Services for reducing duration of hospital care for acute stroke patients

Prevention, management, and rehabilitation of stroke in low- and middle-income countries

Although stroke incidence in high-income countries (HICs) decreased over the past four decades, it increased dramatically in low- and middle-income countries (LMICs). In this review, we describe the current status of primary prevention, treatment, and management of acute stroke and secondary prevention of and rehabilitation after stroke in LMICs. Although surveillance, screening, and accurate diagnosis are important for stroke prevention, LMICs face challenges in these areas due to lack of resources, awareness, and technical capacity. Maintaining a healthy lifestyle, such as no tobacco use, healthful diet, and physical activity are important strategies for both primary and secondary prevention of stroke. Controlling high blood pressure is also critically important in the general population and in the acute stage of hemorrhagic stroke. Additional primary prevention strategies include community-based education programs, polypill, prevention and management of atrial fibrillation, and digital health technology. For treatment of stroke during the acute stage, specific surgical procedures and medications are recommended, and inpatient stroke care units have been proven to provide high quality care. Patients with a chronic condition like stroke may require lifelong pharmaceutical treatment, lifestyle maintenance and self-management skills, and caregiver and family support, in order to achieve optimal health outcomes. Rehabilitation improves physical, speech, and cognitive functioning of disabled stroke patients. It is expected that home- or community-based services and tele-rehabilitation may hold special promise for stroke patients in LMICs.

Coaching or gaming? Implications of strategy choice for home based stroke rehabilitation

Background

The enduring aging of the world population and prospective increase of age-related chronic diseases urge the implementation of new models for healthcare delivery. One strategy relies on ICT (Information and Communications Technology) home-based solutions allowing clients to pursue their treatments without institutionalization. Stroke survivors are a particular population that could strongly benefit from such solutions, but is not yet clear what the best approach is for bringing forth an adequate and sustainable usage of home-based rehabilitation systems. Here we explore two possible approaches: coaching and gaming.

Methods

We performed trials with 20 healthy participants and 5 chronic stroke survivors to study and compare execution of an elbow flexion and extension task when performed within a coaching mode that provides encouragement or within a gaming mode. For each mode we analyzed compliance, arm movement kinematics and task scores. In addition, we assessed the usability and acceptance of the proposed modes through a customized self-report questionnaire.

Results

In the healthy participants sample, 13/20 preferred the gaming mode and rated it as being significantly more fun (p < .05), but the feedback delivered by the coaching mode was subjectively perceived as being more useful (p < .01). In addition, the activity level (number of repetitions and total movement of the end effector) was significantly higher (p < .001) during coaching. However, the quality of movements was superior in gaming with a trend towards shorter movement duration (p = .074), significantly shorter travel distance (p < .001), higher movement efficiency (p < .001) and higher performance scores (p < .001). Stroke survivors also showed a trend towards higher activity levels in coaching, but with more movement quality during gaming. Finally, both training modes showed overall high acceptance.

Conclusions

Gaming led to higher enjoyment and increased quality in movement execution in healthy participants. However, we observed that game mechanics strongly determined user behavior and limited activity levels. In contrast, coaching generated higher activity levels. Hence, the purpose of treatment and profile of end-users has to be considered when deciding on the most adequate approach for home based stroke rehabilitation.

Patients' expectations of coming home with Very Early Supported Discharge and home rehabilitation after stroke - an interview study

BACKGROUND

An Early Supported Discharge (ESD) and rehabilitation from a coordinated team in the home environment is recommended in several high-income countries for patients with mild to moderate symptoms after stroke. Returning home from the hospital takes place very early in Sweden today (12 days post stroke), thus the term Very Early Supported Discharge (VESD) is used in the current study. The aim of this study was to describe patients' expectations of coming home very early after stroke with support and rehabilitations at home.

METHOD

This is an interview study nested within a randomized controlled trial; Gothenburg Very Early Supported Discharge (GOTVED), comparing VESD containing a home rehabilitation intervention from a coordinated team to conventional care after stroke. Ten participants (median age 69) with mild to moderate stroke symptoms (NHISS 0 to 8 points) were recruited from the intervention group in GOTVED. Interviews were conducted 0-5 days before discharge and the material was analyzed with qualitative content analysis.

RESULTS

Four main categories containing 11 subcategories were found. The VESD team was expected to provide "Support towards independency", by helping the participants to manage and feel safe at home as well as to regain earlier abilities. The very early discharge gave rise to expectations of coming home to "A new and unknown situation", causing worries not to manage at home and to leave the safe environment at the ward. A fear to suffer a recurrent stroke when being out of reach of immediate professional help was also pronounced. In contrast to these feelings of insecurity and fear, "Returning to one's own setting" described the participants longing home, where they would become autonomous and capable people again. They expected this to facilitate recovery and rehabilitation. "A new everyday life" waited for the participants at home and this was expected to be challenging. Different strategies to deal with these challenges were described.

