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nthony Herd’s comprehensive, evidence- based, and optimistic reviews of acute stroke management (pages 1787 and 1795) are particu- larly timely for three reasons. First, we are on the brink of a sharp increase in the burden of cere- brovascular diseases as Canada’s baby boomers move into the high-risk age group. Second, the articles provide a backdrop for an array of new ini- tiatives to deal with the problem more effectively.Third, they offer an opportunity to highlight the role of family physicians in the team approach to a complex medical condition.
Herd delivers the key message at the end of the second article: organized stroke care saves lives and reduces disability among sur vivors. A systematic review of the evidence from ran- domized trials shows that treatment in stroke units rather than general medical wards results in about 70 fewer dead or institutionalized patients for ever y 1000 treated.1Moreover, this benefit is durable,2reproducible in routine clin- ical settings,3 and not restricted to any particu- lar subgr oup of patients.1 In other wor ds, organized stroke unit care is appropriate for vir tually all patients and is likely to be highly cost effective.4
In the trials, organized care was characterized by geographically defined and coordinated multi- disciplinar y teams of health professionals with interest and expertise in stroke and rehabilita- tion care. Caregivers were involved in the reha- bilitation process, and education was provided for hospital staff as well as for patients and their caregivers.1A more recent study5found that the significant factors in a stroke unit “treatment package” included earlier mobilization, earlier use of acetylsalicylic acid, more frequent admin- istration of parenteral fluid, and more frequent use of antipyr etic and antibiotic therapy.
Organized stroke unit care appears to benefit a range of stroke patients in a variety of ways, reducing death from secondary complications of stroke, and decreasing the need for institutional care through a reduction in disability.6
Despite all this evidence, organized stroke unit care is not widely available and accessible. For example, in a 1998 survey of acute care hospitals in Ontario, only 4% had a dedicated stroke unit.7But things are changing. The Canadian Stroke Systems Coalition (which includes the College of Family Physicians of Canada) was formed to provide leadership in development of a coordinated national approach to a comprehensive integrated stroke system. At the core of the coalition’s recently pub- lished recommendations8 is the concept of a national network of regional stroke programs.
Planning for a more coordinated approach to stroke care that spans prevention, emergency intervention, in-hospital treatment and rehabilita- tion on a stroke unit, and community reintegration is already under way in several parts of the coun- try.9Family physicians play a key role along this continuum, including providing acute care. The sur vey of Ontario hospitals7showed that family physicians were the attending physicians for stroke patients in 78% of acute care hospitals. A central role in the reform of stroke care is clearly appropriate for family physicians, too. In Nova Scotia, family physicians are leading the way by actively participating in development of an inte- grated stroke strategy for the province.
Deliver y of thrombolysis treatment to those who are eligible is only one component of orga- nized stroke care. Tissue plasminogen activator (TPA) has given us the capability to reverse the devastating consequences of stroke, and nation- wide experience10-14indicates that the treatment canbe administered effectively within our health care system. Yet questions and concerns persist about the role of TPA for acute stroke that pub- lished trials have not answered. Do the very elder- ly benefit? Should strokes of any severity be treated? How should the appearances of a com- puted tomography scan influence decisions about treatment? Is TPA effective when administered between 3 and 6 hours after stroke onset, as is sug- gested by the Cochrane Collaboration’s meta- analysis?15Can the therapy be delivered effectively
Editorials Editorials
Moving stroke care forward
Stephen Phillips, MD Gord Gubitz, MD
1700 Canadian Family Physician•Le Médecin de famille canadien❖VOL 47: SEPTEMBER • SEPTEMBRE 2001
Editorials
in community hospitals without stroke neurolo- gists or neuroradiologists? These questions are being addressed by the Third International Stroke Trial (IST-3),16,17a large, pragmatic randomized placebo-controlled trial now beginning in several countries. Canadian participation in IST-3 is cur- rently being organized and will likely help facilitate wider deployment of thrombolysis for stroke, as was the case for hospitals that participated in the trials of thrombolysis for MI.18
Organized stroke care brings the added advan- tage of providing a framework for conducting clini- cal research, including treatment trials.8 Many research questions relating to all facets of stroke care are beginning to be more systematically addressed by the Canadian Stroke Network19 (recently funded by the federal Network of Centres of Excellence program). This offers much scope for collaboration involving family physicians.
Thrombolysis has served as a catalyst to improve long-standing deficiencies in the way our health sys- tem deals with stroke. A coordinated approach involving physicians at all levels of the health care system is essential. Could it be that organized stroke care has emerged in Canada?
