***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Background and Purpose — Integrated care pathways ( ICP ) may not reduce disability , institutionalization , or duration of hospitalization compared with conventional multidisciplinary team ( MDT ) care in organized stroke rehabilitation . Their potential to improve patient heath status or satisfaction with care is not known . Methods — A comparison of quality of life , caregiver strain , and patient/caregiver satisfaction at 6 months after stroke was undertaken in 152 stroke patients r and omized to receive ICP or MDT care .  Differences in processes of care were recorded with the use of a predefined schedule . Multivariate analyses were undertaken to identify the effect of age , sex , stroke severity , functional status , mood , and use of care pathway on quality of life score . Results — The 2 groups were comparable for baseline characteristics of age , sex , stroke severity , and initial disability . MDT care was characterized by greater emphasis on return of higher function and caregiver needs compared with ICP . EuroQol Visual Analogue Scale ( EQ-VAS ) scores were higher in the MDT group ( median , 72 versus 63;P < 0.005 ) , who also had higher scores for EuroQol dimension of social functioning ( P = 0.014 ) . Higher EQ-VAS scores were independently related to MDT care ( P = 0.04 ) , Rankin score ( P = 0.01 ) , and psychological function ( P < 0.0001 ) but not to age , sex , or stroke severity . There were no significant differences in patient or caregiver satisfaction between the 2 setting s. Conclusions — Better quality of life in patients receiving conventional MDT care may be attributable to improved social functioning and greater attention to higher function and caregiver needs during rehabilitation OBJECTIVES Clinical pathways have been implemented nationwide but little is understood about their effects on efficiency of care and patient outcomes . The present study examined the effects of both development and implementation of two renal transplant pathways . METHODS Cohorts of patients at a university hospital were compared before , during , and after the development and implementation of two renal transplant clinical pathways :  isolated renal transplant from cadaveric donors ( n = 170 ) or from living donors ( n = 178 ) .  Clinical pathways for cadaveric and living related donor renal transplants were developed and implemented . Hospital length of stay and complications and infections after renal transplant were determined . RESULTS Mean length of hospital stay decreased after development and implementation of the cadaveric donor pathway ( 11.8 days after implementation versus 17.5 days before development ) . Cadaveric kidney recipients also had statistically fewer complications and infections after both guideline development and guideline implementation ( 57.1 % before , 24.5 % during , 18.5 % after ) , but the greatest effect occurred during development . All of these findings persisted after control for demographic and comorbid factors . There were no changes in hospital stay , complications , or infections in the patients who received kidneys from living donors . CONCLUSIONS The development and use of a clinical pathway for cadaveric donor renal transplant patients was associated with a significant decline in length of stay , complications , and infections , but much of the effect was seen during development rather than during implementation , and a closely related pathway for living related donor patients had no effect . Further underst and ing of what factors predict an effective pathway and what elements ( ie , development or implementation ) have an effect should be undertaken Background Negative variation in the management of patients with the same clinical condition is frequent , and affects quality of care . Recent studies indicate that single interventions are not an effective solution . We aim to demonstrate that a multifaceted strategy can favor the introduction of research into practice , and to assess its long-term effects on a set of common medical conditions exhibiting significant negative variation at our institution . Methods The strategy , devised and agreed upon by a multidisciplinary group , was first applied to one relevant medical condition – cerebral ischemic stroke . To test its effectiveness a quasi-experimental study was conducted , comparing an intervention group with historical controls . After validation the strategy was extended to other pathologies , and its long-term effect measured using evidence -based quality indicators . Adherence to each indicator was determined prospect ively on a six-month basis for a period of at least two consecutive years . Measures are expressed as proportions with 95 % confidence intervals . Results Validation findings demonstrated that the strategy improved compliance with scientific evidence : the percentage of patients who received a CT scan within 24 hours of hospital presentation rose from 56 % to 75 % , ( χ2 = 7.43 p < 0.01 ) ; admissions to selected wards increased from 45 % to 64 % , ( χ2 = 7.81 p < 0.01 ) ; the number of physical medicine visits within 24 hours of the request grew from 59 % to 91 % ( χ2 = 14,40 p < 0.001 ) . Over a four-year period the program was gradually applied to 14 medical conditions . Except for 3 cases , compliance with the pathway , i.e. number of eligible patients for whom data on the care process is collected , was above the minimum requirement of 75 % . Indicator adherence generally exhibited a positive trend , though variability was observed both among different