The benefit of an acute stroke unit in patients with intracranial haemorrhage: a controlled trial.

OBJECTIVES: Patients with stroke receiving organised inpatient (stroke unit) care after stroke are more likely to be alive and independent compared with patients offered conventional care. The objective was to determine the effect of an acute stroke unit on patients with primary intracranial haemorrhage. METHODS: In a prospective controlled study, the effect of an acute stroke unit was examined on 30 day and 1 year mortality in patients with primary intracranial haemorrhage. Patients treated in general medical wards served as controls. RESULTS: Of 121 patients included, 56 were allocated to an acute stroke unit and 65 to a general medical ward. The 30 day mortality rate was 39% in the acute stroke unit compared with 63% in the general medical wards, and the 1 year mortality rates were 52% and 69%, respectively. There was a difference between the 30 day and 1 year survival curves between the groups (p=0.007 and 0.013, respectively); however, there was no difference in survival between 30 and 365 days. There was no difference in risks of being discharged home or to long term care between the groups. CONCLUSIONS: In this study admission to an acute stroke unit reduced mortality 30 days and 1 year after primary intracranial haemorrhage, which could be attributed to a large difference in survival during the first 30 days.

The health-related quality of life of patients with epilepsy compared with angina pectoris, rheumatoid arthritis, asthma and chronic obstructive pulmonary disease.

The objective of this study was to compare the health-related quality of life (HRQL) of patients with epilepsy with populations suffering from different chronic diseases, using the short form 36 (SF-36) health profile measure. The populations to be compared were adult patients drawn from hospital based registers, with confirmed epilepsy (n = 397), angina pectoris (n = 785), rheumatoid arthritis (n = 1,030), asthma (n = 117) and chronic obstructive pulmonary disease (COPD) (n = 221). Health-related quality of life scores were compared using analysis of covariance (ANCOVA) for predicting mean scores adjusted for age, gender, education and comorbidity. Patients with epilepsy on average scored highest on all scales, reflecting that in our sample the majority had well-controlled epilepsy. Our results indicate that the HRQL of a representative sample of patients with epilepsy is good, when compared with other chronic disorders, although reduced in several dimensions compared with a general reference population. Patients with rheumatoid arthritis (RA) and COPD scored lowest on the physical function scales, while rheumatoid arthritis patients reported most pain.

[Should patients with acute stroke routinely receive supplemental oxygen?]. / Skal pasienter med akutt hjerneslag rutinemessig ha ekstra oksygentilførsel?

BACKGROUND: Supplemental oxygen is often given routinely to all patients suffering from an acute stroke, although clinical evidence for its efficacy is not available. The object of this study was to study the impact on mortality, impairment and disability of supplemental oxygen given the first 24 hours after an acute stroke. MATERIAL AND METHODS: Patients admitted to hospital with acute stroke were randomly allocated to two groups: one group received supplemental oxygen (100% atmospheres, 3 litres/minute) for 24 hours (n = 292); whereas a control group did not receive additional oxygen (n = 258). RESULTS: One-year survival was 69% in the oxygen group and 73% in the control group (odds ratio 0.82; 95% CI 0.57-1.19; p = 0.30). Impairment scores and disability scores were comparable seven months after stroke. Among patients with Scandinavian Stroke Scale (SSS) > or = 40.82% in the oxygen group and 91% in the control group survived (odds ratio 0.45; 95% CI 0.23-0.90; p = 0.02). For patients with SSS < 40, 53% in the oxygen group and 48% in the control group survived (odds ratio 1.26; 95% CI 0.76-2.09; p = 0.54). INTERPRETATION: The study indicates that supplemental oxygen should not be given routinely to non-hypoxic stroke victims with minor or moderate strokes. Further research is needed for giving conclusive advice concerning oxygen supplementation for patients with severe strokes.

Should stroke victims routinely receive supplemental oxygen? A quasi-randomized controlled trial.

