There’s No Place Like Home … for Some
To the Editor:
With great interest, we read the article by Mayo et al,1 which compares the effectiveness of early poststroke discharge and multidisciplinary home rehabilitation with other practices of poststroke rehabilitation. The authors suggest that “prompt discharge combined with home rehabilitation appeared to translate motor and functional gains … into a greater degree of higher-level function and satisfaction with community reintegration … .”
In reviewing the study data, we note that only 194 (12.6%) of the 1542 potential stroke subjects screened were included in the randomization. The vast majority of the stroke survivors seen in the emergency room were deemed ineligible or inappropriate for this level of care. Thus, it is difficult to generalize findings to the larger stroke population. Furthermore, the authors defined their “usual care” group as experiencing “a range of services, including … extended acute-care hospital stays; inpatient or outpatient rehabilitation; or home care via local community health clinics … .” Since only 52% in the control group received nursing visits and 50% received physical therapy visits, this implies that some patients received no rehabilitation care at all. By lumping subjects who received no or varying intensities of rehabilitation services together into one group, the potential of identifying superior outcomes for any individual level of care in this group is diluted. Therefore, it is difficult to conclude that the home care intervention is superior to any other venue of rehabilitation. A more appropriate conclusion would be that prompt discharge combined with home rehabilitation appeared to translate into a greater degree of high-level satisfaction and community integration for a select group of stroke survivors.
Another issue raised by the data are the functional levels of the groups prior to randomization. The average Barthel Scale scores of 82.7 in the “usual group” and 84.6 in the “home care group” indicate that the stroke survivors in this study had extremely mild disabilities. This compares to a mean admission Barthel score of 37 from an earlier study of 539 stroke survivors treated on 17 inpatient rehabilitation units.2 The mean discharge Barthel score of the inpatients was 66, which still is significantly lower than the average mean entry score of the stroke survivors in the home care protocol. Thus, the discharge planners and home care clinicians who cared for the inpatients faced even greater challenges.
Overall, the authors may not be addressing the correct question. Many studies have claimed superiority of acute rehabilitation,3 subacute rehabilitation,4 day hospital,5 and coordinated home care6 in rehabilitating stroke survivors. However, further research needs to address the optimal level of care for stroke survivors of differing functional severities. A number of authors have focused on the “middle band of stroke survivors” as the most appropriate for hospital-level rehabilitation.7 8 In contrast, stroke survivors with mild disabilities and supportive families can go directly home, and those with severe disabilities might be best served in skilled nursing or extended care facilities. Depending on the level of disability, one might triage care based on a clinical guideline, such as that proposed by the Agency for Health Care Research and Quality (formerly the Agency for Health Care Policy and Research).9
With this in mind, the home care program may be a viable alternative for some patients, but it assumes that the family is capable of caring for the stroke survivor or that the stroke survivor is able to care for himself or herself. It may not be appropriate for those with complex strokes (eg, stroke survivors at risk for aspiration due to dysphagia or those who are incontinent of bowel and/or bladder, impulsive, or at risk of falling). A coordinated home care program might be more appropriate than more intensive settings for stroke survivors with mild disabilities whose goals focus more on community reintegration and instrumental rather than basic activities of daily living.
This article makes one point of importance to the rehabilitation process regardless of where it takes place. Outside of the randomization process, the authors note that the intervention empowered the subject and his or her family to take charge of decisions for rehabilitation services. If rehabilitation clinicians fail to involve stroke survivors and families in the decision-making process, and rather render them as passive observers, they are not doing their jobs.
- Copyright © 2000 by American Heart Association
Mayo NE, Wood-Dauphonee S, Cote R, Gayton D, Carlton J, Buttery J, Tamblyn R. There’s no place like home: an evaluation of early supported discharge for stroke. Stroke. 2000;31:1016–1023.
Granger CV, Hamilton BB, Gresham GE. Stroke rehabilitation outcome study, part I. Arch Phys Med Rehabil.. 1988;65:506–509.
Kramer AM, Steiner JF, Schlenker RE, Eilertsen TB, Hrincevich CA, Tropea DA, Ahmad LA, Eckhoff DG. Outcomes and costs after hip fracture and stroke: a comparison of rehabilitation settings. JAMA. 1997;277:396–404.
Keith RA, Wilson DB, Gutierrez P. Acute and subacute rehabilitation for stroke: a comparison. Arch Phys Med Rehabil. 1995;76:495–500.
Dekker R, Drost EA, Groothoff JW, Arendzen JH, van Gijn JC, Eisma WH. Effects of day-hospital rehabilitation in stroke patients: a review of randomized clinical trials. Scand J Rehabil Med. 1998;30:87–94.
