Services for reducing duration of hospital care for acute stroke patients

Patricia Fearon; Peter Langhorne; Early Supported Discharge Trialists

doi:10.1002/14651858.CD000443.pub3

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Figure 1

Flow diagram illustrating the results of the updated searches

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Figure 2

'Risk of bias' graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

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Figure 3

'Risk of bias' summary: review authors' judgements about each risk of bias item for each included study.

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Analysis 1.1

Comparison 1 Early supported discharge service versus conventional care: patient outcomes, Outcome 1 Death.

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Analysis 1.2

Comparison 1 Early supported discharge service versus conventional care: patient outcomes, Outcome 2 Death or requiring institutional care.

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Analysis 1.3

Comparison 1 Early supported discharge service versus conventional care: patient outcomes, Outcome 3 Death or dependency.

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Analysis 1.4

Comparison 1 Early supported discharge service versus conventional care: patient outcomes, Outcome 4 Activities of daily living (Barthel ADL) score.

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Analysis 1.5

Comparison 1 Early supported discharge service versus conventional care: patient outcomes, Outcome 5 Extended activities of daily living (EADL) score.

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Analysis 1.6

Comparison 1 Early supported discharge service versus conventional care: patient outcomes, Outcome 6 Subjective health status.

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Analysis 1.7

Comparison 1 Early supported discharge service versus conventional care: patient outcomes, Outcome 7 Mood status.

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Analysis 1.8

Comparison 1 Early supported discharge service versus conventional care: patient outcomes, Outcome 8 Satisfaction with services.

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Analysis 2.1

Comparison 2 Early supported discharge service versus conventional care: duration of follow‐up, Outcome 1 Death: within 6 months.

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Analysis 2.2

Comparison 2 Early supported discharge service versus conventional care: duration of follow‐up, Outcome 2 Death or dependency: within 6 months.

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Analysis 2.3

Comparison 2 Early supported discharge service versus conventional care: duration of follow‐up, Outcome 3 Death: within 1 year.

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Analysis 2.4

Comparison 2 Early supported discharge service versus conventional care: duration of follow‐up, Outcome 4 Death or dependency: within 1 year.

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Analysis 2.5

Comparison 2 Early supported discharge service versus conventional care: duration of follow‐up, Outcome 5 Death: within 5 years.

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Analysis 2.6

Comparison 2 Early supported discharge service versus conventional care: duration of follow‐up, Outcome 6 Death or dependency: within 5 years.

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Analysis 3.1

Comparison 3 Early supported discharge service versus conventional care: carer outcomes, Outcome 1 Subjective health status.

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Analysis 3.2

Comparison 3 Early supported discharge service versus conventional care: carer outcomes, Outcome 2 Mood status.

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Analysis 3.3

Comparison 3 Early supported discharge service versus conventional care: carer outcomes, Outcome 3 Satisfaction with services.

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Analysis 4.1

Comparison 4 Early supported discharge service versus conventional care: resource use, Outcome 1 Length of initial hospital stay (days).

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Analysis 4.2

Comparison 4 Early supported discharge service versus conventional care: resource use, Outcome 2 Readmission to hospital.

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Analysis 5.1

Comparison 5 Early supported discharge service versus conventional care: age subgroups, Outcome 1 Death or dependency.

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Analysis 5.2

Comparison 5 Early supported discharge service versus conventional care: age subgroups, Outcome 2 Length of stay (days).

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Analysis 6.1

Comparison 6 Early supported discharge service versus conventional care: gender subgroups, Outcome 1 Death or dependency.

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Analysis 6.2

Comparison 6 Early supported discharge service versus conventional care: gender subgroups, Outcome 2 Length of stay (days).

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Analysis 7.1

Comparison 7 Early supported discharge service versus conventional care: stroke severity subgroups, Outcome 1 Death or dependency.

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Analysis 7.2

Comparison 7 Early supported discharge service versus conventional care: stroke severity subgroups, Outcome 2 Length of stay (days).

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Analysis 8.1

Comparison 8 Early supported discharge service versus conventional care: carer subgroups, Outcome 1 Death or dependency.

