Stroke liaison workers for stroke patients and carers: an individual patient data meta-analysis: Cochrane systematic review
Assessed as up to date: 2009/08/13
Many patients experience depression, social isolation and anxiety post stroke. These are associated with a poorer outcome. Ameliorating these problems may improve patient wellbeing.Objectives
To evaluate the impact of a healthcare worker or volunteer whose multi-dimensional roles have been grouped under the title 'stroke liaison worker'.Search methods
We searched the Cochrane Stroke Group Trials Register (searched February 2009), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 1, 2009), MEDLINE (1966 to 2009), EMBASE (1980 to 2009) and four other databases. We performed a cited reference search, searched conference proceedings and trials registers, checked reference lists and contacted authors and trial investigators.Selection criteria
Randomised controlled trials investigating the impact of a stroke liaison worker versus usual care.Data collection and analysis
We invited trialists to participate in a review of individual patient data. Primary outcomes for patients were subjective health status and extended activities of daily living. Primary outcomes for carers were subjective health status including measures of carer strain.Main results
We included 16 trials involving 4759 participants. Analysis did not show a significant overall difference for subjective health status (standardised mean difference (SMD) -0.03, 95% confidence interval (CI) -0.11 to 0.04, P = 0.34) or extended activities of daily living (SMD 0.04, 95% CI -0.03 to 0.11, P = 0.22). There was no overall significant effect for the outcome of carer subjective health status (SMD 0.04, 95% CI -0.05 to 0.14, P = 0.37). Patients with mild to moderate disability (Barthel 15 to 19) had a significant reduction in dependence (odds ratio (OR) 0.62, 95% CI 0.44 to 0.87, P = 0.006). This would equate to 10 fewer dependent patients (95% CI 17 fewer to 4 fewer) for every 100 patients seen by the stroke liaison worker. Similar results were seen for the outcome of death or dependence for the subgroup with Barthel 15 to 19 (OR 0.55, 95% CI 0.38 to 0.81, P = 0.002). This risk difference equates to 11 fewer dead or dependent patients (95% CI 17 fewer to 4 fewer) for every 100 patients seen by the stroke liaison worker.Authors' conclusions
There is no evidence for the effectiveness of this multifaceted intervention in improving outcomes for all groups of patients or carers. Patients with mild to moderate disability benefit from a reduction in death and disability. Patients and carers do report improved satisfaction with some aspects of service provision.
Ellis Graham, Mant Jonathan, Langhorne Peter, Dennis Martin, Winner Simon
Stroke liaison workers for stroke patients and carers
Many patients experience depression, anxiety and isolation after a stroke. These post-stroke problems can lead to subsequent poor health, low mood or increased caring burden. It seems reasonable to expect that providing more emotional and psychological support in addition to appropriate information about stroke and services available might help to reduce anxiety, improve mood and improve health or satisfaction. In this review, we evaluated 16 studies (involving 4759 participants) of healthcare workers or volunteers (a 'stroke liaison worker') providing education and social support (including counselling) and liaison with services. Overall, there do not appear to be any significant benefits for patients in terms of their perceived health, mood, activities or participation. Patients appeared to be more satisfied that someone had really listened to them, and carers appeared to be more satisfied with aspects of the care provided. It also appears that patients with mild to moderate disability may benefit from a reduction in disability and death as a result of the input from the stroke liaison worker. The reason for this is not yet clear and further research is required.
Implications for practice
There is little evidence from this meta-analysis to support stroke liaison workers for all groups of patients and carers. There appears to be significant benefit from stroke liaison worker input to patients with mild to moderate disability (e.g. Barthel 15 to 19) and it seems reasonable to ensure that services do not neglect this group. Patients and carers do report improved satisfaction with aspects of service provision. Healthcare providers need to evaluate the value of this outcome.
Implications for research
Research into this multifaceted intervention must be re-evaluated. Research should consider evaluating more closely the relationship between more focused interventions for specific impairments (e.g. counselling for depression) and their wider impact on participation (e.g. extended activities of daily living). Multifaceted interventions with broad intentions also need to be linked more closely to evidenced therapeutic methods. Further work on the model of interventions for psychosocial problems is warranted. In addition, it must be noted that most trials were conducted in well-developed healthcare settings with established stroke services. Extrapolation cannot be made to all settings or healthcare organisations.
The impact of stroke liaison worker interventions on patients with mild to moderate disability needs to be explored. Further work should concentrate on establishing if this is a real effect of the intervention or simply reflects the ability of patients with mild to moderate disability to improve with continued healthcare input. The implications are significant. Potential overlap exists with the well-documented effects of early supported discharge after stroke. No such services existed in the trials evaluated in this review.Get full text at The Cochrane Library
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