Widen Holmqvist L, von Koch L, Kostulas V, Holm M, Widsell G, Tegler H, Johansson K, Almazan J, de Pedro-Cuesta J. A randomized controlled trial of rehabilitation at home after stroke in southwest Stockholm. Stroke. 1998;29:591–597.
Stineman MG, Fiedler RC, Granger CV, Maislin G. Functional task benchmarks for stroke rehabilitation. Arch Phys Med Rehabil. 1998;79:497–504.
Alexander MP. Stroke rehabilitation outcome: a potential use of predictive variables to establish levels of care. Stroke. 1994;25:128–134.
Gresham GE, Duncan PW, Stason WB, Adams HP, Adelman AM, Alexander DN, Bishop DS, Diller L, Donaldson NE, Granger CV, Holland AL, Kelly-Hayes M, McDowell FH, Myers L, Phipps MA, Roth EJ, Siebens HC, Tarvin GA, Trombley CA. Clinical Practice Guideline Number 16: Post-Stroke Rehabilitation. Rockville, Md: US Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research; 1995. AHCPR Publication 95-0662.
Thank you for directing to us this interesting letter regarding our recent study on early supported discharge for stroke.
The first comment of Drs Zorowitz and Stineman concerns our conclusion, but they have slightly misquoted our conclusion, and this small difference in wording greatly changes the interpretation.
In the abstract, our conclusion was “Prompt discharge combined with home rehabilitation appeared to translate motor and functional gains that occur through natural recovery and rehabilitation into a greater degree of higher-level function and satisfaction with community re-integration, and these in turn were translated into a better physical health.”
We did not conclude that the intervention translated to motor and functional gains—the to was not part of our conclusion. We do not think that the intervention had an effect on motor and function per se but permitted these gains, that would have been made anyway, to be used by the person in everyday activities.
Randomized trials are notorious for lacking in generalizability. The question arises as to whether the people excluded from this trial were ineligible for this type of intervention or only ineligible for participating in a research project evaluation this type of intervention. We suspect the latter. The most common cause of ineligibility was not having a caregiver at home, but in fact, many of these people went home anyway and, in the absence of a research project, they could have benefited, perhaps even more.
We did not include people that did not need rehabilitation services after stroke, but a generalized program would also have excluded these people. We excluded people who were not medically ready for discharge by 28 days or who still needed 2 people to assist them to walk by this time. People with a deficit this severe probably should be kept as inpatients, but there is to date no data supporting this presumption. We did not evaluate this question.
Thus, we think the results of this program are generalizable to those persons for whom therapeutic options are available. If there are no therapeutic options, then the research question is moot. There is no need to study something that cannot be changed.
This is a study of healthcare delivery. One can only offer a particular program—here it was prompt discharge with home rehabilitation. The comparison for this option is not sending everyone to inpatient rehabilitation. Many people did not want to go for further inpatient care; for others, this level of care was too intense. The alternative was to compare our intervention with whatever the healthcare team in conjunction with the family deemed to be optimal for this patient—usual care. We showed that providing that continuity of care into the community, even for patients that the health care team deemed not to need very much care, was beneficial. Just as usual care was tailor made to the patient, so, too, was this intervention: patients who required a lot of intervention got it and those that didn’t were watched carefully.
We have also finished our cost analysis of this study (soon to be submitted to Stroke), and our program of intervening with everyone was actually less expensive in the long run than any other option (inpatient rehabilitation in Montreal costs about $250 per day). The cost of sending even 10% of the stroke population for 4 weeks of inpatient rehabilitation in Canada would be astronomical, considering that there are 50 000 new cases of stroke in Canada per year (5000 people×30 days×$250 days=$37.5 million dollars). This would purchase a lot of home care: our intervention cost about $1000 per patient, so for the same price we could offer home support for 75% of the entire stroke population.
Although subgroup analyses are often misleading in clinical trials, the small group that went to inpatient rehabilitation did no better than those age- and severity-matched individuals who participated in the home intervention—nor did they do any worse.
Finally, we agree that empowering the patient and family to take charge is an integral part of the rehabilitation process, and that if this is not done someone is not doing his job. The experience we had with this study is that that particular rehabilitation goal is more easily operationalized and subsequently met when patients are in their own homes and not in a hospital—acute or otherwise.
By no means did this study answer all questions that about how to offer the best care, to the greatest number of patients, at the least cost. These are complex questions that would require a complex research design to answer. We hope that this project will stimulate other investigators to take up the challenge that will help patients, families, and providers in the decision-making process.