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Analysis 8.2

Comparison 8 Early supported discharge service versus conventional care: carer subgroups, Outcome 2 Length of stay (days).

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Analysis 9.1

Comparison 9 Early supported discharge service versus conventional care: ESD service subgroups: service base, Outcome 1 Death or dependency.

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Analysis 9.2

Comparison 9 Early supported discharge service versus conventional care: ESD service subgroups: service base, Outcome 2 Length of stay (days).

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Analysis 10.1

Comparison 10 Early supported discharge service versus conventional care: ESD service subgroups: MDT co‐ordination, Outcome 1 Death.

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Analysis 10.2

Comparison 10 Early supported discharge service versus conventional care: ESD service subgroups: MDT co‐ordination, Outcome 2 Death or requiring institutional care.

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Analysis 10.3

Comparison 10 Early supported discharge service versus conventional care: ESD service subgroups: MDT co‐ordination, Outcome 3 Death or dependency.

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Analysis 10.4

Comparison 10 Early supported discharge service versus conventional care: ESD service subgroups: MDT co‐ordination, Outcome 4 Length of stay (days).

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Analysis 11.1

Comparison 11 Early supported discharge service versus conventional care: conventional service subgroups, Outcome 1 Death or dependency.

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Analysis 11.2

Comparison 11 Early supported discharge service versus conventional care: conventional service subgroups, Outcome 2 Length of stay (days).

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Table 1. Characteristics and staffing of ESD trials

Trial	Setting	Key features	Control service base	ESD staffing (whole time equivalents for caseload of 100 patients/year; median and range)
Trial	Setting	Key features	Control service base	Medical	Nursing	Physio	OT	SALT	Assistant	Other	Total
Adelaide 2000	Urban	PHMR Goals documented	Rehabilitation unit (stroke and neurological)	0.06	0.06	0.7	1.6	0.25	0.4	Social work	2.6
Aveiro	Mixed	Tailored	Mixture (stroke unit, case managers in community‐based team)	0.8	0	1.0	1.5	0	0	Psychology	3.2
Belfast 2004	Mixed	PHMR	Mixture (medical, geriatric, stroke unit)	0.1	0	1.5	1.0	0.5	1.5	Secretary Social work	4.6
Copenhagen 2009	Urban	Tailored	Stroke unit
Glostrup 2006	Mixed	Tailored	Neurology, geriatrics	0	0	2.0	2.0	0	0	0	4.0
London 1999	Urban	Equipment store	Mixture (medical, stroke unit)	0.1	0	1	1	0.5	0.5	‐	3.1
Manchester 2001	Urban		Mixture (medical, stroke team or unit)	nd	nd	nd	nd	nd	nd	‐	nd
Montreal 2000	Urban		Mixture (medical neurology)	0	0.4	1.0	0.7	0.4	‐	Dietitian	2.7
Newcastle 1997	Urban	Envt visit Key worker 7‐day input PHMR	Mixture (medical, geriatric)	0	0	0.8	1.0	0.3	0.2	Secretary Social work Carers	2.8
Stockholm 1998	Urban	Case manager Patient diary	Stroke unit	0.03	0	1.0	1.0	0.5	‐	‐	2.6
Oslo 2000	Urban	Key worker Community services	Stroke unit	nd	nd	nd	nd	nd	nd	‐	nd
Trondheim 2000	Urban	Key worker Team Community services	Stroke unit	0.12	1.2	1.2	1.2	0	‐	‐	3.7
Trondheim 2004	Rural		Stroke unit	0.12	1.2	1.2	1.2	0	‐	‐	3.7
West Denmark	Mixed	Tailored	Neurorehabilitation centres (3)	?	0	?	?	0	0	0	?
	9 urban 4 mixed 1 rural		6 stroke unit 6 mixed service 2 neurorehabilitation unit	0.08 (0 to 0.12)	0 (0 to 1.2)	1.1 (0.7 to 2)	1.0 (0.7 to 2)	0.1 (0 to 0.5)	0.2 (0 to 1.5)	‐	3.0 (2.6 to 4.6)
MDT mtg: multidisciplinary team meeting N: number of participants nd: no comparable data OT: occupational therapy PDHV: pre‐discharge home visit PHMR: patient held medical record physio: physiotherapy PNH: private nursing home SALT: speech and language therapy

