Efficacy of acute stroke units : Updated meta-analysis

824Background A Cochrane review (2009) has concluded that the provision of care in stroke units (SU) improves stroke outcomes significantly. This study aimed to update the Cochrane review on acute SU care. We performed a meta-analysis on the benefit of acute SUs against alternatives. Methods Clinical trials published before 2006 were identified via the Cochrane review. Trials after 2006 were identified through a thorough electronic database search. For meta-analysis dichotomous outcomes were estimated by odds ratio (OR) and continuous outcomes were estimated by standardized mean difference. Weight of a study was calculated based on inverse variance. Results After two screenings 20 trials were included in the study: 12 compared SUs with alternative, 5 compared SUs with a specific protocol versus conventional SU care, 3 compared SUs followed by specific interventions versus SUs followed by conventional follow-up. Acute SU care significantly improved patient outcomes in terms of institutional care (OR=0.61, 95% confidence interval (CI) 0.47 to 0.79, P=0.0002); death or institutional care (OR=0.70, 95% CI 0.60 to 0.83, P<0.0001), death or dependency (OR=0.81, 95% CI 0.69 to 0.96, P=0.01; (4) length of hospital stay, standardized mean difference=-0.27 day, 95% CI -0.36 to -0.19, P<0.0001). The effect of SUs on mortality was around bottom-line statistical significance (OR=0.84, 95% CI 0.71 to 1.00, P=0.05). The benefit of SUs on mortality can be easily altered by changing the inclusion criteria (e.g. randomized controlled trials only, use of unpublished data). Effect of SUs on dependency was not significant (OR=0.92, 95% CI 0.74 to 1.13, P= 0.42). Conclusion This update confirmed the findings of the previous Cochrane review in general. Yet it showed that the benefit of SUs was more significant on composite outcomes (e.g. death or dependency, death or institutional care) than on individual outcomes (e.g. death, dependency)

Quality indicators for stroke units : A combination of evidence and experts consensus

478Background The provision of care in stroke units (SU) improves stroke outcomes significantly. The European Stroke Organization set up a working group for accreditation in stroke care but in Belgium there are today no national quality criteria applied to SU. The aim of the present study was to define a set of quality indicators (QI) for SUs in Belgium. Methods Generic and disease-specific QIs databases and QIs used in other countries were searched and an exhaustive list of stroke QIs was prepared. All QIs were grouped according to their characteristics and by their occurrence in the flow of care. QIs with a similar content but with different definitions were grouped into a single QI. The level of evidence to support each QI was summarized using the Scottish Intercollegiate Guidelines Network methodology. The process was validated by a first group of stroke experts. Seven stroke experts further rated the QIs on a scale from 1 (strongly disagree) to 9. They were asked to take 6 dimensions into account: relevance, validity, reliability, specificity, feasibility, potential for improvement. Results This process first identified 98 indicators and the final list included 48 QIs. A large amount of evidence were identified concerning process QIs (N=28) but less so for structure (N=15) and outcome QIs (N=5). Structure QIs included multidisciplinary stroke team and 24 hour brain imaging, training of medical staff, availability of vascular imaging and of diagnostic methods, documentation and risk assessment in the medical records. Process QIs were classified as hyper-acute phase, early acute management, inpatient care, discharge care. The outcome QIs were mortality, improvement on speech and language, level of dependency, quality of life, and hospital-acquired pneumonia. Conclusion This study provided an exhaustive list of QIs for SU as well as their level of evidence. The findings are now further used by authorities and specialists to set up an accreditation system in Belgium

Accreditation in stroke units of 6 European regions : One name different realities

481Background: ESO guidelines aim to promote standardised care of high quality in Europe but the organisation of acute care in stroke units (SU) largely differs between countries. This study aimed to scrutinize the accreditation or certification procedures of SU in 6 countries/regions: Scotland, Sweden, The Netherlands, France, Germany and the “London Stroke Services” (LSS). Methods: the information was collected with standardised questionnaires (25 pages) sent by mail to 12 experts from the 6 countries/regions. The research team analyzed the answers and clarified further issues by interviews. Results: an official mandatory accreditation procedure (organized and paid by governmental agencies) exists in Scotland, in LSS and in France. In Germany this procedure exists (private organizations) but is not mandatory. The accreditation process always implies at least site-visits and patient data review. Accreditation is renewed on a 1-, 3-, or 5-year basis. Some countries differentiate between types of SU (e.g. primary, comprehensive SU). The study further listed the criteria that SU must fulfil and the indicators measured for their accreditation (structure, process and outcome). Few of them refer to outcomes e.g. mortality, complications and recurrence. Incentives to encourage better quality differ between countries: public reporting of the results of the accreditation procedure, support to poor performers, benchmarking between hospitals, financial consequences. Conclusion: this exhaustive analysis gives an overview of the accreditation procedures in selected European countries. Care of high quality relies on a common evidence base but the quality assurance procedures, the indicators used as well as the consequences of the measurement largely differ between the countries. The question is to know if these various accreditation procedures result in differences in patients' outcomes