Middleton Sandy, Coughlan Kelly, Mnatzaganian George, Low Choy Nancy, Dale Simeon, Jammali-Blasi Asmara, Levi Chris, Grimshaw Jeremy M, Ward Jeanette, Cadilhac Dominique A, McElduff Patrick, Hiller Janet E, D'Este Catherine
From the Nursing Research Institute, St Vincent's Health Australia (Sydney) and Australian Catholic University, St Vincent's Hospital, New South Wales (S.M., K.C., S.D., A.J.-B.); College of Science, Health and Engineering, La Trobe Rural Health School, La Trobe University, Victoria, Australia (G.M.); School of Physiotherapy, Faculty of Health Sciences, Australian Catholic University, Queensland (N.L.C.); John Hunter Hospital and Centre for Translational Neuroscience and Mental Health, University of Newcastle/Hunter Medical Research Institute, New South Wales, Australia (C.L.); Clinical Epidemiology Program, Ottawa Health Research Institute, Ottawa Hospital-General Campus, Centre for Practice-Changing Research (CPCR), Ontario, Canada and Department of Medicine, University of Ottawa, Ontario, Canada (J.M.G.); School of Epidemiology, Public Health and Preventive Medicine (SEPHPM), University of Ottawa, Ontario, Canada and Nulungu Research Institute, University of Notre Dame Australia, Western Australia (J.W.); Translational Public Health Division, Stroke and Ageing Research, School of Clinical Sciences, Monash University, Australia and Public Health, Stroke Division, The Florey Institute of Neuroscience and Mental Health, Victoria, Australia (D.A.C.); School of Medicine and Public Health, The University of Newcastle, New South Wales, Australia (P.M.); Health Sciences, Faculty of Health Sciences, Swinburne University of Technology, Victoria, Australia and School of Public Health, University of Adelaide, South Australia, Australia (J.E.H.); and National Centre for Epidemiology and Population Health (NCEPH), Research School of Population Health, Australian National University, Australian Capital Territory (C.D.).
Stroke. 2017 May;48(5):1331-1336. doi: 10.1161/STROKEAHA.116.016038. Epub 2017 Apr 7.
Implementation of nurse-initiated protocols to manage fever, hyperglycemia, and swallowing dysfunction decreased death and disability 90 days poststroke in the QASC trial (Quality in Acute Stroke Care) conducted in 19 Australian acute stroke units (2005-2010). We now examine long-term all-cause mortality.
Mortality was ascertained using Australia's National Death Index. Cox proportional hazards regression compared time to death adjusting for correlation within stroke units using the cluster sandwich (Huber-White estimator) method. Primary analyses included treatment group only unadjusted for covariates. Secondary analysis adjusted for age, sex, marital status, education, and stroke severity using multiple imputation for missing covariates.
One thousand and seventy-six participants (intervention n=600; control n=476) were followed for a median of 4.1 years (minimum 0.3 to maximum 70 months), of whom 264 (24.5%) had died. Baseline demographic and clinical characteristics were generally well balanced by group. The QASC intervention group had improved long-term survival (>20%), but this was only statistically significant in adjusted analyses (unadjusted hazard ratio [HR], 0.79; 95% confidence interval [CI], 0.58-1.07; =0.13; adjusted HR, 0.77; 95% CI, 0.59-0.99; =0.045). Older age (75-84 years; HR, 4.9; 95% CI, 2.8-8.7; <0.001) and increasing stroke severity (HR, 1.5; 95% CI, 1.3-1.9; <0.001) were associated with increased mortality, while being married (HR, 0.70; 95% CI, 0.49-0.99; =0.042) was associated with increased likelihood of survival. Cardiovascular disease (including stroke) was listed either as the primary or secondary cause of death in 80% (211/264) of all deaths.
Our results demonstrate the potential long-term and sustained benefit of nurse-initiated multidisciplinary protocols for management of fever, hyperglycemia, and swallowing dysfunction. These protocols should be a routine part of acute stroke care.
URL: http://www.anzctr.org.au. Unique identifier: ACTRN12608000563369.
在澳大利亚19个急性卒中单元开展的QASC试验（急性卒中护理质量研究，2005 - 2010年）中，实施由护士发起的用于管理发热、高血糖和吞咽功能障碍的方案可降低卒中后90天的死亡和残疾发生率。我们现在研究长期全因死亡率。
使用澳大利亚国家死亡指数确定死亡率。Cox比例风险回归采用聚类夹心（Huber - White估计量）方法比较死亡时间，并对卒中单元内的相关性进行校正。主要分析仅包括未对协变量进行校正的治疗组。次要分析采用多重填补法对缺失的协变量进行校正，纳入年龄、性别、婚姻状况、教育程度和卒中严重程度等因素。
1076名参与者（干预组n = 600；对照组n = 476）被随访了中位数4.1年（最短0.3年至最长70个月），其中264人（24.5%）死亡。各基线人口统计学和临床特征在组间总体平衡良好。QASC干预组的长期生存率有所提高（>20%），但仅在校正分析中具有统计学意义（未校正风险比[HR]，0.79；95%置信区间[CI]，0.58 - 1.07；P = 0.13；校正HR，0.77；95% CI，0.59 - 0.99；P = 0.045）。年龄较大（75 - 84岁；HR，4.9；95% CI，2.8 - 8.7；P < 0.001）和卒中严重程度增加（HR，1.5；95% CI，1.3 - 1.9；P < 0.001）与死亡率增加相关，而已婚（HR，0.70；95% CI，0.49 - 0.99；P = 0.042）与生存可能性增加相关。在所有死亡病例中，80%（211/264）的主要或次要死亡原因被列为心血管疾病（包括卒中）。
我们的结果表明，由护士发起的用于管理发热、高血糖和吞咽功能障碍的多学科方案具有潜在的长期持续益处。这些方案应成为急性卒中护理的常规组成部分。