Table 1. Characteristics and staffing of ESD trials

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Table 2. Plan and timing of primary analyses

Trial	Death	Institutional care	Dependency	Defined dependent	Length of stay
Adelaide 2000	6 months	6 months	6 months	Barthel index < 95/100	Initial hospital discharge
Akershus 1998	7 months	7 months	7 months	Barthel index < 95/100	Not used ‐ only available for acute hospital
Bangkok 2002	6 months	6 months	6 months	Barthel index < 95/100	Initial hospital discharge
Belfast 2004	12 months	12 months	12 months	Barthel index < 19/20	Initial hospital discharge
Copenhagen 2009	5 months	5 months	3 months	Rankin score 3 to 5	Initial hospital stay
Glostrup 2006	12 months	12 months	6 months	Barthel index ‐ significant reduction	Initial hospital discharge
London 1999	12 months	12 months	12 months	Barthel index < 19/20	Initial hospital discharge
Manchester 2001	12 months	12 months	12 months	Barthel index < 19/20	Initial hospital stay (acute and rehabilitation wards)
Montreal 2000	3 months	3 months	3 months	Barthel index < 95/100	Initial hospital stay
Newcastle 1997	3 month	3 month	3 month	Rankin score 3 to 5	Initial hospital stay
Oslo 2000	6 month	6 month	6 month	Rankin score 3 to 5	Initial hospital stay
Stockholm 1998	6 month	6 month	6 month	Barthel index 95/100	Initial hospital stay
Trondheim 2000	6 months	6 months	6 months	Barthel index 95/100	Initial hospital stay
Trondheim 2004	12 months	12 months	12 months	Rankin score 3 to 5	Initial hospital stay (acute and rehabilitation wards)

Table 2. Plan and timing of primary analyses

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Table 3. Plan of secondary analyses: patient outcomes

Trial	Timing of outcome	ADL score	Extended ADL score	Subjective health	Mood	Service satisfaction	Hospital readmission
Adelaide 2000	6 months	Barthel index (median, IQR)	Adelaide Activities Profile	SF‐36 (General health perceptions)	SF‐36 (mental health)	Satisfied with rehabilitation programme	6 months
Akershus 1998	7 month	Barthel index (median, imputed SD)	‐	SF‐36 (general health perceptions)	SF‐36 (mental health)	‐	‐
Bangkok 2002	‐	‐	‐	‐	‐	‐	‐
Belfast 2004	12 months	Barthel index	Nottingham extended ADL	SF‐36 (general health perceptions)	SF‐36 (mental health)	Satisfied with outpatient rehabilitation	6 month
Copenhagen 2009	3 months	Barthel Index (median, imputed SD)	‐	EQ‐5D	‐		5 months
Glostrup 2006	6 months	Barthel index	Frenchay activities index	SF‐36	GDS	‐	12 month
London 1999	12 months	Barthel index	Rivermead ADL score	Nottingham health profile (score reversed)	Number abnormal on hospital anxiety and depression scale	Satisfied with care in general	12 month
Manchester 2001	12 months	Barthel index	Nottingham extended ADL score	Euroquol scale (0 to 100)	Hospital anxiety and depression scale (depression subscore, score reversed)	‐	‐
Montreal 2000	3 month	Barthel index	Instrumental ADL (OARS) scale	SF‐36 (general health perceptions)	SF‐36 (mental health)	‐	‐
Newcastle 1997	3 month	‐	Nottingham extended ADL score (median, IQR)	Dartmouth COOP chart overall health section (median, IQR; scale reversed)	Dartmouth COOP chart feelings section (median, IQR; scale reversed)	‐	3 month
Oslo 2000	6 month	‐	Nottingham extended ADL score (median, IQR)	General Health Questionnaire (reversed score)	MADRS score	Satisfied with care in general	‐
Stockholm 1998	8 months	‐	Frenchay Activities index (median, IQR)	Sickness impact profile score (median, IQR)	‐	Satisfied with care received	6 months
Trondheim 2000	12 months	‐	Frenchay social activity index	Nottingham Health Profile (average of sum 1 and 2)	MADRS	‐	‐
Trondheim 2004	12 months	Barthel Index	‐	Nottingham health profile	‐	‐	‐
ADL: activities of daily living COOP: Care Cooperative Information Project GDS: Geriatric Depression Scale IQR: interquartile range MADRS: Montgomery‐Åsberg Depression Rating Scale OARS: Older Americans Resources and Services scale SD: standard deviation SF: short form

