ReviewCare pathways for acute stroke care and stroke rehabilitation: From theory to evidence
Section snippets
Care pathways: The theory
Care pathways are increasingly being implemented across many countries to improve the care of stroke patients, but there is relatively little debate about what they are and how they affect patient care and outcome.[1], [2] One reason could be that care pathways are generally regarded as harmless, and policy makers are keen to adopt new health service interventions that are intuitively beneficial, even though they have not yet been thoroughly tested. This paper describes the definition and
Different forms of stroke care pathways
Since care pathways were first introduced for stroke care in the mid-1980s,35 many different forms of ‘pathways’ have been developed, such as those used to aid the diagnosis of acute stroke and screening for thrombolytic therapy.[36], [37] Others have been developed to guide patient care in the community after hospital discharge.[38], [39] In general, stroke care pathways can be broadly divided into three categories: (i) those used for acute stroke management only; (ii) those used for stroke
Care pathways for stroke: The evidence
Compared with trials of pharmacological agents or surgical procedures, the evaluation of health service interventions such as care pathways is more complex. In practice, care pathways are highly variable in their nature and their operation depends greatly on the local circumstances. Consequently, the results generated by studies of care pathways may have questionable internal validity (that is, the extent to which differences between the study groups are real rather than a product of bias) and
Evidence from the Cochrane review
Using Cochrane methodology, a recent systematic review evaluated the effects of care pathways, as compared to standard medical care, among patients with acute stroke who had been admitted to hospital.81 The major databases were searched including the Cochrane Controlled Trials Register, MEDLINE, EMBASE, and CINAHL. The review considered randomised controlled trials and non-randomised studies, which included quasi-randomised trials, comparative studies, before-and-after studies, and interrupted
Interpretation of results
Non-randomised studies are particularly susceptible to biases, and all clinical studies of care pathways are susceptible to confounding. One obvious bias is selection bias, that is stroke patients may have been selected to be managed using a care pathway and may have differed from those who were managed using standard medical care. In one study, it was stated that patients were “selected for care pathway care using strict screening criteria”53 and we suspect that this was also the common
Effect of care pathways on major outcomes
Many experts think that care pathways must be beneficial and could not possibly do any harm, but this view is not wholly supported by this review. There is no conclusive evidence that care pathways provide additional benefit over standard care for the major clinical outcomes (death or discharge destination). In fact, there is some evidence from one randomised60 and one non-randomised study83 that patients in the care pathway group might be significantly less independent at discharge.
Care pathways and the basic structure of the stroke service
Care pathways are only likely to be effective in improving stroke care if the basic structure of the stroke service is already in place, such as the routine admission of patients to a stroke unit where patient care is provided by a coordinated multidisciplinary team made up of dedicated, motivated and skilled healthcare professionals.[89], [90] If the basic structure is not in place (for example, if patients managed by different medical teams in different general wards), then care pathways are
Care pathways for acute stroke management or stroke rehabilitation?
Although only a small number of studies were included in this systematic review, the results were consistently better for acute stroke pathways than stroke rehabilitation pathways. This can be explained by that fact that care pathways probably have the best potential to improve the process of care during the acute (or hyperacute) phase of stroke where the process of assessment, investigation, diagnosis can be highly complex (and often disorganised), and where speed is the essence when emergency
Electronic care pathways
Many hospital documents which have traditionally been paper-based (e.g. patient records) are increasingly becoming electronic. However, the introduction of any electronic patient record would be too expensive and time-consuming if it is only used as a tool to facilitate documentation and retrieve data faster; it must also add value in supporting clinical decision-making, improve quality of care, and possibly reduce hospitalisation costs.93 For this purpose, care pathways are increasingly being
Acknowledgement
Financial support: The author’s salary was supported by the Glaxo Wellcome Stroke Training Fellowship (2000–1) and Stroke Association Clinical Training Fellowship (2001–2).
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