Retrospective case note review of acute and inpatient stroke outcomes
BMJ 2000; 320 doi: https://doi.org/10.1136/bmj.320.7248.1511 (Published 03 June 2000) Cite this as: BMJ 2000;320:1511
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We agree with the comments by Bakta and Geddes that the majority of
the striking difference in outcome between those admitted with a stroke
and those who suffer a stroke in hospital having come in with some other
illness is probably explained by the comorbidity but we are planning a
further prospective study to identify what role the 'care' provided in the
early period after the event may have an influence on the outcome. It is
our impression that diagnosis may be delayed in post operative patients
particularly where the effects of surgery and drugs may confuse the issue.
Anil Sharma
Competing interests: No competing interests
Dear Editor
We read with interest the study by Aly et al who report that patients who
have stroke while in hospital do worse than people admitted with stroke.
(1) Metaanalysis has shown that organised care from knowledgeable
multdisciplinary teams improves outcome (2) and we agree with Aly and
colleagues that the poorer outcome they observed may be partly explained
due to differential staff awareness.
However it is important to identify the effect of co-morbid
conditions of patients who were not admitted with a stroke, but who
subsequently had a stroke, as this may also contribute to outcome. For
example, an individual admitted for treatment of heart failure who is
already relatively immobile is likely to have a poorer outcome if mobility
is further reduced due to a stroke occurring whilst in hospital.
1. Aly N, McDonald K, Leathley M, Sharma A and Watkins C.
Retrospective case note review of acute and inpatient stroke outcomes. BMJ
2000; 320: 1511-1512.
2. Stroke Unit Trialist's Collaboration. Collaborative systematic review
of randomised trials of organised inpatient (stroke unit) care after
stroke. BMJ 1997; 314: 1151-1159.
Competing interests: none
Competing interests: No competing interests
Stroke in hospitalized patients: incidence and risk factors
Editor – Aly and colleagues (June 3 issue)(1) state that stroke
outcomes in hospitalized patients are poorer than in patients admitted
with a stroke. Although we agree with their conclusion, we think that some
comments should be made.
The 11 per 1000 annual incidence of stroke among inpatients they cite
from our study(2) is the crude incidence. The age-adjusted incidence is
5.46 per 1000, still more than twofold the annual incidence in the
community.
In our study we did not exclude patients without obvious iatrogenic
predisposing factors, as reported in their paper. All patients with a
stroke occurring during hospitalization were considered. In some patients
stroke complicated various diagnostic and therapeutic procedures, and they
were excluded from further analysis, because the frequency of iatrogenic
stroke may be influenced by hospital-related variables, such as type and
frequency of procedures, and morbidity of surgical teams.
Comparing the two groups of stroke patients, Aly and colleagues found
that cardiovascular risk factors were higher among inpatients, while
previous strokes or transient ischaemic attacks were more common among
admitted patients. Although similar in terms of age and sex, the two
groups are very different in terms of size, the inpatients being 100, and
the admitted patients being 1274, and in both groups the percentage of
patients for which risk factors are not clearly documented is
considerable. These aspects might have biased their findings.
As suggested by the authors, a better identification and
documentation of known risk factors for stroke may improve outcome. In
their series, though, some important predictors of stroke outcome, such as
severity of neurological deficit and level of consciousness at onset, were
not documented. These clinical variables, independent from staff awareness
about risk factors, have a strong role in influencing stroke prognosis and
should be considered in interpreting different outcomes in the two groups
of patients.
Francesco Nonino
MD, Neurologist
Department of Neurology, Piacenza General Hospital
29100 Piacenza, Italy
e-mail: fnonino@yahoo.com
Giuseppe Azzimondi
MD, Neurologist
Unit of Neuroepidemiology, Institute of Clinical Neurology
40100 Bologna, Italy
e-mail: azzi.giu@libero.it
Roberto D’Alessandro
MD, Neurologist
Unit of Neuroepidemiology, Institute of Clinical Neurology
40100 Bologna, Italy
e-mail: daless.rob@iol.it
1. Aly N, McDonald K, Leathley M, Sharma A and Watkins C.
Retrospective case note review of acute and inpatient stroke outcomes. BMJ
2000; 320: 1511-1512.
2. Azzimondi G, Nonino F, Fiorani L, Vignatelli L, Stracciari A,
Pazzaglia P, et al. Incidence of stroke among inpatients in a large
Italian hospital. Stroke 1994; 25: 1752-1754
Competing interests: none
Competing interests: No competing interests