Table 3. Plan of secondary analyses: patient outcomes

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Table 4. Plan of secondary analyses: carer outcomes

Trial	Timing of outcome	Subjective health	Mood	Service satisfaction
Adelaide 2000	6 months	SF‐36 general health perceptions	SF‐36 mental health	Satisfied with rehabilitation programme
Akershus 1998	‐	‐	‐	‐
Bangkok 2002	‐	‐	‐	‐
Belfast 2004	6 months	Caregiver strain index (score reversed)	‐	Satisfied with outpatient services
Copenhagen 2009	3 months			Satisfied with rehabilitation programme
Glostrup 2006	‐	‐	‐	‐
London 1999	12 months	Caregiver strain index (score reversed)	‐	Satisfied with care in general
Manchester 2001	12 month	‐	Hospital anxiety and depression scale (depression subscore, score reversed)	‐
Montreal 2000	3 months	Caregiver Burden Index	‐	‐
Newcastle 1997	3 months	General health questionnaire (median, range; score reversed)	‐	‐
Oslo 2000	6 months	General health questionnaire (score reversed)	‐	Satisfied with care in general
Stockholm 1998	‐	‐	‐	‐
Trondheim 2000	12 months	Caregiver Burden score	‐	‐
Trondheim 2004	12 months	Caregiver strain index (score reversed)	‐	‐

Table 4. Plan of secondary analyses: carer outcomes

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Table 5. Patterns of discharge from hospital in ESD and control groups

Time from randomisation	Number (%) discharged		Risk difference (95% CI)	Significance
Time from randomisation	ESD service (364 patients)	Control (354 patients)	Risk difference (95% CI)	Significance
2 weeks	116 (32%)	77 (22%)	11 (‐3, 24)	0.13
4 weeks	236 (65%)	179 (50%)	19 (4, 35)	0.01
6 weeks	277 (76%)	249 (70 %)	8 (1, 15)	0.02
8 weeks	303 (83%)	275 (78%)	8 (3, 13)	0.003
3 months	345 (95%)	324 (92%)	2 (‐1, 6)	0.21
6 months	363 (100%)	353 (100%)	0 (‐2, 1)	0.71
Data are presented from six trials (Adelaide 2000, Belfast 2004, London 1999, Manchester 2001, Oslo 2000, Stockholm 1998) that could provide relevant data on 718 participants. Discharges include deaths and do not include readmissions. The risk difference (95% confidence interval) is calculated taking into account variation between trials

Table 5. Patterns of discharge from hospital in ESD and control groups

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Table 6. Service costs of individual trials

Trial	Items costed	ESD cost / patient	Control cost / pt	Percent difference
Adelaide 2000	Cost minimisation. Direct and indirect	$8040 Aus	$10054 Aus	‐ 20%
Glostrup 2006	Direct costs	€7674	€6660	+15%
London 1999	Direct and indirect to 12 months	£6800	£7432	‐ 9%
Montreal 2000	Direct and indirect to 3 months	$7784 Canadian	$11,065 Canadian	‐30%
Newcastle 1997	Direct and indirect	£7155	£7480	‐ 4%
Stockholm 1998	Hospital, community, private costs	2806 SEK	3475 SEK	‐ 19%
Trondheim 2000	Direct costs to 12 months	€5,113	€6,665	‐ 23%

Table 6. Service costs of individual trials

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Comparison 1. Early supported discharge service versus conventional care: patient outcomes

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Death Show forest plot	14	1957	Odds Ratio (M‐H, Fixed, 95% CI)	0.91 [0.67, 1.25]

