Services for Reducing the Duration of Hospital Care for Acute Stroke Patients
In most developed countries, stroke patients are admitted to hospital for a period of acute care and rehabilitation. Services have been developed to try and accelerate discharge home and reduce the duration of hospital stay. These have been termed early supported discharge (ESD) services.
This review tested whether ESD services could reduce length of stay and improve patient outcome compared with conventional hospital care and discharge arrangements.
We searched the Cochrane Specialist Register of Controlled Trials (to August 2004). The contact trialist of all eligible studies was then contacted and asked to provide details of their intervention and control services and to provide individual patient data.
We included randomized controlled trials (RCTs) that compared an ESD service with conventional care for hospitalized stroke patients. The aim of the ESD service was to accelerate discharge from hospital and provide rehabilitation and support in a community setting.
The primary outcome was the composite end point of death or dependence (Barthel index <19/20 or Rankin score >2) recorded at the end of scheduled follow-up. Secondary outcomes were death, death or requiring long-term institutional care, activities of daily living (ADL) score, subjective health status, mood or depression, patient satisfaction, caregiver outcomes (subjective health status, mood score, satisfaction), and resource outcomes (length of stay and hospital readmission).
We identified 11 RCTs (n=1597 participants) that met the selection criteria. Nine RCTs used concealed randomization procedures and 10 used blinded outcome assessment. Median follow-up was 6 months (range 3 to 12 months). In 7 trials, a single multidisciplinary ESD team coordinated a hospital discharge and provided rehabilitation at home. In 2 RCTs, the ESD team coordinated discharge and immediate postdischarge care but not ongoing rehabilitation. Two RCTs evaluated uncoordinated community services or input from healthcare volunteers.
Patients who received ESD services showed reduced odds of death or dependence (Figure) than those who received conventional care. Similar results were seen for the outcome of death or long-term institutional care (odds ratio, 0.74; 95% CI, 0.56 to 0.96; P=0.02). Significant differences were not seen for death, ADL score, subjective health status, or mood scores. Patients who received ESD services were more likely to report satisfaction with outpatient services (odds ratio, 1.6; 95% CI, 1.1 to 2.4; P=0.02). Carer outcomes did not differ between groups. The length of hospital stay was 7.7 days (CI, 4.2 to 10.7) shorter than the ESD group. Hospital readmission rates were similar between groups (27% versus 25%).
In subgroup analysis, no interaction of the ESD effect was observed with patient age, sex, or the presence of a carer. ESD services appeared to be more effective in patients with moderate stroke (baseline Barthel index of ≥10 of 20) and when provided by a coordinated multidisciplinary ESD team.
For stroke patients, in-hospital input and postdischarge support from an ESD service can accelerate discharge home and increase the chance of being independent in the long term. The best results were seen with well-coordinated ESD teams and with patients with less severe stroke.
More research is required to define the important characteristics of effective ESD services, their effectiveness in more dispersed rural communities, and to define the balance of cost and benefit for different patient and service groups.
Note: The full text of this review is available in the Cochrane Library (for subscribers: http://www3.interscience.wiley.com/cgi-bin/mrwhome/106568753/HOME). The full article should be cited as: Early Supported Discharge Trialists. Services for reducing duration of hospital care for acute stroke patients. In: The Cochrane Database of Systematic Reviews, Issue 2, 2005.
- Received September 19, 2005.
- Accepted October 11, 2005.