Services for reducing duration of hospital care for acute stroke patients
Abstract
Background
Stroke patients conventionally receive a substantial part of their rehabilitation in hospital. Services have now been developed which offer patients in hospital an early discharge with rehabilitation at home (early supported discharge (ESD)).
Objectives
To establish the effects and costs of ESD services compared with conventional services.
Search methods
We searched the trials registers of the Cochrane Stroke Group (January 2012) and the Cochrane Effective Practice and Organisation of Care (EPOC) Group, MEDLINE (2008 to 7 February 2012), EMBASE (2008 to 7 February 2012) and CINAHL (1982 to 7 February 2012). In an effort to identify further published, unpublished and ongoing trials we searched 17 trial registers (February 2012), performed citation tracking of included studies, checked reference lists of relevant articles and contacted trialists.
Selection criteria
Randomised controlled trials recruiting stroke patients in hospital to receive either conventional care or any service intervention which has provided rehabilitation and support in a community setting with an aim of reducing the duration of hospital care.
Data collection and analysis
The primary patient outcome was the composite end‐point of death or long‐term dependency recorded at the end of scheduled follow‐up. Two review authors scrutinised trials and categorised them on their eligibility. We then sought standardised individual patient data from the primary trialists. We analysed the results for all trials and for subgroups of patients and services, in particular whether the intervention was provided by a co‐ordinated multidisciplinary team (co‐ordinated ESD team) or not.
Main results
Outcome data are currently available for 14 trials (1957 patients). Patients tended to be a selected elderly group with moderate disability. The ESD group showed significant reductions (P < 0.0001) in the length of hospital stay equivalent to approximately seven days. Overall, the odds ratios (OR) (95% confidence interval (CI)) for death, death or institutionalisation, death or dependency at the end of scheduled follow‐up were OR 0.91 (95% CI 0.67 to 1.25, P = 0.58), OR 0.78 (95% CI 0.61 to 1.00, P = 0.05) and OR 0.80 (95% CI 0.67 to 0.97, P = 0.02) respectively. The greatest benefits were seen in the trials evaluating a co‐ordinated ESD team and in stroke patients with mild to moderate disability. Improvements were also seen in patients' extended activities of daily living scores (standardised mean difference 0.12, 95% CI 0.00 to 0.25, P = 0.05) and satisfaction with services (OR 1.60, 95% CI 1.08 to 2.38, P = 0.02) but no statistically significant differences were seen in carers' subjective health status, mood or satisfaction with services. The apparent benefits were no longer statistically significant at five‐year follow‐up.
Authors' conclusions
Appropriately resourced ESD services provided for a selected group of stroke patients can reduce long‐term dependency and admission to institutional care as well as reducing the length of hospital stay. We observed no adverse impact on the mood or subjective health status of patients or carers.
PICOs
Plain language summary
Services for reducing duration of hospital care for acute stroke patients
Early supported discharge services aim to allow patients to return home from hospital earlier than usual and receive more rehabilitation in the familiar environment of their own home. Early supported discharge services are provided by teams of therapists, nurses and doctors. This review, which identified 14 trials with 1957 participants, found that patients who received these services returned home earlier and were more likely to remain at home in the long term and to regain independence in daily activities. The best results were seen with well organised discharge teams and patients with less severe strokes.
