In the News

Stroke units, opioid prescribing, and more.

Stroke units in community hospitals associated with better patient outcomes

Creating a stroke unit in a community hospital increases patient survival and the proportion of patients discharged home, a recent study found.

Past research has found that multidisciplinary, geographically distinct stroke units in larger, tertiary care hospitals have led to superior patient outcomes, so researchers sought to determine if the same would be true in smaller community hospitals. They performed a retrospective cohort study of 805 stroke patients from 2 community hospitals in Edmonton, Canada, who were admitted from 2003 to 2009. One hospital (<350 beds) created a stroke unit on Jan. 1, 2007; the other hospital was a control matched by size but without a stroke unit. The patient population of both hospitals was divided into 2 cohorts, 1 from 2003 to 2006 and 1 from 2007 to 2009. Outcomes included length of stay, death, disposition at discharge, and complications.

Results were adjusted for age, sex and medical comorbidities. Mortality fell from 17.1% to 8.3% (adjusted odds ratio [OR], 0.54; 95% CI, 0.31 to 0.95) after implementation of the stroke unit, while it remained about 19% at the control hospital. Patients at the stroke unit hospital also had twice the odds of being discharged home independently (OR, 2.17; 95% CI, 1.49 to 3.15; P<0.001). Complication rates at the control hospital didn't change during the study but dropped at the stroke unit hospital, with 50% fewer patients developing pneumonia after the unit was put in place (from 10.2% to 5.3%; P=0.037). In-hospital stroke mortality also improved at the stroke unit hospital but didn't change at the control hospital. Results were published in the January 2014 Stroke.

The use of a control hospital allowed researchers to adjust for overall changes in stroke care during the study period, they wrote. The results “confirm that the benefit of [stroke care units] extends beyond tertiary hospitals to community hospitals with more limited resources,” they wrote. It's not clear why stroke units improve outcomes, but the researchers noted the units are characterized by early mobilization, improved blood pressure management and adherence to guidelines. Stroke units “standardize the early management of stroke, which is where gaps in care often exist between rural and small urban hospitals without [stroke units] and larger metropolitan hospitals,” they wrote.

Few high-quality guidelines exist for prescribing opioids

Few high-quality guidelines exist for prescribing opioids to treat chronic pain, a review found, noting that there was at least consensus among guidelines on ways to mitigate opioid-related risks.

Researchers looked at MEDLINE, the National Guideline Clearinghouse, specialty society websites, and international guideline clearinghouses in July 2013 for guidelines published since January 2007 that addressed using opioids for chronic pain in adults. Guidelines on specific settings, populations and conditions were excluded. The review was published in the Jan. 7 Annals of Internal Medicine.

Researchers used 2 methods for evaluating the literature: the Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument and A Measurement Tool to Assess Systematic Reviews (AMSTAR).

With AGREE II, appraisers rated 23 items across 6 domains, scored from 1 for strongly disagree to 7 for strongly agree. Scaled domain scores (0% to 100%) were based on the sum of ratings across all appraisers and the difference between the maximum and minimum possible scores.

Ratings were highest for a guideline by the American Pain Society and the American Academy of Pain Medicine and for a guideline by the Canadian National Opioid Use Guideline Group. These were the only guidelines that more than half of the appraisers voted to use without modification. A majority of appraisers recommended against using 4 other guidelines because of limited confidence in development methods, lack of evidence summaries or concerns about readability.

In the original version of AMSTAR, appraisers answer 6 domain questions, which typically addressed multiple concepts. Using this system, systematic reviews within 10 guidelines were of poor or fair quality. The authors noted that the American Pain Society and the American Academy of Pain Medicine review was of excellent to outstanding quality, the review by the Canadian National Opioid Use Guideline Group was of good to excellent quality, and a review by the Department of Veterans Affairs and Department of Defense was of good quality.

Reasons for lower scores on other guidelines included limited information about search terms used, inclusion criteria, lists of included studies, and number of databases searched.

On mitigating opioid-related risks, a majority of the guidelines recommended that clinicians avoid doses greater than 90 to 200 mg of morphine equivalents per day, have additional knowledge to prescribe methadone, recognize risks of fentanyl patches, titrate cautiously, and reduce doses by at least 25% to 50% when switching opioids.

Guidelines also agreed on several opioid risk mitigation strategies, including written treatment agreements, and urine drug testing. Most recommendations were supported by observational data or expert consensus.

But, the review authors cautioned, few studies directly addressed questions of whether changing practices decreases risks of opioid use. “Given the pressing need to address opioid-related adverse outcomes, which some have described as an epidemic, developers seem to agree on forging recommendations based on relatively weak or indirect evidence now rather than waiting for more rigorous studies,” they wrote.