Editorial
From the evidence to the organisation of stroke care
De la evidencia a la organización de la atención al ictus
C. Serna-Candel
, J. Matías-Guiu
Corresponding author
Servicio de Neurología, Instituto de Neurociencias, Hospital Clínico San Carlos, Universidad Complutense de Madrid, Madrid, Spain
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Recurrence of strokes or new vascular events according to admission ward. SNW, specialised neurology ward; GMW, general medicine ward.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "J. Alvarez-Sabín, M. Ribó, J. Masjuan, J.R. Tejada, M. Quintana" "autores" => array:6 [ 0 => array:2 [ "nombre" => "J." "apellidos" => "Alvarez-Sabín" ] 1 => array:2 [ "nombre" => "M." "apellidos" => "Ribó" ] 2 => array:2 [ "nombre" => "J." "apellidos" => "Masjuan" ] 3 => array:2 [ "nombre" => "J.R." "apellidos" => "Tejada" ] 4 => array:2 [ "nombre" => "M." "apellidos" => "Quintana" ] 5 => array:1 [ "colaborador" => "on behalf of PRACTIC study researchers" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0213485310003361" "doi" => "10.1016/j.nrl.2010.12.007" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0213485310003361?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173580811000320?idApp=UINPBA00004N" "url" => "/21735808/0000002600000009/v1_201305151311/S2173580811000320/v1_201305151311/en/main.assets" ] "en" => array:17 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Editorial</span>" "titulo" => "From the evidence to the organisation of stroke care" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "507" "paginaFinal" => "509" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "C. Serna-Candel, J. Matías-Guiu" "autores" => array:2 [ 0 => array:4 [ "nombre" => "C." "apellidos" => "Serna-Candel" "email" => array:1 [ 0 => "inc.hcsc@salud.madrid.org" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "J." "apellidos" => "Matías-Guiu" ] ] "afiliaciones" => array:1 [ 0 => array:1 [ "entidad" => "Servicio de Neurología, Instituto de Neurociencias, Hospital Clínico San Carlos, Universidad Complutense de Madrid, Madrid, Spain" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "De la evidencia a la organización de la atención al ictus" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Acute stroke care should be based in stroke units (SUs).<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> Successive meta-analyses on clinical trials that have analysed their benefit with regards to mortality, going back home, independence and cost<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> have been clear<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> when comparing care in SUs to care in general internal medicine wards.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,6</span></a> They achieved a 14% reduction in mortality, 18% reduction in institutionalisation and 18% in death or dependency, but with confidence interval margin reductions that can reach 24%, 27% and 27%, respectively.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> The stroke care model for the SU is not portable<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> and its conclusions are therefore only applicable to hospital organisation. This has meant that implementing SUs has become a priority goal in Europe.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Despite this, the percentage of patients admitted to an SU in Europe is still low.<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10,11</span></a> In Spain, the National Stroke Strategy<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> has also established the SU implementation as a priority goal based on research, programmes and expert opinions that propound its benefits,<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13–15</span></a> even in elderly patients,<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> which has meant an increase of SUs in Spain.