1.1 ESD team co‐ordination and delivery	9	1140	Odds Ratio (M‐H, Fixed, 95% CI)	0.69 [0.44, 1.07]
1.2 ESD team co‐ordination	3	464	Odds Ratio (M‐H, Fixed, 95% CI)	0.95 [0.52, 1.74]
1.3 No ESD team	2	353	Odds Ratio (M‐H, Fixed, 95% CI)	1.90 [0.90, 3.98]
2 Death or requiring institutional care Show forest plot	12	1758	Odds Ratio (M‐H, Fixed, 95% CI)	0.78 [0.61, 1.00]

2.1 ESD team co‐ordination and delivery	7	941	Odds Ratio (M‐H, Fixed, 95% CI)	0.65 [0.45, 0.93]
2.2 ESD team co‐ordination	3	464	Odds Ratio (M‐H, Fixed, 95% CI)	0.75 [0.50, 1.14]
2.3 No ESD team	2	353	Odds Ratio (M‐H, Fixed, 95% CI)	1.32 [0.75, 2.33]
3 Death or dependency Show forest plot	14	1957	Odds Ratio (M‐H, Fixed, 95% CI)	0.80 [0.67, 0.97]

3.1 ESD team co‐ordination and delivery	9	1140	Odds Ratio (M‐H, Fixed, 95% CI)	0.71 [0.55, 0.91]
3.2 ESD team co‐ordination	3	464	Odds Ratio (M‐H, Fixed, 95% CI)	0.77 [0.54, 1.11]
3.3 No ESD team	2	353	Odds Ratio (M‐H, Fixed, 95% CI)	1.23 [0.79, 1.91]
4 Activities of daily living (Barthel ADL) score Show forest plot	9	1124	Std. Mean Difference (IV, Fixed, 95% CI)	0.03 [‐0.08, 0.15]

4.1 ESD team co‐ordination and delivery	7	825	Std. Mean Difference (IV, Fixed, 95% CI)	0.06 [‐0.08, 0.20]
4.2 ESD team co‐ordination	1	48	Std. Mean Difference (IV, Fixed, 95% CI)	‐0.23 [‐0.79, 0.34]
4.3 No ESD team	1	251	Std. Mean Difference (IV, Fixed, 95% CI)	0.0 [‐0.25, 0.25]
5 Extended activities of daily living (EADL) score Show forest plot	9	1051	Std. Mean Difference (IV, Fixed, 95% CI)	0.14 [0.02, 0.26]

5.1 ESD team co‐ordination and delivery	7	729	Std. Mean Difference (IV, Fixed, 95% CI)	0.17 [0.02, 0.32]
5.2 ESD team co‐ordination	2	322	Std. Mean Difference (IV, Fixed, 95% CI)	0.07 [‐0.15, 0.29]
5.3 No ESD team	0	0	Std. Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
6 Subjective health status Show forest plot	12	1377	Std. Mean Difference (IV, Fixed, 95% CI)	0.00 [‐0.10, 0.11]

6.1 ESD team co‐ordination and delivery	8	860	Std. Mean Difference (IV, Fixed, 95% CI)	‐0.07 [‐0.21, 0.06]
6.2 ESD team co‐ordination	3	370	Std. Mean Difference (IV, Fixed, 95% CI)	0.14 [‐0.07, 0.34]
6.3 No ESD team	1	147	Std. Mean Difference (IV, Fixed, 95% CI)	0.14 [‐0.19, 0.47]
7 Mood status Show forest plot	8	851	Std. Mean Difference (IV, Fixed, 95% CI)	‐0.06 [‐0.19, 0.07]

7.1 ESD team co‐ordination and delivery	5	383	Std. Mean Difference (IV, Fixed, 95% CI)	‐0.02 [‐0.22, 0.18]
7.2 ESD team co‐ordination	2	321	Std. Mean Difference (IV, Fixed, 95% CI)	‐0.08 [‐0.30, 0.14]
7.3 No ESD team	1	147	Std. Mean Difference (IV, Fixed, 95% CI)	‐0.12 [‐0.45, 0.20]
8 Satisfaction with services Show forest plot	5	513	Odds Ratio (M‐H, Fixed, 95% CI)	1.60 [1.08, 2.38]