conditions and between different semesters for the same pathology . Conclusion According to our experience , incorporation of research into practice can be favored by systematic ally applying a shared , multifaceted strategy , involving multidisciplinary teams supported by central coordination . Institutions should device a tailor-made approach , should train personnel on implementation strategies , and create cultural acceptance of change . Just like for experimental trials , human and economic re sources should be allocated within health care services to allow the achievement of this objective OBJECTIVE to evaluate whether integrated care pathways improve the processes of care in stroke rehabilitation . DESIGN comparison of processes of care data collected in a r and omized controlled trial . PARTICIPANTS acute stroke patients undergoing rehabilitation r and omized to receive integrated care pathways management ( n=76 ) or conventional multidisciplinary care ( n=76 ) . MEASUREMENTS proportion of patients meeting recommended st and ards for processes of care using a vali date d stroke audit tool . RESULTS integrated care pathways methodology was associated with higher frequency of stroke specific assessment s , notably testing for inattention ( 84 % versus 60 % ; P=0.015 ) and nutritional assessment ( 74 % versus 22 % , P<0.001 ) . Documentation of provision of certain information to patients /carers ( 89 % versus 70 % ; P=0.024 ) and early discharge notification to general practitioners ( 80 % versus 45 % ; P<0.001 ) were also more common in this group . There were no significant differences in the processes of interdisciplinary co-ordination and patient management between the integrated care pathways group and the control group . CONCLUSION integrated care pathways may improve assessment and communication , even in specialist stroke setting BACKGROUND AND PURPOSE Despite the volume of research into patient satisfaction , it is not clear whether satisfaction ratings reflect differences in care received after stroke or the characteristics of patients . The aim of this study is to test the hypothesis that patient satisfaction is independently related to differences in care received after stroke . METHODS Stroke patients participating in a r and omized controlled trial of early discharge to community therapy  completed a satisfaction question naire and physical and psychological outcome measures at 4 and 12 months . Two hundred seventy-four patients ( 83 % ) were followed up at 4 months and 262 patients ( 79 % ) at 12 months . Use of therapy and community services was quantified . Logistic regression was used to investigate associations between satisfaction , patient characteristics , and service provision . RESULTS The more therapy , meals on wheels , and home help visits patients received , the more likely they were to be satisfied . Patients in the conventional arm of the trial were less likely to express satisfaction than those discharged early to community therapy . Women , older people , anxious people , and those more functionally independent were more likely to be satisfied , while those with depression , speech and swallowing deficit , motor deficit , and poor subjective health were less likely to be satisfied . CONCLUSIONS The finding that satisfaction assessment s reflect real differences in the provision of care and occur independently of any associations with patient characteristics is new . Patient satisfaction should be taken seriously as an outcome BACKGROUND AND PURPOSE Integrated Care Pathway ( ICP ) is an organized , goal -defined , and time-managed plan that has the potential of facilitating timely interdisciplinary coordination , improving discharge planning , and reducing length of hospital stay . METHODS An ICP for stroke rehabilitation based on evidence of best practice , professional st and ards , and existing infrastructure was developed . Its effectiveness was tested in 152 stroke patients undergoing rehabilitation who were r and omized to receive ICP care coordinated by an experienced nurse ( n=76 ) or conventional multidisciplinary care ( n=76 ) . RESULTS The age , sex , premorbid functional ability , and stroke characteristics of the 2 groups were comparable . There were no differences in mortality rates ( 10 [ 13 % ] versus 6 [ 8 % ] ) , institutionalization ( 10 [ 13 % ] versus 16 [ 21 % ] ) , or length of hospital stay ( 50+/-19 versus 45+/-23 days ) between patients receiving ICP or multidisciplinary care . Patients receiving conventional multidisciplinary care improved significantly faster between 4 and 12 weeks ( median change in Barthel Activities of Daily Living Index 6 versus 2 ; P<0.01 ) and had higher Quality of Life scores at 12 weeks ( 65 versus 59 ; P=0.07 ) and 6 months ( 72 versus 63 ; P<0.005 ) . There were no significant differences in the mean duration of physiotherapy ( 42.8+/-41.2 versus 39.4+/-36.4 hours ) or occupational therapy ( 8.5+/-7.5 versus 8.0+/-7.5 hours ) received between the 2 groups . CONCLUSIONS ICP management offered no benefit over conventional multidisciplinary care on a stroke rehabilitation unit . Functional recovery was faster and Quality of Life outcomes better in patients receiving conventional multidisciplinary care BACKGROUND This r and omized controlled trial tested the effectiveness of comprehensive , interdisciplinary postdischarge care management in improving a profile of indicators of health recovery and secondary prevention ( profile of health and prevention ) in stroke and transient ischemic attack ( TIA ) patients . METHODS Ninety-six stroke/TIA patients were