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">In this issue of <span class="elsevierStyleSmallCaps">Neurología,</span> we publish the results of PRACTIC, an observational study on SU benefits in Spain in 2004, before the start-up of the National Stroke Strategy<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> (“this issue”). PRACTIC is an observational study that included 88 hospitals in Spain, with a sample that resulted from choosing 10 consecutive patients who had attended the centre, comparing the care results in an SU with those in general wards. Similar analyses have been published in some other countries,<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">19,20</span></a> but PRACTIC is of special importance due to the unique characteristics of the Spanish health system. Our system is characterised by 17 health services, caring for patients with universal support; it therefore links decisions in a decentralisation of geographic areas, but is centralised when referring to planning. This is why it is a good example of how scientific evidence influences strategic and operating decisions.</p><p id="par0015" class="elsevierStylePara elsevierViewall">The first fact that arises from PRACTIC is that more than 75% of patients were attended in an SU. This would probably not be true if we applied it to Spain as a whole; a recent study has shown that the presence of SUs is currently uneven because the 39 SUs are distributed irregularly, mainly concentrated in large urban areas, especially Madrid and Barcelona.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> That derives from the fact that the centres that took part in the study had an SU, so the comparison relating to prognosis and evolution was more favourable, given that there were no significant differences in the descriptive data.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Some extra data obtained from PRACTIC should be highlighted. Mortality from a stroke is nearly four times higher when a patient is not admitted to an SU. This information implies significant ethical responsibilities, as an administrative organisation's decision to set up an SU or not influences survival in a much greater measure than any known drug. The decision taken to admit or not to admit to an SU by the admissions department becomes an element that influences prognosis and goes far beyond that based on patients’ comfort when finding them beds.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> This occurs in a number of ways: because specific treatments are involved in this action (as all thrombolytic therapy is carried out in an SU), through clinical pathways and standardised procedures<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> or through the training and experience of the professionals that comprise the SU.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">As seen in PRACTIC, patients show a significantly lower percentage of complications, have less disability when discharged and a greater percentage go back to their homes in the univariate and multivariate analysis, confirming what was seen in random trials. An interesting fact as a consequence of PRACTIC is that admittance to an SU conditions the risk of new events and long-term recurrences; this is significant not only both in survival curves and in multivariate analysis, with a reduction of practically 50%. Although this is an aspect that should be confirmed in future studies, it is probably indicative of the type of stroke information and health training given in the SU and not on the general wards that can condition the attitude of the patients and their families in the immediate future, especially in prevention of risk factors. However, as the authors suggest, this could be influenced by greater efficiency in clinical diagnosis and hospital aetiology that makes better secondary prevention therapy possible.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Thrombolytic therapy is the drug treatment that has the greatest benefit in acute strokes,<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> although in a slightly less measure that the SU. The dependence on both of them is very high, as it is in the centres having an SU where it is applied in higher percentage rates.<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">25,26</span></a> In PRACTIC, the frequency of thrombolytic therapy is low, and exclusively in the SUs, probably due to the temporary limitation that existed at that time. Due to this, it cannot justify the prognosis benefits of the SUs.