Predicting independent survival after stroke: a European study for the development and validation of standardised stroke scales and prediction models of outcome.

BACKGROUND: Accurate prediction of stroke outcome is desirable for clinical management and provision of appropriate care, and potentially for stratification of patients into studies. OBJECTIVES: To investigate the predictive properties of validated scales and severity measures, and their constituent variables, and to compare their prediction in six European populations. METHODS: We studied 2033 first-ever stroke patients in population-based stroke registers in France, Italy, Lithuania, the UK, Spain and Poland. Logistic models were used to predict independent survival at 3 and 12 months after stroke using a range of measures including the Six Simple Variable (SSV), Barthel index (BI) and the National Institute of Heath Stroke Scale (NIHSS). Predictions were compared within and between populations using receiver operating characteristic curves. A five-variable scale was developed and validated. RESULTS: Comparisons of BI with BI+age, and NIHSS with NIHSS+age, across populations showed that inclusion of age significantly improved prediction. Fairly equal predictions were obtained by three models: five variables, BI+age, and NIHSS+age. Better agreement between predicted and actual outcomes, and more precise estimates were obtained by the five variables model (age, verbal component of the Glasgow Coma Scale, arm power, ability to walk, and pre-stroke dependency). CONCLUSIONS: Living alone before the stroke was not significantly associated with independent survival after the stroke. Five variables (excluding living alone, from the SSV) provided good prediction for all populations and subgroups. Further external validation for our estimates is recommended before utilisation of the model in practice and research.

Variations in acute stroke care and the impact of organised care on survival from a European perspective: the European Registers of Stroke (EROS) investigators.

BACKGROUND: The need for stroke care is escalating with an ageing population, yet methods to estimate the delivery of effective care across countries are not standardised or robust. Associations between quality and intensity of care and stroke outcomes are often assumed but have not been clearly demonstrated. OBJECTIVE: To examine variations in acute care processes across six European populations and investigate associations between the delivery of care and survival. METHODS: Data were obtained from population-based stroke registers of six centres in France, Lithuania, UK, Spain, Poland and Italy between 2004 and 2006 with follow-up for 1 year. Variations in the delivery of care (stroke unit, multidisciplinary team and acute drug treatments) were analysed adjusting for case mix and sociodemographic factors using logistic regression methods. Unadjusted and adjusted survival probabilities were estimated and stratified by levels of Organised Care Index. RESULTS: Of 1918 patients with a first-ever stroke registered, 30.7% spent more than 50% of their hospital stay in a stroke unit (13.9-65.4%) among centres with a stroke unit available. The percentage of patients assessed by a stroke physician varied between 7.1% and 96.6%. There were significant variations after adjustment for confounders, in the organisation of care across populations. Significantly higher probabilities of survival (p<0.01) were associated with increased organisational care. CONCLUSIONS: This European study demonstrated associations between delivery of care and stroke outcomes. The implementation of evidence-based interventions is suboptimal and understanding better ways to implement these interventions in different healthcare settings should be a priority for health systems.

Heterogeneity of treatment responses in rheumatoid arthritis using group based trajectory models: secondary analysis of clinical trial data.

BACKGROUND: Traditionally rheumatoid arthritis (RA) trials classify patients as responders and non-responders; they ignore the potential range of treatment responses. Group Based Trajectory Models (GBTMs) provide a more refined approach. They identify patient subgroups with similar outcome trajectories. We used GBTMs to classify patients into subgroups of varying responses and explore factors associated with different responses to intensive treatment in a secondary analysis of intensive treatment in the TITRATE clinical trial. METHODS: The TITRATE trial enrolled 335 patients with RA: 168 patients were randomised to receive intensive management, which comprised monthly assessments including measures of the disease activity score for 28 joints (DAS28), treatment escalation when patients were not responding sufficiently and psychosocial support; 163 of these patients completed the trial. We applied GBTMs to monthly DAS28 scores over one year to these patients who had received intensive management. The control group had standard care and were assessed every 6 months; they had too few DAS28 scores for applying GBTMs. RESULTS: GBTMs identified three distinct trajectories in the patients receiving intensive management: good (n = 40), moderate (n = 76) and poor (n = 47) responders. Baseline body mass index (BMI), disability, fatigue and depression levels were significantly different between trajectory groups. Few (10%) good responders were obese, compared to 38% of moderate, and 43% of poor responders (P = 0.002). Few (8%) good responders had depression, compared to 14% moderate responders, and 38% poor responders (P < 0.001). The key difference in treatments was using high-cost biologics, used in only 5% of good responders but 30% of moderate and 51% of poor responders (P < 0.001). Most good responders had endpoint remissions and low disability, pain, and fatigue scores; few poor responders achieved any favourable outcomes. CONCLUSION: GBTMs identified three trajectories of disease activity progression in patients receiving intensive management for moderately active RA. Baseline variables like obesity and depression predicted different treatment responses. Few good responders needed biologic drugs; they responded to conventional DMARDs alone. GBTMs have the potential to facilitate precision medicine enabling patient-oriented treatment strategies based on key characteristics. REGISTRATION: TITRATE Trial ISRCTN 70160382.