Published online before print October 23, 2003, doi: 10.1161/01.STR.0000101665.18062.21
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(Stroke. 2003;34:2691.)
© 2003 American Heart Association, Inc.
Original Contributions |
Editorial Comment—Early Supported Discharge: An Idea Whose Time Has Come?
Academic Section of Geriatric Medicine, Royal Infirmary, Glasgow, UK
In most developed countries, stroke patients follow a broadly predictable pathway of care beginning with hospital admission. In hospital they receive acute care and a variable period of rehabilitation, but rehabilitation services frequently stop or are significantly reduced after discharge home from hospital. Early supported discharge (ESD) services aim to alter this conventional pathway of care in 2 ways; first, by moving forward the time of discharge from hospital, and second, by providing a more continuous process of rehabilitation spanning both the period in hospital and the first few weeks at home.1
There have been several arguments made in favor of the ESD concept. First, in countries like the United Kingdom it has been argued2 that more stroke patient care should be provided in a community setting. Second, it has been claimed that ESD services can be less costly than conventional services and allow a freeing up of hospital beds.3 Finally, it has been suggested that ESD services can improve patient care by providing a 
seamless service
that spans the period of discharge home, a time that patients and carers frequently find difficult. In contrast, critics have argued that most stroke patients are discharged as early as is reasonably possible. They also point out the potential hazard of trying to manage dependent patients at home with the risk of increasing stress on carers and causing poorer patient outcomes.4
Until recently, none of these assertions had been adequately tested in clinical trials. However, since 1997 several single-blind randomized controlled trials have reported, initially from the United Kingdom,5,6 Scandinavia,7,8 Australia,9 and Canada.10 These single-center trials recruited a selected group of stroke patients (15% to 50%) admitted to hospital who were randomized to receive input from an ESD service or conventional hospital care and discharge procedures. The ESD service was based on a coordinated multidisciplinary team comprising physiotherapy and occupational therapy staff with variable amounts of medical, nursing, and speech and language therapy input. These trials demonstrated that such ESD services could significantly reduce the length of hospital stay and achieve similar patient outcomes at 6 months after stroke, although the confidence intervals were wide. Economic analyses11–13 indicate that the total costs of ESD services could be less than the notional value of hospital bed days freed by the service.
This issue of Stroke features a 1-year follow-up of a clinical trial of an early supported discharge service from Trondheim, Norway.14 The trial is of high methodological quality and evaluated an ESD service within a well-established and well-proven hospital stroke unit.15 The surprising result was that 1 year after the index stroke, patients who received the ESD service had not only spent less time in hospital but were more likely to be independent and to be living at home. In a subsequent subgroup analysis the benefits were seen most clearly among patients with intermediate stroke severity.
How could such good results have been achieved? It seems unlikely that the early pathological process of stroke and the associated impairments are influenced by this type of service. A more credible explanation is that the ESD service has improved the patient’s ability to regain normal activities despite residual impairment. In particular, the patient’s own home is probably the best place to relearn the skills needed to function in that environment.
The Trondheim study certainly indicates that ESD services can work well within the Norwegian context, where the ESD team was also able to access a high quality of rehabilitation services in primary care. What is less clear is whether these positive findings can apply equally to other settings in other countries. The suggestion that particular patient groups may benefit also requires further exploration. We also need to establish whether other patient and carer outcomes, such as mood, satisfaction, and subjective health status, are affected. The ESD service trialists are currently undertaking a detailed analysis of all available trials to try and answer these questions. In the meantime, the ESD approach appears to offer a promising contribution to a comprehensive stroke service.
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1. Early Supported Discharge Trialists. Services for reducing duration of hospital care for acute stroke patients. Oxford, UK: Cochrane Library, 1999.
2. Young J. Is stroke better managed in the community? Community care allows patients to reach their full potential. Br Med J. 1994; 309: 1356–1357.
3. Langhorne P. Developing comprehensive stroke services: an evidence-based approach. Postgrad Med J. 1995; 71: 733–737.
4. Lincoln NB. Only hospitals can provide the required skills. Br Med J. 1994; 309: 1357–1358.
5. Rudd AG, Wolfe CDA, Filling K, Beech R. Randomised controlled trial to evaluate early discharge scheme for patients with stroke. Br Med J. 1997; 315: 1039–1044.
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11. Beech R, Rudd AG, Tilling K, Wolfe CDA. Economic consequences of early supported discharge to community-based rehabilitation for stroke in an inner-London teaching hospital. Stroke. 1999; 30: 729–735.
12. McNamee P, Rodgers RH, Craig N, Pearson P, Bond J. Cost analysis of early supported hospital discharge for stroke. Age Ageing. 1998; 27: 345–351.
13. Anderson C, Mhurchu CN, Rubenach S, Clark M, Spencer C, Winsor A. Hospital or home for stroke rehabilitation? Results of a randomized controlled trial, II: cost minimization analysis at 6 months. Stroke. 2000; 31: 1032–1037.
14. Fjærtoft H, Indredavik B, Lydersen S. Stroke unit care combined with early supported discharge: long term follow-up of a randomized controlled trial. Stroke. 2003; 34: 2687–2692.
15. Indredavik B, Bakke F, Solberg R, Rokseth R, Haahein LL, Holme I. Benefit of stroke unit: a randomised controlled trial. Stroke. 1991; 22: 1026–1031.
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  A.-M. Thorsen, L. Wides Holmqvist, J. de Pedro-Cuesta, and L. von Koch A Randomized Controlled Trial of Early Supported Discharge and Continued Rehabilitation at Home After Stroke: Five-Year Follow-Up of Patient Outcome Stroke, February 1, 2005; 36(2): 297 - 303. [Abstract] [Full Text] [PDF]
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