BACKGROUND AND PURPOSE: We sought to test the hypothesis that breathing 100% oxygen for the first 24 hours after an acute stroke would not reduce mortality, impairment, or disability. METHODS: Subjects admitted to the Central Hospital of Akershus, Norway, with stroke onset <24 hours before admittance were allocated to 2 groups by a quasi-randomized design using birth numbers. All patients with acute stroke admitted to hospital within 24 hours after a stroke were included and enrolled. Patients were allocated to a group that received supplemental oxygen treatment (100% atmospheres, 3 L/min) for 24 hours (n=292) or to the control group, which did not receive additional oxygen. Main outcome measures were 1-year survival, neurological impairment (Scandinavian Stroke Scale), and disability (Barthel Index) 7 months after stroke. RESULTS: One-year survival was 69% in the oxygen group and 73% in the control group (OR 0.82; 95% CI 0.57 to 1.19; P=0.30). Impairment scores and disability scores were comparable 7 months after stroke. Among patients with Scandinavian Stroke Scale (SSS) scores of >/=40, 82% in the oxygen group and 91% in the control group survived (OR 0. 45; 95% CI 0.23 to 0.90; P=0.023). For patients with SSS scores of <40, 53% in the oxygen group and 48% in the control group survived (OR 1.26; 95% CI 0.76 to 2.09; P=0.54). CONCLUSIONS: Supplemental oxygen should not routinely be given to nonhypoxic stroke victims with minor or moderate strokes. Further research is needed to give conclusive advice concerning oxygen supplementation for patients with severe strokes.

Can patient satisfaction improve health among patients with angina pectoris?

OBJECTIVE: To identify and explore the components of patient satisfaction that have the strongest association with health-related quality of life among patients with angina. DESIGN: Cross-sectional study with postal questionnaires sent to patients 6 weeks after discharge from hospital, followed-up by one reminder. SETTING: The Central Hospital of Akershus in Norway. STUDY PARTICIPANTS: All 589 angina patients discharged between January 1 1995 and December 31 1996. The response rate was 67% (n=395). MAIN OUTCOME MEASURES: Physical and mental component summary scales in SF-36. RESULTS: When adjusted for relevant background factors such as age, sex, education, social network, health behaviour and sense of coherence, patient satisfaction explained 9% of the variation in the physical, and 7% of the variation in the mental component summary scales. In particular, satisfaction with medical treatment (P=0.002) and with information (P=0.003) were associated with improved physical and mental health-related quality of life. Patients who experienced their physicians as caring and competent were more likely to be satisfied with the medical treatment and with the information. Sense of coherence contributed to health-related quality of life both directly, and through improving patient satisfaction. CONCLUSION: This cross-sectional study supports the hypothesis that patient satisfaction contributes to both physical and mental health-related quality of life. Other research designs are needed to assess whether the associations identified are truly causal.

Outcome of subacute stroke rehabilitation: a randomized controlled trial.

BACKGROUND AND PURPOSE: Organized acute stroke treatment reduces mortality, functional deficits, and the need of institutionalization after stroke. It is largely unknown whether the effects of treatment are due to early or subacute efforts. The aim of this randomized, controlled study was to test the hypothesis that rehabilitation of stroke patients in the subacute phase in a hospital rehabilitation unit is beneficial in reducing death and dependency and increasing health-related quality of life. METHODS: 251 patients initially treated in the hospital were randomized to subacute rehabilitation in a hospital rehabilitation unit (n = 127) or to the health services in the municipality (n = 124) and were followed up for 7 months. RESULTS: The combined outcome of patients being dead or dependent (Barthel Index score of < 75) was 23% in the hospital group and 38% in the municipality group (P=.01). Seven-month survival rates were 90.6% and 83.9% (P=.11), respectively. Dependency in activities of daily living was 12.6% in the hospital group and 25.0% in the municipality group (P=.07). Patients with a BI score of < 50 before rehabilitation had significantly better outcome in the hospital rehabilitation unit, with fewer patients becoming dependent (P=.005) and patients having higher Scandinavian Stroke Scale (P=.026) and BI scores (P=.005). No significant differences in health-related quality of life were found. Many patients treated in the municipalities (30%) did not receive any organized rehabilitation in this study. CONCLUSIONS: Subacute rehabilitation of stroke patients in a hospital-based rehabilitation unit improves outcome. Patients with moderate or severe stroke appear to benefit most.