8.1 ESD team co‐ordination and delivery	4	450	Odds Ratio (M‐H, Fixed, 95% CI)	1.74 [1.13, 2.67]
8.2 ESD team co‐ordination	1	63	Odds Ratio (M‐H, Fixed, 95% CI)	1.01 [0.36, 2.83]
8.3 No ESD team	0	0	Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]

Comparison 1. Early supported discharge service versus conventional care: patient outcomes

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Comparison 2. Early supported discharge service versus conventional care: duration of follow‐up

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Death: within 6 months Show forest plot	9	1177	Odds Ratio (M‐H, Fixed, 95% CI)	0.80 [0.48, 1.34]

2 Death or dependency: within 6 months Show forest plot	9	1177	Odds Ratio (M‐H, Fixed, 95% CI)	0.68 [0.53, 0.87]

3 Death: within 1 year Show forest plot	8	1381	Odds Ratio (M‐H, Fixed, 95% CI)	0.91 [0.66, 1.26]

4 Death or dependency: within 1 year Show forest plot	7	1183	Odds Ratio (M‐H, Fixed, 95% CI)	0.84 [0.66, 1.05]

5 Death: within 5 years Show forest plot	2	403	Odds Ratio (M‐H, Fixed, 95% CI)	0.81 [0.54, 1.21]

6 Death or dependency: within 5 years Show forest plot	2	403	Odds Ratio (M‐H, Fixed, 95% CI)	0.78 [0.52, 1.17]

Comparison 2. Early supported discharge service versus conventional care: duration of follow‐up

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Comparison 3. Early supported discharge service versus conventional care: carer outcomes

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Subjective health status Show forest plot	8	749	Std. Mean Difference (IV, Fixed, 95% CI)	‐0.03 [‐0.17, 0.12]

1.1 ESD team co‐ordination and delivery	5	373	Std. Mean Difference (IV, Fixed, 95% CI)	‐0.15 [‐0.35, 0.06]
1.2 ESD team co‐ordination	3	376	Std. Mean Difference (IV, Fixed, 95% CI)	0.09 [‐0.12, 0.29]
1.3 No ESD team	0	0	Std. Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
2 Mood status Show forest plot	2	58	Std. Mean Difference (IV, Random, 95% CI)	‐0.19 [‐1.60, 1.22]

2.1 ESD team co‐ordination and delivery	2	58	Std. Mean Difference (IV, Random, 95% CI)	‐0.19 [‐1.60, 1.22]
2.2 ESD team co‐ordination	0	0	Std. Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
2.3 No ESD team	0	0	Std. Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
3 Satisfaction with services Show forest plot	4	279	Odds Ratio (M‐H, Fixed, 95% CI)	1.56 [0.87, 2.81]

3.1 ESD team co‐ordination and delivery	3	246	Odds Ratio (M‐H, Fixed, 95% CI)	1.60 [0.85, 3.01]
3.2 ESD team co‐ordination	1	33	Odds Ratio (M‐H, Fixed, 95% CI)	1.28 [0.24, 6.70]
3.3 No ESD team	0	0	Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]

Comparison 3. Early supported discharge service versus conventional care: carer outcomes

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Comparison 4. Early supported discharge service versus conventional care: resource use

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Length of initial hospital stay (days) Show forest plot	13	1695	Mean Difference (IV, Random, 95% CI)	‐7.10 [‐10.03, ‐4.17]

1.1 ESD team co‐ordination and delivery	9	1129	Mean Difference (IV, Random, 95% CI)	‐6.84 [‐11.20, ‐2.49]
1.2 ESD team co‐ordination	3	464	Mean Difference (IV, Random, 95% CI)	‐10.36 [‐15.39, ‐5.33]
1.3 No ESD team	1	102	Mean Difference (IV, Random, 95% CI)	‐7.0 [‐8.61, ‐5.39]
2 Readmission to hospital Show forest plot	7	918	Odds Ratio (M‐H, Fixed, 95% CI)	1.26 [0.94, 1.67]

2.1 ESD team co‐ordination and delivery	7	918	Odds Ratio (M‐H, Fixed, 95% CI)	1.26 [0.94, 1.67]
2.2 ESD team co‐ordination	0	0	Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
2.3 No ESD team	0	0	Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]

