6 C URR ENT I SS U ES

have addressed the decrease in hospital stay from 3-4 weeks to 5-10 days. Instead. they have compared the quality of care received by patients admitted to hospital for several weeks with thai of patients adm itted for several months. Increasingly, hospitali. sarlon is only approved for patients who are suicidaJ or homicidal. Such guidelines arc inadequate for patients with psychiatric disorders. say the investigators. TIley believe that clear docwnentation of patients' behaviour can assist with prehospilalisalion approval.

"Quick completion of the most cost-effective treat­m Mt pilln and thorough allention to discharge

planning improlle the quality a/patient carr and can assist with approl'cl of continued inpaliud cQre', suggest the investigators.

The development of explicit guidelines for hospital admission and ongoing care for patients with psychiatric disorders will improve hcalthcare providers' ability to deliver cost-effective care, as well as secure reimbursement. These guidelines need to be based on outcomes data. they note.

Sch",SIer J. ~ o. fotcl B. Rescak R. TlKkcr o. n.d. C05I.-eifective inpatient care of neurop5yclUarric: puirnu. JOIIllW of N~ychiacry and ainaJ N~iences 1: I·S, No. I, I99S __

International Research and Opinion

Better outcomes through organised stroke management

Organised stroke management can reduce the duration of hospitalisation and the need for long-Ienn institutional care, and increase patient independence in daily activities, according to Finnish study findings.'

The study involved 243 elderly patients with acute stroke who were admitted to Meilahti Hospital* in Helsinki. Patients were randomi sed to receive care in either the medical or neurology departments of the hospital.

Around 71 % and 90% of patients in the medical and neurology wards , respectively, underwent neuroradiological tests, report the study authors. Notably, the mean total duralion of hospitalisation was 41.7 and 25.4 days, respectively. Also, medical ward patients were less likely to be discharged to home than those in the neurological ward.

Improved functional status and QOL During a I-year follow-up, there was no difference

between the paliem groups in the incidence of recurrent stroke or death. However, functional status was better among patients who had received care in the neurological, rather than medical, wards. based on the Barthel Index and the Rankin Scale. ** Patient quality of life was also more favou rable in the neurological group.

The study authors believe that improved outcomes following neurology department care were the resu lt of systematic and rational stroke manage­ment; i.e. organised diagnosis , acute treatment, and early systematic rehabilitation of patients by a stroke team. ***

In Finland, the annual cost of institutional care for a patient with stroke is around SUS85 000, compared with SUS50 000 for residential care and SUS25 000 for home care from outpatient nurses.

Dr James Bowen and Caroline Yaste from the US have shown that the introduction of a t reatment protocol for the management of stroke is associated with sign ifi cant savings in hospital costs.1

They implemented a cost-containment protocol for stroke in a hospital depanment that combined a

25 Mat 11M PHARMACOFlESOUFICES

critical path, or timeline, for particular tests and treatments, an emergency depanment treatment algorithm (e.g. criteria for IV heparin therapy and computed tomography scanning) and physician admission order sheets with options that could be selected for tests, treatments and consu ltations.

Shorter hospital stays The study involved 386 patients with stroke who

were assigned to either an historical control. concurrent conlJ"ol. or protocol group. Mean hospital charges for the 3 groups were SUS8831, SUS77 17 and SUS6764. respectively, excluding the 40 patients who received intensive care.

The duration of hospitalisation for patients in the protocol group was 38% and 18% shorter than that for patients in the historical and concurrent control groups, respectively. However. there was no difference in complications between the groups. Also. the proportions of patients who died, or were discharged to home, residential care or rehabilitation were similar. The outcomes remained unchanged when an analysis of all patients was conducted.

The protocol reduced hospital costs by mobilising hospital discharge services such as social work and rehabilitation. However, it appeared to have minimal impact on the type and number of tests and treat­ments ordered by physicians. Importantly, the shorter duration of hospitali sation associated with the protocol did not lead to an increase in outpatient costs. Dr Bowen and Ms Yasle point out.

• an 8(X)..bed instituJilHl that is part of Helsinki University Cefllraf Hospital

•• 1M Barthel lruiex as.ressed patients' ability 10 per/onn daily activities. while the Rankin Scale assessed overaff patient outcome.

... ~ stroke team incfutkd a patieflls individual physician and nurse, a social worker. physiotherapist. occupational therapist, speech therapist, neuropsychologist, and the hospitals senior neurologist and head nurse.

I. Kas~ M. eI a1. When: and how shoIild elderly stroke ~ticnlS he tre~1 A rmxIomilCd 1riaI. stroke 26: 249·253, Feb I99S 2. Bowen J. n a1. EffCCl of. iIrOkc prOIOCOI on hospiDI tOSIS <:I strOke patirnu. Neurology 44: 1%1· 1964, Oct 1994 _ ....