Stroke: no clear role for an integrated care pathway for patient management

Clinical bottom line (level 1b-)

  1. Patients with an acute stroke treated on a stroke unit using an integrated care pathway compared with standard care were not clearly less likely to die or be institutionalised, nor spend less time in hospital.
Sulch et al: Stroke 2000; 31 : 1929-1934
Expires November 2003

The study

Unblinded ?concealed randomised trial with intention-to-treat
Setting: stroke unit, university hospital, UK

152 patients (aged mean 75, 51% male) with an acute stroke within 2 weeks and persistent motor, sensory, vision, speech, perceptual or cognitive impairment resulting in limitation of personal activities of daily living and required inpatient rehabilitation.

Excluded if
  • mild deficit not requiring inpatient rehabilitation
  • severe premorbid physical or cognitive disability
  • neurologically or medical unstable

Control Group: (n = 76, 76 analysed): usual care
Experimental Group: (n = 76, 76 analysed): integrated care pathway: organised, goal-defined and time-managed plan to facilitate timely interdisciplinary coordination, improve discharge planning and reduce length of hospital stay - co-ordinated by a senior nurse

100% followed for 6 months

The evidence

Outcome Time to outcome CER EER RRR
(95% CI)		 ARR
(95% CI)		 NNT
(95% CI)
death or instiutionalisation 6 weeks 22
(29.0%)		 20
(26.3%)		 9%
(-52% to 46%)		 2.63%
(-11.6% to 16.8%)		 38
(NNT = 6 to infinity;
NNH = 9 to infinity)

Outcome Control Group
(SD)		 Experimental Group
(SD)		 Mean Difference
(95% CI)
length of stay in hospital (days) 45
() 		50
(19) 		5
(-2 to 12)

  • No difference in functional outcome scores, duration of physiotherapy or occupational therapy, anxiety or depression was noted between the two groups.

    Comments

    1. Patients were randomised in blocks of ten.
    2. Patients in both groups were treated by the same healthcare teams who were unblinded to treatment allocation. Clinicians may have shared techniques learnt from the integrated pathway on control group patients.
    3. The study was too small to show any difference between the two groups.

    Citation

    1. Sulch D, Perez I, Melbourn A, et al: randomized controlled trial of integrated (managed) care pathway for stroke rehabilitation. Stroke 2000; 31 : 1929-1934
    Search Terms: from ACP Journal Club other articles noted
    Contributor: Chris Ball, November 2001
    Reviewer:

    Clinical Question.
    Patient acute stroke
    Intervention or Exposure integrated care pathway
    Comparison standard care
    Outcome death, institutionalisation, length of hospital stay
    		•