</p><p id="par0035" class="elsevierStylePara elsevierViewall">PRACTIC represents an analysis of the SU role in Spain with regards to patients before the approval of the National Stroke Strategy and makes us see the improvement to which a greater implementation of SUs could lead. We should also add the effects that the neurology educational programme for new specialists, with vast specific training on strokes, can entail.<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">27,28</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Scientific evidence based on observational studies such as PRACTIC and on other previous random and cost studies has shown the benefit of SUs, recommending that their implications should applied to clinical practice and hospital organisation. Nowadays, caring for an acute stroke outside an SU is already a non-scientific medical practice, with negative consequences for the patient in survival rate, sequelae and return to normal life.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2010-12-29" "fechaAceptado" => "2011-01-07" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec157658" "palabras" => array:3 [ 0 => "Stroke" 1 => "Stroke unit" 2 => "Stroke care" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec157659" "palabras" => array:3 [ 0 => "Ictus" 1 => "Unidad de ictus" 2 => "Asistencia al ictus" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span class="elsevierStyleSectionTitle">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Acute stroke care in stroke units (SUs) compared to care in general medicine wards provides benefits to the patient.</p> <span class="elsevierStyleSectionTitle">Development</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Acute stroke care in an SU has shown benefits in reducing mortality, institutionalisation, dependency and costs compared to care in internal medicine wards, and even a lower risk of recurrence in the long term. The benefits are associated with specific treatments developed in the SU, such as thrombolytic therapy, development of clinical pathways, standardised procedures, and training and experience of professionals in the SU. This evidence should lead to the proper organisation of hospitals to ensure that all acute stroke patients may benefit from care in an SU. The introduction of SUs is a priority in Europe, although the number of stroke patients admitted to SUs is still low.</p> <span class="elsevierStyleSectionTitle">Conclusions</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Based on current evidence, acute stroke patients should be cared for in an SU due to the associated clinical benefits and hospitals should organise to provide this care to patients.</p>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span class="elsevierStyleSectionTitle">Introducción</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">La atención al ictus agudo en unidades de ictus (UI) respecto a su atención en salas de medicina general aporta beneficio al paciente.</p> <span class="elsevierStyleSectionTitle">Desarrollo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La atención al ictus agudo en UI ha demostrado beneficio en reducción de mortalidad, institucionalización, dependencia y costes respecto a la atención en salas de medicina interna, e incluso un menor riesgo de recurrencias a largo plazo. Los beneficios se asocian a los tratamientos específicos desarrollados en las UI como el tratamiento trombolítico, al desarrollo de vías clínicas y procedimientos estandarizados o al entrenamiento y experiencia de los profesionales que integran la UI. Esta evidencia debería conducir a una adecuada organización de los hospitales que pueda garantizar que todos los pacientes con ictus agudo puedan beneficiarse de la asistencia en UI. La implantación de UI es un objetivo prioritario en Europa, aunque el número de pacientes con ictus que ingresan en UI es todavía bajo.</p> <span class="elsevierStyleSectionTitle">Conclusiones</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Sobre la base de la evidencia actual, los pacientes con ictus agudo deberían ingresar en UI por el beneficio clínico asociado y los hospitales deberían organizarse para poder ofrecer esta atención a los pacientes.</p>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara">Please cite this article as: Serna-Candel C, Matías-Guiu J. De la evidencia a la organización de la atención al ictus. Neurología. 2011;26:507–9.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:28 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Do stroke units save lives?" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "P. Langhorne" 1 => "B.O. Williams" 2 => "W. Gilchrist" 3 => "K. Howie" 4 => "M. Kaste" 5 => "H. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 1 | 0 | 1 |