Drs Phillips and Gubitz are with the Division of Neurology, Department of Medicine, at Dalhousie University and the Queen Elizabeth II Health Sciences Centre in Halifax, NS.
Correspondence to: Dr Stephen J. Phillips, 3831 Halifax Infirmary, 1796 Summer St, Halifax, NS B3H 3A7; telephone (902) 473-5423; fax (902) 473-4438;
e-mail [email protected]
References
1. Stroke Unit Trialists’ Collaboration. Organised inpatient (stroke unit) care for stroke. The Cochrane Library [database on disk and CD-ROM]. The Cochrane Collaboration. Oxford, Engl: Update Software; 1996.
2. Indredavik B, Bakke F, Slørdahl SA, Rokseth R, Håheim LL. Stroke unit treat- ment. 10-year follow-up. Stroke 1999;30:1524-7.
3. Stegmayr B, Asplund K, Hulter-Asberg K, Norrving B, Peltonen M, Terent A, et al for the Riks-Stroke Collaboration. Stroke units in their natural habitat.
Can results of randomized trials be reproduced in routine clinical practice?
Stroke1999;30:709-14.
4. Hankey GJ, Warlow CP. Treatment and secondary prevention of stroke: evi- dence, costs, and effects on individuals and populations. Lancet 1999;354:1457-63.
5. Rønning OM, Guldvog B. Stroke unit versus general medical wards, II: neu- rological deficits and activities of daily living: a quasi-randomized controlled trial. Stroke 1998;29:586-90.
6. Stroke Unit Trialists’ Collaboration. How do stroke units improve patient out- comes? A collaborative systematic review of the randomized trials. Stroke 1997;28:2139-44.
7. Tu JV, Porter J. Stroke care in Ontario: hospital survey results [webpage].
Toronto, Ont: Institute for Clinical Evaluative Sciences; 1999. Available from:
http://www.ices.on.ca.Accessed 2001 June 28.
8. Wilson E, Taylor G, Phillips S, Stewart PJ, Dickinson G, Ramsden VR, et al, on behalf of the Canadian Stroke Systems Coalition. Creating a Canadian stroke system. Can Med Assoc J 2001;164:1853-5.
9. Ontario Ministry of Health and Long-Term Care. Report of the Joint Stroke Strategy Working Group. Toronto, Ont: Ontario Ministry of Health and Long- Term Care; June 2000. Available from:http://www.gov.on.ca/health/english/
pub/ministry/stroke/stroke_mn.html.Accessed 2001 June 28.
10. Hill MD, Barber PA, Demchuk AM, Sevick RJ, Newcommon NJ, Green T, et al. Building a “brain attack” team to administer thrombolytic therapy for acute ischemic stroke. Can Med Assoc J 2000;162:1589-93.
11. Riopelle RJ, Howse DC, Bolton C, Elson S, Groll DL, Holtom D, et al.
Regional access to acute ischemic stroke intervention. Stroke 2001;32:652-5.
12. Hill MD, Buchan AM, on behalf of the CASES Investigators. The Canadian Activase for Stroke Effectiveness Study. Can J Neurol Sci 2001;28(Suppl 2):S16.
13. Jarrett J, Gubitz G, Phillips S. Outcomes following intravenous tissue-plas- minogen activator (IV TPA) on a Canadian stroke unit. Stroke 2000;31:2882.
14. Gubitz G, Phillips S, Jarrett J. Cost savings following tissue plasminogen activator (IV TPA) on a Canadian stroke unit. Stroke 2000;31:2888.
15. Wardlaw JM, del Zoppo G, Yamaguchi T. Thrombolysis for acute ischaemic stroke. The Cochrane Library [database on disk and CD-ROM]. The Cochrane Collaboration. Oxford, Engl: Update Software, 1996.
16. Gubitz G, for the IST-3 Collaborative Group. The Third International Stroke Trial (IST-3)—Thrombolysis for acute ischemic stroke. Can J Neurol Sci 2001;28(Suppl 2):S28-S29.
17. The IST-3 Collaborative Group. Protocol for the Third International Stroke Trial. Available from: http://www.dcn.ed.ac.uk/IST3. Accessed 2001 June 28.
18. Ketley D, Woods KL. Impact of clinical trials on clinical practice: example of thrombolysis for acute myocardial infarction. Lancet 1993;342:891-4.
19. The Canadian Stroke Network. Available from: http://www.canadianstrokenetwork.ca.
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