[PS-RESKVA (Patient Satisfaction, Results and Quality)--patient satisfaction in hospitals]. / PS-RESKVA--pasienttilfredshet i sykehus.

The reliability and acceptability of a 39-question patient-satisfaction questionnaire (PS-RESKVA) for use in hospitals is assessed. Postal questionnaires were sent to 19,395 patients, aged between 15 and 100 years, who were discharged from the medical, surgical, gynaecological, and neurological wards of two Norwegian hospitals; they were followed up with one reminder. The response rate was 59% for all patients, and 71% among those who were considered medically capable of answering. Six underlying factors were identified in the PS-RESKVA profile, which contained 11 different aspects satisfaction. The PS-RESKVA satisfied the psychometric criteria for internal consistency. Results indicate that the PS-RESKVA is a possible measure of patient satisfaction after discharge from hospital. It seems acceptable to patients in general, and is a reliable measure of satisfaction for a wide range of patients. Further studies on its validity are warranted.

Stroke unit versus general medical wards, II: neurological deficits and activities of daily living: a quasi-randomized controlled trial.

BACKGROUND AND PURPOSE: The efficacy of stroke units has been extensively examined. It is unknown, however, whether the superiority of the stroke unit will remain after the increased focus on stroke treatment in general medicine. This study of patients admitted to the hospital early and with a short length of stay determines the effect and identifies certain important components of a stroke unit. METHODS: Five hundred fifty patients aged 60 years or older with acute stroke were allocated by a quasi-randomized design to a stroke unit or a general medical ward based on date of birth in the month. Patients admitted within 24 hours of onset were enrolled. Outcomes after 7 months were death, proportion needing long-term care, and change in neurological and functional state assessed by the Scandinavian Stroke Scale and Barthel Index. RESULTS: Seven months after admission there was a trend in favor of the stroke unit in all outcome measures, but no significant differences in clinical outcomes were found except for change in the Scandinavian Stroke Scale score. Recurrent stroke during hospitalization occurred more often in the general medical ward (P = .03). The stroke unit was significantly more aggressive in mobilization out of bed (P<.01) and use of parenteral fluid (P<.0001), aspirin (P<.0001), antipyretics (P<.0001), and antibiotics (P<.0001). CONCLUSIONS: Our study confirms the benefit of the stroke unit, but the effects on the most reliable clinical outcomes were modest and insignificant. Treatment in this stroke unit hastened recovery. More aggressive rehabilitation and use of parenteral fluid, aspirin, antipyretics, and antibiotics appeared in the stroke unit.

Stroke units versus general medical wards, I: twelve- and eighteen-month survival: a randomized, controlled trial.

BACKGROUND AND PURPOSE: The long-term effect on survival of treatment in stroke units is still under debate. The hypothesis that a stroke unit with short length of stay increases 1-year and 18-month survival rates was tested in this study. METHODS: A quasi-randomized, controlled study was undertaken among 802 patients > or =60 years old admitted to the Central Hospital of Akershus in Norway with a diagnosis of stroke between January 1, 1993, and February 1, 1995. All patients with onset of symptoms <24 hours before admittance were included and enrolled and were followed until death or to the end of the observation 18 months after stroke. Patients were allocated to a stroke unit (n=364) or a general medical ward (n=438). RESULTS: Case fatality within the first 10 days was 8.2% among patients in the stroke unit and 15.1% among patients in the general medical ward (P=.0019). One-year survival among patients treated in the stroke unit was 70.6% and in the general medical wards 64.6% (P=.026); 18-month survival rates were 65.1% and 58.0%, respectively (P=.021). Among patients with cerebral hemorrhage, 10-day case fatality was 24.5% and 51.6% (P=.004) in favor of the stroke unit. CONCLUSIONS: Stroke units increase survival rates among stroke patients compared with general medical wards. The effect on survival occurs early after the stroke and sustains during at least 18 months of observation.

