randomly assigned to placebo. Mean duration of trial treatment was 167 days (SD 48·1). At 6 months, mRS data were available in 624 (97%) patients in the fluoxetine group and 632 (99%) in the placebo group. The distribution of mRS categories was similar in the fluoxetine and placebo groups (adjusted common odds ratio 0·94, 95% CI 0·76–1·15; p=0·53). Compared with patients in the placebo group, patients in the fluoxetine group had more falls (20 [3%] vs seven [1%]; p=0·018), bone fractures (19 [3%] vs six [1%]; p=0·014), and epileptic seizures (ten [2%] vs two [<1%]; p=0·038) at 6 months. Interpretation Oral fluoxetine 20 mg daily for 6 months after acute stroke did not improve functional outcome and increased the risk of falls, bone fractures, and epileptic seizures. These results do not support the use of fluoxetine to improve functional outcome after stroke

Current and future concepts in stroke prevention

STROKE IS A MAJOR CAUSE OF MORBIDITY and mortality in an aging population. The current understanding of the pathophysiology of atherosclerotic diseases, the most common cause of stroke, and the evidence for existing therapeutic interventions for the prevention of stroke are presented. Specifically, we review the evidence for antiplatelet agents, anticoagulants, antihypertensive medications, lipid-lowering agents and carotid endarterectomy for stroke prevention

Stroke care in older people

Strokes are common in the population of older adults. However, the evidence for the management of strokes in older adults is scarce. This paper reviews the current knowledge of stroke care in the context of the management of older adults with stroke

Management for motor and non-motor complications in late Parkinson's disease

The prevalence of neurodegenerative diseases such as Parkinson's disease (PD) increases with age. in an aging population, an understanding of the management of late complications of PD is becoming ever more important. Drug treatment for Parkinson's disease is largely symptomatic and relies primarily on levodopa (L-dopa) and adjuvant therapies including dopamine agonists and catechoi-0-methyitransferase (COMT) inhibitors. Rehabilitation and allied health input also constitutes a core part of successful management. Most subjects who are symptomatic for more than 5 years are prone to late complications of PD. Some of these are related to the treatment, such as motor fluctuations, including the "on-off" phenomenon and levodopa-related peak dose dyskinesia. Others, such as postural hypotension, falls, psychosis, and dementia, although well-recognized problems in the elderly, often require different treatment strategies if occurring in the context of PD. The practical evidence-based management of motor and non-motor complications in late PD is discussed

Preferences, barriers and facilitators for establishing comprehensive stroke units: a multidisciplinary survey

Objectives. To determine the preferences of multidisciplinary stroke clinicians for models of inpatient stroke unit care and perceived barriers to establishing a comprehensive stroke unit (CSU) model (acute and rehabilitation care in the same ward). Methods. Written questionnaires distributed and completed at multidisciplinary stroke unit case conferences in NSW, Australia. Results. Twenty hospitals with 22 stroke units were surveyed, 13 acute stroke units, 7 rehabilitation stroke units, 2 CSUs. Two hundred and twenty-eight respondents: 99 (43.4%) allied health, 72 (31.6%) nurses and 57 (25.0%) doctors. One hundred and fifty-one respondents (67.0%) thought CSU to be the best model. Seventy-three % of doctors and 79% of allied health preferred CSU v. 57% of nurses (P = 0.041). Of doctors, rehabilitation specialists were most likely to favour comprehensive model (84.2%) and neurologists least (57.0%). The main perceived advantages of CSU were reduced cost and improved functional outcomes; perceived disadvantages were increased workload and unwell patients unable to participate in rehabilitation. Main perceived barriers to establishing CSU were lack of space, money, staffing and time. Conclusion. Although most current stroke unit care in NSW is based on the traditional model of acute and rehabilitation components in separate wards or hospitals, the majority of multidisciplinary stroke team clinicians believe CSU is the optimum model. What is known about the topic? Stroke unit care is known to improve survival and dependency but the optimum model of care is unproven, despite some small studies suggesting that the CSU model may result in better outcomes. What does this paper add? This paper is the first to survey stroke clinicians from various disciplines and types of unit, to determine their preferences for stroke unit model. What are the implications for practitioners? A majority of clinicians expressed a preference for the CSU model, suggesting that most would be comfortable caring for patients in both acute and rehabilitation phases of stroke care if further such units are established. </jats:p