PubMed · 6562556
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L Applin. Shifting the system.. https://pubmed.ncbi.nlm.nih.gov/6562556/
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BACKGROUND: Using previously published data, the purpose of this study was to identify and discriminate between three different forms of inpatient stroke care based on timing and duration of treatment and to compare the results of clinically important outcomes. METHODS: Randomized controlled trials, including a recent review of inpatient stroke unit/rehabilitation care, were identified and grouped into three models of care as follows: (a) acute stroke unit care (patients admitted within 36 h of stroke onset and remaining for up to 2 weeks; n = 5), (b) units combining acute and rehabilitative care (combined; n = 4), and (c) rehabilitation units where patients were transferred onto the service approximately 2 weeks following stroke (post-acute; n = 5). Pooled analyses for the outcomes of mortality, combined death and dependency and length of hospital stay were calculated for each model of care, compared to conventional care. RESULTS: All three models of care were associated with significant reductions in the odds of combined death and dependency; however, acute stroke units were not associated with significant reductions in mortality when this outcome was analyzed separately (OR 0.80; 95% CI: 0.61-1.03). Post-acute stroke units were associated with the greatest reduction in the odds of mortality (OR 0.60; 95% CI: 0.44-0.81). Significant reductions in length of hospital stay were associated with combined stroke units only (weighted mean difference -14 days; 95% CI: -27 to -2). CONCLUSIONS: Overall, specialized stroke services were associated with significant reductions in mortality, death and dependency and length of hospital stay although not every model of care was associated with equal benefit.
The study of pancreatic diseases requires specific knowledge and experience. There are many reasons for the need of a specific approach: pancreatic diseases are rare, their clinical presentation is often misleading, diagnostic investigations pose many challenges and pancreatic surgery is very complex. Due to these characteristics, it is difficult for a physician who only occasionally deals with a pancreatic disease to correctly manage it. For example, it is not sufficient to make a diagnosis of "pancreatic tumor", because we have to precisely define its extension and its relationship with the surrounding vessels, to recognize rare histological types different from adenocarcinoma, to have a "pancreatic" surgical experience to lessen the risk of serious surgical complications. On the other hand, several reports have shown that pancreatic resections have lower mortality rates and better long-term outcomes if carried out in Centers with a high caseload of patients. These considerations support the creation of Pancreas Units, not mere high-volume Departments specialized in pancreatic diseases, but multidisciplinary teams (composed of surgeons, oncologists, gastroenterologists, pathologists, radiologists, radiotherapists and different types of researchers) devoted to all aspects (etiology, pathogenesis, diagnosis, treatment) of pancreatic diseases. We think that the adoption of a Pancreas Unit model could represent the right answer to the recent changes observed in Medicine and could offer a better approach to patients with pancreatic diseases.
It is well known that stroke is associated with high morbidity and mortality. Previous studies and metaanalysis provide evidence favouring care of stroke patients in Stroke Units (SU). We published data on SU coverage for seven Italian regions during 2000-2001. The aim of this study is to conduct a new recent survey of SUs in the entire national territory and to evaluate changes in number of SUs and in organisation of in-hospital care in the seven Italian regions evaluated in our previous survey. Hospital services were identified through the diagnosis-related groups (DRG 14) from national hospital discharge registers. We selected services recording at least 50 acute stroke discharges per year. The characteristics of hospital services were obtained from a structured questionnaire submitted by phone by trained researchers to the doctors in charge of services. A SU was defined as a ward that admits acute stroke patients cared for in dedicated beds and by dedicated staff. Out of 676 hospital services evaluated during 2003-2004, 68 were SUs. The national coverage for SU services was 10%, ranging from 0% to 50% in different regions. In 2003-2004 SUs admitted 10% of the total national acute stroke cases. SUs have a more facilitated access to diagnostic evaluations and also seem to be better organised than general wards. Between 2000 and 2004 the number of SUs increased from 7% to 11% in the seven regions evaluated in our first survey. Notwithstanding we found an increase of 30% in the number of SUs, at least in the regions previously evaluated, there is still a shortage of SU beds and high regional heterogeneity.