[How do working conditions of hospital personnel affect patients?]. / Hvordan påvirker sykehuspersonalets arbeidsmiljø resultatene for pasientene?

This study was performed to investigate to which extent job satisfaction and psychosocial working environment could explain variations in patient satisfaction with treatment and care. Questionnaires were mailed to nursing staff and to patients in 17 in-patient treatment units within two Norwegian hospitals. 2408 patients (61 per cent) replied on detailed questions concerning satisfaction with care, and 488 employees (78 per cent) replied on detailed questions concerning job satisfaction and psychosocial working conditions. Associations between 77 factors related to job satisfaction and 14 domains of patient satisfaction were assessed by simple correlations and multiple regression procedures using patient, employee and treatment ward as unit of analysis. Job satisfaction concerning bureucracy/organization, information from superiors, level of knowledge among leadership, economic constraints, collaboration, backup, stress, autonomy, skill, in-service training and fighting spirit were all significantly associated with various domains of patient satisfaction (all p values < 0.05). The study strengthens the hypothesis that job satisfaction play an important role for patient care and satisfaction. Leadership, organisation and continuity seem crucial.

[Life expectancy in Norway. An international perspective--causes of death]. / Utviklingen av dødeligheten i Norge. Et internasjonalt perspektiv--dødsårsakene.

We have shown before that Norway is experiencing an unfavourable trend in life expectancy compared with Japan, France and several other OECD countries. In this article, we discuss the cause-specific differences in mortality that explain these contrasts. Heart infarction is the predominant cause of death in Norway, with a mortality five times higher than in Japan and three times higher than in France. Both Norway and France have three times higher mortality rates for breast cancer than found in Japan, and the mortality rate for cervical cancer is twice as high in Norway as in the two other countries. Norwegian women show a mortality rate for lung cancer that is twice as high as that of their French sisters. Suicide among young Norwegians is a rapidly growing problem, and twice as common among Norwegian men aged 20-24 than among Japanese men of the same age. We challenge the health authorities and the specialists in the relevant fields to reflect again on their preventive strategies, in light of these contrasts.

[Life expectancy in Norway--an international perspective]. / Utviklingen av dødeligheten i Norge--et internasjonalt perspektiv.

Contrasts in life expectancy among countries are an important input for defining targets for the health service and for setting priorities for disease prevention and health promotion. In this article, the trend in life expectancy in Norway is compared with the trend in a selection of other OECD countries. Standardised measures of life expectancy were collected from WHO and OECD statistics. In 1960 Norwegians ranged among the top three countries as regards life expectancy for both women and men. In 1990 Norwegians ranged tenth for women and ninth for men. Life expectancy was two years shorter for Norwegian than for Japanese women in 1990, corresponding to a 20% surplus mortality throughout life. Similar differences were found for men. If Japanese age specific death rates are applied to the Norwegian population, this corresponds to a reduction of 9,600 deaths this year. The relatively unfavourable trend in life expectancy in Norway relative to other OECD countries raises concern, and should be considered when designing the future health policy.

[Costs of medical treatment of injuries in Norway]. / Medisinske behandlingskostnader for skader i Norge.