| 2024 October | 20 | 2 | 22 |
| 2024 September | 13 | 3 | 16 |
| 2024 August | 16 | 9 | 25 |
| 2024 July | 10 | 1 | 11 |
| 2024 June | 8 | 6 | 14 |
| 2024 May | 10 | 4 | 14 |
| 2024 April | 11 | 3 | 14 |
| 2024 March | 25 | 4 | 29 |
| 2024 February | 10 | 5 | 15 |
| 2024 January | 11 | 1 | 12 |
| 2023 December | 13 | 7 | 20 |
| 2023 November | 12 | 11 | 23 |
| 2023 October | 15 | 6 | 21 |
| 2023 September | 15 | 1 | 16 |
| 2023 August | 12 | 4 | 16 |
| 2023 July | 6 | 7 | 13 |
| 2023 June | 14 | 3 | 17 |
| 2023 May | 25 | 5 | 30 |
| 2023 April | 33 | 4 | 37 |
| 2023 March | 23 | 4 | 27 |
| 2023 February | 10 | 6 | 16 |
| 2023 January | 11 | 5 | 16 |
| 2022 December | 11 | 5 | 16 |
| 2022 November | 19 | 10 | 29 |
| 2022 October | 10 | 7 | 17 |
| 2022 September | 14 | 7 | 21 |
| 2022 August | 25 | 5 | 30 |
| 2022 July | 8 | 8 | 16 |
| 2022 June | 8 | 9 | 17 |
| 2022 May | 13 | 5 | 18 |
| 2022 April | 9 | 9 | 18 |
| 2022 March | 9 | 7 | 16 |
| 2022 February | 10 | 9 | 19 |
| 2022 January | 9 | 9 | 18 |
| 2021 December | 10 | 13 | 23 |
| 2021 November | 13 | 5 | 18 |
| 2021 October | 10 | 10 | 20 |
| 2021 September | 7 | 14 | 21 |
| 2021 August | 12 | 3 | 15 |
| 2021 July | 9 | 10 | 19 |
| 2021 June | 9 | 7 | 16 |
| 2021 May | 13 | 7 | 20 |
| 2021 April | 9 | 11 | 20 |
| 2021 March | 13 | 10 | 23 |
| 2021 February | 14 | 5 | 19 |
| 2021 January | 8 | 9 | 17 |
| 2020 December | 10 | 12 | 22 |
| 2020 November | 9 | 6 | 15 |
| 2020 October | 11 | 9 | 20 |
| 2020 September | 13 | 6 | 19 |
| 2020 August | 11 | 5 | 16 |
| 2020 July | 16 | 14 | 30 |
| 2020 June | 7 | 4 | 11 |
| 2020 May | 12 | 11 | 23 |
| 2020 April | 11 | 3 | 14 |
| 2020 March | 22 | 0 | 22 |
| 2020 February | 23 | 6 | 29 |
| 2020 January | 23 | 6 | 29 |
| 2019 December | 16 | 8 | 24 |
| 2019 November | 17 | 7 | 24 |
| 2019 October | 10 | 2 | 12 |
| 2019 September | 21 | 3 | 24 |
| 2019 August | 16 | 3 | 19 |
| 2019 July | 44 | 10 | 54 |
| 2019 June | 46 | 18 | 64 |
| 2019 May | 103 | 21 | 124 |
| 2019 April | 26 | 13 | 39 |
| 2019 March | 4 | 3 | 7 |
| 2019 February | 8 | 8 | 16 |
| 2019 January | 4 | 3 | 7 |
| 2018 December | 2 | 4 | 6 |
| 2018 November | 5 | 3 | 8 |
| 2018 October | 14 | 3 | 17 |
| 2018 September | 5 | 4 | 9 |
| 2018 August | 2 | 6 | 8 |
| 2018 July | 0 | 1 | 1 |
| 2018 June | 2 | 1 | 3 |
| 2018 May | 0 | 0 | 0 |
| 2018 April | 2 | 1 | 3 |
| 2018 March | 7 | 2 | 9 |
| 2018 February | 2 | 1 | 3 |
| 2018 January | 8 | 7 | 15 |
| 2017 December | 3 | 3 | 6 |
| 2017 November | 9 | 2 | 11 |
| 2017 October | 4 | 2 | 6 |
| 2017 September | 13 | 3 | 16 |
| 2017 August | 7 | 1 | 8 |
| 2017 July | 8 | 2 | 10 |
| 2017 June | 7 | 3 | 10 |
| 2017 May | 16 | 1 | 17 |
| 2017 April | 13 | 3 | 16 |
| 2017 March | 12 | 35 | 47 |
| 2017 February | 2 | 5 | 7 |
| 2017 January | 4 | 3 | 7 |
| 2016 December | 19 | 9 | 28 |
| 2016 November | 22 | 4 | 26 |
| 2016 October | 25 | 3 | 28 |
| 2016 September | 19 | 8 | 27 |
| 2016 August | 21 | 6 | 27 |
| 2016 July | 21 | 1 | 22 |
| 2016 June | 19 | 9 | 28 |
| 2016 May | 25 | 11 | 36 |
| 2016 April | 12 | 12 | 24 |
| 2016 March | 30 | 23 | 53 |
| 2016 February | 24 | 15 | 39 |
| 2016 January | 19 | 9 | 28 |
| 2015 December | 17 | 15 | 32 |
| 2015 November | 7 | 4 | 11 |
| 2015 October | 16 | 12 | 28 |
| 2015 September | 24 | 6 | 30 |
| 2015 August | 16 | 6 | 22 |
| 2015 July | 9 | 7 | 16 |
| 2015 June | 5 | 0 | 5 |
| 2015 May | 17 | 6 | 23 |
| 2015 April | 22 | 8 | 30 |
| 2015 March | 15 | 7 | 22 |
| 2015 February | 22 | 3 | 25 |
| 2015 January | 36 | 8 | 44 |
| 2014 December | 25 | 10 | 35 |
| 2014 November | 23 | 2 | 25 |
| 2014 October | 28 | 6 | 34 |
| 2014 September | 30 | 1 | 31 |
| 2014 August | 31 | 3 | 34 |
| 2014 July | 22 | 5 | 27 |
| 2014 June | 13 | 0 | 13 |
| 2014 May | 18 | 5 | 23 |
| 2014 April | 12 | 2 | 14 |
| 2014 March | 20 | 2 | 22 |
| 2014 February | 14 | 3 | 17 |
| 2014 January | 18 | 5 | 23 |
| 2013 December | 20 | 2 | 22 |
| 2013 November | 19 | 8 | 27 |
| 2013 October | 27 | 6 | 33 |
| 2013 September | 23 | 6 | 29 |
| 2013 August | 37 | 5 | 42 |
| 2013 July | 15 | 2 | 17 |
Show all
