Taylor William J, Wong Annie, Siegert Richard J, McNaughton Harry K
Rehabilitation Teaching & Research Unit, Wellington School of Medicine & Health Sciences, University of Otago, PO Box 7343, Wellington, New Zealand.
BMC Health Serv Res. 2006 Feb 23;6:16. doi: 10.1186/1472-6963-6-16.
Organised stroke care saves lives and reduces disability. A clinical pathway might be a form of organised stroke care, but the evidence for the effectiveness of this model of care is limited.
This study was a retrospective audit study of consecutive stroke admissions in the setting of an acute general medical unit in a district general hospital. The case-notes of patients admitted with stroke for a 6-month period before and after introduction of the pathway, were reviewed to determine data on length of stay, outcome, functional status, (Barthel Index, BI and Modified Rankin Scale, MRS), Oxfordshire Community Stroke Project (OCSP) sub-type, use of investigations, specific management issues and secondary prevention strategies. Logistic regression was used to adjust for differences in case-mix.
N = 77 (prior to the pathway) and 76 (following the pathway). The median (interquartile range, IQR) age was 78 years (67.75-84.25), 88% were European NZ and 37% were male. The median (IQR) BI at admission for the pre-pathway group was less than the post-pathway group: 6 (0-13.5) vs. 10 (4-15.5), p = 0.018 but other baseline variables were statistically similar. There were no significant differences between any of the outcome or process of care variables, except that echocardiograms were done less frequently after the pathway was introduced. A good outcome (MRS < 4) was obtained in 66.2% prior to the pathway and 67.1% after the pathway. In-hospital mortality was 20.8% and 23.1%. However, using logistic regression to adjust for the differences in admission BI, it appeared that admission after the pathway was introduced had a significant negative effect on the probability of good outcome (OR 0.29, 95%CI 0.09-0.99).
A clinical pathway for acute stroke management appeared to have no benefit for the outcome or processes of care and may even have been associated with worse outcomes. These data support the conclusions of a recent Cochrane review.
有组织的卒中护理可挽救生命并减少残疾。临床路径可能是有组织的卒中护理的一种形式，但这种护理模式有效性的证据有限。
本研究是对一家地区综合医院急性普通内科病房连续收治的卒中患者进行的回顾性审计研究。对引入该路径前后6个月内收治的卒中患者的病历进行审查，以确定住院时间、结局、功能状态（巴氏指数、BI和改良Rankin量表、MRS）、牛津郡社区卒中项目（OCSP）亚型、检查的使用、具体管理问题和二级预防策略的数据。采用逻辑回归调整病例组合的差异。
路径实施前N = 77例，路径实施后N = 76例。年龄中位数（四分位间距，IQR）为78岁（67.75 - 84.25），88%为欧洲裔新西兰人，37%为男性。路径实施前组入院时的BI中位数（IQR）低于路径实施后组：6（0 - 13.5）对10（4 - 15.5），p = 0.018，但其他基线变量在统计学上相似。除引入路径后超声心动图检查频率降低外，任何结局或护理过程变量之间均无显著差异。路径实施前66.2%的患者获得了良好结局（MRS < 4），路径实施后为67.1%。住院死亡率分别为20.8%和23.1%。然而，使用逻辑回归调整入院BI差异后，似乎引入路径后入院对获得良好结局概率有显著负面影响（OR = 0.29,95%CI 0.09 - 0.99）。
急性卒中管理的临床路径似乎对结局或护理过程无益处，甚至可能与更差的结局相关。这些数据支持了最近Cochrane综述的结论。