Comparison 4. Early supported discharge service versus conventional care: resource use

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Comparison 5. Early supported discharge service versus conventional care: age subgroups

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Death or dependency Show forest plot	9	1175	Odds Ratio (M‐H, Fixed, 95% CI)	0.85 [0.67, 1.08]

1.1 Age < 75 years	9	695	Odds Ratio (M‐H, Fixed, 95% CI)	0.82 [0.60, 1.12]
1.2 Age > 75 years	9	480	Odds Ratio (M‐H, Fixed, 95% CI)	0.90 [0.61, 1.31]
2 Length of stay (days) Show forest plot	8	911	Mean Difference (IV, Random, 95% CI)	‐9.69 [‐13.56, ‐5.82]

2.1 Age < 75 years	8	566	Mean Difference (IV, Random, 95% CI)	‐11.68 [‐18.00, ‐5.36]
2.2 Age > 75 years	7	345	Mean Difference (IV, Random, 95% CI)	‐6.26 [‐10.51, ‐2.01]

Comparison 5. Early supported discharge service versus conventional care: age subgroups

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Comparison 6. Early supported discharge service versus conventional care: gender subgroups

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Death or dependency Show forest plot	9	1175	Odds Ratio (M‐H, Fixed, 95% CI)	0.83 [0.65, 1.05]

1.1 Male	9	654	Odds Ratio (M‐H, Fixed, 95% CI)	0.73 [0.54, 1.01]
1.2 Female	9	521	Odds Ratio (M‐H, Fixed, 95% CI)	0.98 [0.68, 1.40]
2 Length of stay (days) Show forest plot	8	909	Mean Difference (IV, Fixed, 95% CI)	‐4.54 [‐6.48, ‐2.60]

2.1 Male	8	518	Mean Difference (IV, Fixed, 95% CI)	‐4.32 [‐6.65, ‐1.98]
2.2 Female	7	391	Mean Difference (IV, Fixed, 95% CI)	‐5.05 [‐8.55, ‐1.55]

Comparison 6. Early supported discharge service versus conventional care: gender subgroups

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Comparison 7. Early supported discharge service versus conventional care: stroke severity subgroups

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Death or dependency Show forest plot	11	1545	Odds Ratio (M‐H, Fixed, 95% CI)	0.86 [0.69, 1.07]

1.1 Initial Barthel 10 to 20	11	1164	Odds Ratio (M‐H, Fixed, 95% CI)	0.77 [0.61, 0.98]
1.2 Initial Barthel < 10	10	381	Odds Ratio (M‐H, Fixed, 95% CI)	1.40 [0.83, 2.36]
2 Length of stay (days) Show forest plot	9	960	Mean Difference (IV, Random, 95% CI)	‐7.33 [‐12.15, ‐2.50]

2.1 Initial Barthel 10 to 20	9	788	Mean Difference (IV, Random, 95% CI)	‐3.11 [‐7.13, 0.92]
2.2 Initial Barthel < 10	7	172	Mean Difference (IV, Random, 95% CI)	‐28.32 [‐39.93, ‐16.71]

Comparison 7. Early supported discharge service versus conventional care: stroke severity subgroups

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Comparison 8. Early supported discharge service versus conventional care: carer subgroups

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Death or dependency Show forest plot	10	1237	Odds Ratio (M‐H, Fixed, 95% CI)	0.87 [0.69, 1.10]

1.1 Carer present	10	799	Odds Ratio (M‐H, Fixed, 95% CI)	0.86 [0.64, 1.14]
1.2 No carer	9	438	Odds Ratio (M‐H, Fixed, 95% CI)	0.90 [0.61, 1.32]
2 Length of stay (days) Show forest plot	9	970	Mean Difference (IV, Random, 95% CI)	‐7.96 [‐12.01, ‐3.92]

2.1 Carer present	9	636	Mean Difference (IV, Random, 95% CI)	‐9.70 [‐16.06, ‐3.33]
2.2 No carer	8	334	Mean Difference (IV, Random, 95% CI)	‐6.17 [‐9.00, ‐1.34]

