Estimating the impact of stroke unit care on stroke deaths in a whole population: An epidemiological study using routine data
Résumé
Background and Purpose: Organised inpatient (stroke unit) care is effective in randomised trials where an absolute risk reduction (ARR) of 3% was observed for case fatality. However, it is unclear to what extent this complex intervention can have an impact in routine practice. We used the comprehensive national data available in Scotland to study the impact of stroke unit implementation on case fatality. Methods: We used the Scottish linked discharge database to identify all patients admitted to hospital with an incident stroke. Analyses compared case fatality (adjusted for age, sex, deprivation and co-morbidity) for hospitals with or without a stroke unit during four consecutive study periods (1986-90, 1991-95, 1996-2000, 2001-05). Results: The percentage of admissions to hospitals that had a stroke unit rose from 0% to 87% and the six-month case fatality dropped from 45% to 29% over the study period. Adjusted odds ratios (95% CI) for stroke unit versus no unit in each consecutive study period were; not calculable (no units before 1991), 0.83 (0.78-0.89), 0.90 (0.86-0.94), 0.87 (0.82-0.91). These equate to ARRs of 0%, 4.4%, 2.4%, 3.1% and hence estimated deaths avoided of 0, 205, 380 and 835 respectively. The total estimated impact of implementing stroke unit care was therefore 1,420 lives saved. This compared with 1425 estimated using clinical trial data. Conclusions: The results of this study are consistent with the positive impact of a policy of stroke unit care on case fatality. The estimated impact, after adjusting for case mix, appears very similar to that calculated using clinical trial data.
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