r and omized to usual care or intervention at discharge from our acute stroke unit . The intervention group received an in-home biopsychosocial assessment by an advanced practice nurse at 1 month . A care plan was developed by an interdisciplinary team and implemented in collaboration with the patient 's primary care physician . The profile of health and prevention , measured at 3 months , was comprised of 5 domains : ( 1 ) Neuromotor Function , ( 2 ) Severe Complications , ( 3 ) Quality of Life , ( 4 ) Management of Risk for common poststroke complications and recurrent stroke , and ( 5 ) Stroke Knowledge . A single global hypothesis test across multiple end points was used to compare the 2 groups . RESULTS The intervention significantly improved the profile of health and prevention ( P < .0001 ) . In addition , each domain showed a positive effect of the intervention . Effect sizes ( in st and ard deviation units ) of the intervention on domains were .1 for Neuromotor Function ( 90 % confidence interval [ CI ] = -.3 to .5 ) ; .4 for Severe Complications ( 90 % CI = .1 to .8 ) ; .5 for Quality of Life ( 90 % CI = .1 to .9 ) ; .6 for Management of Risk for common poststroke complications and recurrent stroke ( 90 % CI = .3 to 1 . ) ; and 1.0 for Stroke Knowledge ( 90 % CI = .6 to 1.4 ) . CONCLUSIONS This model of care management result ed in a significantly better profile of health and prevention for stroke/TIA patients 3 months postdischarge The diagnosis of stroke , which is diagnosis-related group ( DRG ) 014 , is the fourth most frequent discharge DRG at Macomb Hospital Center , Warren , Michigan . The length of stay for stroke was 7.52 days before intervention .  Quality improvement techniques identified areas of delay that presented opportunities for improvement . After the initiation of a critical pathway that begins its interventions in the Emergency Department , the length of stay decreased to 6.33 days . Quality of care was also improved in delivery time of carotid artery ultrasound examinations  , as well as in timeliness of obtaining head computed tomography scans and reports . This article describes the development , implementation , and results of a stroke critical pathway that was implemented to address excessive length of stay INTRODUCTION Stroke is a complicated disease that requires a multidisciplinary approach for its management . We postulated that variance analysis applied to a stroke pathway , by identifying major problem areas and encouraging timely corrective actions , would lead to more efficient healthcare delivery to hospitalised stroke patients . MATERIAL S AND METHODS Prospect ively collected variance data from consecutive stroke patients discharged from a tertiary hospital in Singapore during a 3-month period in 2000 were used to identify the major variances causing increased length of stay . These were compared and contrasted to variance data collected during the same 3-month period in the subsequent year ( 2001 ) , after the implementation of stroke pathway and the availability of monthly variance analysis reports .  Patient characteristics and outcome measures were also compared between the two study periods . RESULTS The four major variances that accounted for increased length of stay were , in descending order of the number of patients affected , awaiting bed availability in step-down facilities , delay in head computed tomographic scan performance , awaiting family 's decision on discharge plan and incomplete application su bmi tted to step-down facilities . After implementation of the stroke pathway with ongoing variance analysis , all four variances showed different extent of improvements . There were no significant differences in patient characteristics between the two study periods , whereas the average length 
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RESULTS Therefore , we do not know whether the costs of ICP development and implementation are justified by any of the reported benefits .
Implication s for practice There is some evidence that ICPs may support certain elements of service integration in the context of stroke care .
This seems to be as a result of their ability to support the timely implementation of clinical interventions and the mobilisation of re sources around the patient without incurring additional increases in length of stay .
ICPs appear to be most successful in improving service coordination in the acute stroke context where patient care trajectories are predictable .
Their value in the context of rehabilitation setting s in which recovery pathways are more variable is less clear .
There is some evidence that ICPs may be effective in bringing about behavioural changes in context s where deficiencies in service provision have been identified .
Their value in context s where inter-professional working is well established is less clear .
While earlier before and after studies show a reduction in length of stay in ICP-managed care , this may reflect wider healthcare trends , and the failure of later studies to demonstrate further reductions suggests that there may be limits as to how far this can continue to be reduced .
There is some evidence to suggest that ICPs bring about improvements in documentation , but we do not know how far documented practice reflects actual practice .
It is unclear how ICPs have their effects and the relative importance of the process of development and the artefact in use .
As none of the studies review ed included an economic evaluation , moreover , it remains unclear whether the benefits of ICPs justify the costs of their implementation