The objective of this study was to estimate the cost of medical treatment of injuries in Norway. We analysed aggregated data from two sources, the National Hospital Discharge Register and the National Injury Register, in order to calculate such costs in 1994. Approximately 400,000 injuries treated in hospitals and emergency departments in 1994 cost NOK 1.7 billion in terms of medical treatment. Unintentional injuries accounted for 91%, self-inflicted injuries for 3%, and injuries stemming from violence for 6% of the costs. Injuries requiring hospitalisation accounted for 71% of the total costs. Persons aged 65 years or more constituted 14% of the cases but accounted for 46% of the cost of treating unintentional injuries. Injuries at home or during leisure time accounted for 75% of the costs of the unintentional injuries, while traffic injuries accounted for 7%, occupational injuries for 8%, and 10% of the costs could not be classified. Hip fractures alone accounted for 27% of the total costs. Traffic and occupational injuries remain important targets for prevention, but greater efforts are required to reduce risk of injuries in the home and during leisure time, injuries to elderly people, hip fractures, and injuries that stem from violence.

[Results of health care services. A tool for better decision making]. / Resultater av helsetjenester. Et redskap for bedre beslutninger.

Until recently, post-war health care was characterized first by expansion and later by cost containment. We now appear to have entered a period focusing on assessment and accountability, often described as the outcomes movement. Patients' outcomes are regarded as the most important information on effectiveness and quality. The outcomes movement includes the traditional outcome measures of mortality and morbidity, as well as clinical endpoints, social, mental and physical well-being, general health, quality of life and patient satisfaction. Establishing the effectiveness of medical care in the "real world" is an important aspect of outcomes research. The article discusses the emergence of outcomes research, the central elements of outcomes management, and some critical views on the outcomes initiative.

Surgical treatment for partial epilepsy among Norwegian adults.

We conducted a retrospective longitudinal self-controlled study of 124 adult patients treated with resective surgery for medically uncontrolled partial epilepsy from 1949 to 1988. Approximately 65% of the patients experienced > 95% reduction in seizure frequency, and 75% had worthwhile improvement of at least 75% seizure reduction. Significant reductions were noted in all major seizure types treatable with resective surgery; complex partial (CPS), simple partial (SPS), and secondarily generalized tonic-clonic seizures (GTC) (all p < 0.05). Tissue pathology and region of resection did not provide significant information with respect to seizure outcome. EEG in the first postoperative year was an important predictor of long-term seizure outcome (p = 0.03). One third of the temporal lobe resected patients had neurologic deficits as a consequence of the resection as compared with 14% of patients with frontal resections (p = 0.03). One third of the deficits among the temporal lobe resected patients were considerable, with possible social implications. Half of the patients with preoperative focal spike activity had a normal EEG postoperatively. One fifth of patients maintained their preoperative epileptic focus after the operation, and about one fifth displayed new foci. Approximately one fourth of the patients were free of medication for a median of 16 years postoperatively, and 60% of patients who were seizure-free were still receiving medication. There was no operative mortality, but the late mortality, as expected, was higher than that of the general population. Two male patients (1.6%) committed suicide.

Surgical treatment for partial epilepsy among Norwegian children and adolescents.

We conducted a retrospective longitudinal self-controlled study of 64 patients aged 4-19 years treated with resective surgery for partial epilepsy from 1952 to 1988. Approximately 60% of patients experienced > 95% reduction in seizure frequency, and 70% had worthwhile improvement of at least 75% reduction. Seizure relief was more frequent among patients who underwent operation after 1978, and significant differences by time period of operation were noted for those with temporal lobe excisions and patients with normal tissue histology. The region of resection and the age at treatment did not provide significant information with respect to seizure outcome. Postresection electrocorticography (ECoG) and EEG of the first postoperative year predicted later seizure outcome. Small neurologic deficits were more common among patients resected in the temporal lobe than in patients resected in the frontal lobe. Half of the patients with preoperative unilateral focal activity and a third of those with bilateral focal activity had normal EEG postoperatively. One fourth had discontinued antiepileptic drug (AED) therapy. As expected, long-term mortality was significantly higher than the mortality of the general population. Seven patients died during follow-up. Two male patients committed suicide.