Comparison 8. Early supported discharge service versus conventional care: carer subgroups

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Comparison 9. Early supported discharge service versus conventional care: ESD service subgroups: service base

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Death or dependency Show forest plot	12	1604	Odds Ratio (M‐H, Fixed, 95% CI)	0.73 [0.59, 0.90]

1.1 Community in‐reach	6	755	Odds Ratio (M‐H, Fixed, 95% CI)	0.72 [0.53, 0.96]
1.2 Hospital out‐reach	6	849	Odds Ratio (M‐H, Fixed, 95% CI)	0.74 [0.56, 1.00]
2 Length of stay (days) Show forest plot	11	1395	Mean Difference (IV, Random, 95% CI)	‐7.86 [‐11.99, ‐3.73]

2.1 Community in‐reach	6	744	Mean Difference (IV, Random, 95% CI)	‐4.34 [‐7.34, ‐1.34]
2.2 Hospital out‐reach	5	651	Mean Difference (IV, Random, 95% CI)	‐9.62 [‐17.88, ‐1.36]

Comparison 9. Early supported discharge service versus conventional care: ESD service subgroups: service base

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Comparison 10. Early supported discharge service versus conventional care: ESD service subgroups: MDT co‐ordination

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Death Show forest plot	14	1957	Odds Ratio (M‐H, Fixed, 95% CI)	0.91 [0.67, 1.25]

1.1 MDT co‐ordination	12	1604	Odds Ratio (M‐H, Fixed, 95% CI)	0.77 [0.54, 1.09]
1.2 No MDT	2	353	Odds Ratio (M‐H, Fixed, 95% CI)	1.90 [0.90, 3.98]
2 Death or requiring institutional care Show forest plot	12	1758	Odds Ratio (M‐H, Fixed, 95% CI)	0.78 [0.61, 1.00]

2.1 MDT co‐ordination	10	1405	Odds Ratio (M‐H, Fixed, 95% CI)	0.69 [0.53, 0.91]
2.2 No MDT	2	353	Odds Ratio (M‐H, Fixed, 95% CI)	1.32 [0.75, 2.33]
3 Death or dependency Show forest plot	14	1957	Odds Ratio (M‐H, Fixed, 95% CI)	0.80 [0.67, 0.97]

3.1 MDT co‐ordination	12	1604	Odds Ratio (M‐H, Fixed, 95% CI)	0.73 [0.59, 0.90]
3.2 No MDT	2	353	Odds Ratio (M‐H, Fixed, 95% CI)	1.23 [0.79, 1.91]
4 Length of stay (days) Show forest plot	13	1695	Mean Difference (IV, Random, 95% CI)	‐7.21 [‐10.12, ‐4.30]

4.1 MDT co‐ordination	12	1593	Mean Difference (IV, Random, 95% CI)	‐7.62 [‐11.39, ‐3.86]
4.2 No MDT	1	102	Mean Difference (IV, Random, 95% CI)	‐7.0 [‐8.61, ‐5.39]

Comparison 10. Early supported discharge service versus conventional care: ESD service subgroups: MDT co‐ordination

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Comparison 11. Early supported discharge service versus conventional care: conventional service subgroups

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Death or dependency Show forest plot	14	1957	Odds Ratio (M‐H, Fixed, 95% CI)	0.80 [0.67, 0.97]

1.1 Stroke unit	9	1115	Odds Ratio (M‐H, Fixed, 95% CI)	0.83 [0.66, 1.06]
1.2 Other wards	7	842	Odds Ratio (M‐H, Fixed, 95% CI)	0.76 [0.56, 1.02]
2 Length of stay (days) Show forest plot	12	1517	Mean Difference (IV, Random, 95% CI)	‐7.28 [‐10.64, ‐3.93]

2.1 Stroke unit	9	882	Mean Difference (IV, Random, 95% CI)	‐6.37 [‐12.76, 0.02]
2.2 Other wards	6	635	Mean Difference (IV, Random, 95% CI)	‐7.25 [‐11.47, ‐3.03]

Comparison 11. Early supported discharge service versus conventional care: conventional service subgroups

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