CONCLUSIONS

The participants described mixed expectations such as insecurity and fear, and on the other hand, longing to come home. Moreover, they had a high degree of confidence in the expected support of the VESD team. The health professionals at the hospital may build on this trust to reduce the patients' insecurity for coming home. In addition, it may be beneficial to explore the patients' expectations thoroughly in front of discharge, as certain feelings and thoughts could complicate or support the home coming process. Thus, a greater attention on such expectations may facilitate the patient's transition from hospital to home after stroke.

An assessment of randomized controlled trials (RCTs) for non-communicable diseases (NCDs): more and higher quality research is required in less developed countries

Research is crucial to implement evidence-based health interventions for control of non-communicable diseases (NCDs). This study aims to assess main features of randomized controlled trials (RCTs) for control of NCDs, and to identify gaps in clinical research on NCDs between high-income and less developed countries. The study included 1177 RCTs in 82 Cochrane Systematic reviews (CSRs) and evaluated interventions for adults with hypertension, diabetes, stroke, or heart diseases. Multivariate logistic regression analyses were conducted to explore factors associated with risk of bias in included RCTs. We found that 78.2% of RCTs of interventions for major NCDs recruited patients in high-income countries. The number of RCTs included in the CSRs was increasing over time, and the increasing speed was more noticeable for RCTs conducted in middle-income countries. RCTs conducted in less developed countries tended to be more recently published, less likely to be published in English, with smaller sample sizes, and at a higher risk of bias. In conclusion, there is still a lack of research evidence for control of NCDs in less developed countries. To brace for rising NCDs and avoid waste of scarce research resources, not only more but also higher quality clinical trials are required in low-and-middle-income countries.

Usual Clinical Practice for Early Supported Discharge after Stroke with Continued Rehabilitation at Home: An Observational Comparative Study

INTRODUCTION

Based on randomised controlled trials, evidence exists that early supported discharge (ESD) from the hospital with continued rehabilitation at home has beneficial effects after stroke; however, the effects of ESD service in regular clinical practice have not been investigated. The purpose of the current study was to compare ESD service with conventional rehabilitation in terms of patient outcomes, caregiver burden at 3 and 12 months and the use and costs of healthcare during the first year after stroke.

MATERIAL AND METHODS

This study was a subgroup analysis of a longitudinal observational study of patients who received care in the stroke unit at Karolinska University Hospital in Sweden. Patients who met the inclusion criteria for ESD in previous experimental studies were included. The patients were referred to available rehabilitation services at discharge, and comparisons between those who received ESD service (the ESD group, n = 40) and those who received conventional rehabilitation (the NoESD group, n = 110) were performed with regard to independence in activities of daily living (ADL), the frequency of social activities, life satisfaction, and caregiver burden and the use and costs of healthcare during the first year after stroke.

RESULTS

At 3 and 12 months, no differences were observed with regard to patient outcomes; however, ESD was associated with a lower caregiver burden (p = 0.01) at 12 months. The initial length of stay (LOS) at the hospital was 8 days for the ESD group and 15 days for the NoESD group (p = 0.02). The median number of outpatient rehabilitation contacts was 20.5 for the ESD group (81% constituting ESD service) and 3 for the NoESD group (p<0.001). There was no difference between the groups with regard to overall healthcare costs.

CONCLUSIONS

ESD service in usual clinical practice renders similar health benefits as conventional rehabilitation but a different pattern of resource use and with released capacity in acute stroke care.

Development and evaluation of a Smartphone-enabled, caregiver-supported educational intervention for management of physical disabilities following stroke in India: protocol for a formative research study

The incidence and prevalence of stroke in India has reached epidemic proportions. The growing magnitude of disability in patients with stroke in India poses a major public health challenge. Given the nature of the condition, affected individuals often become disabled with profound effects on their quality of life. The availability of rehabilitation services for people with disabilities is inadequate in India. Rehabilitation services are usually offered by private hospitals located in urban areas and many stroke survivors, especially those who are poor or live in rural areas, cannot afford to pay for, or do not have access to, such services. Thus, identification of cost-effective ways to rehabilitate people with stroke-related disability is an important challenge. Educational interventions in stroke rehabilitation can assist stroke survivors to make informed decisions regarding their on-going treatment and to self-manage their condition with support from their caregivers. Although educational interventions have been shown to improve patient knowledge for self-management of stroke, an optimal format for the intervention has not as yet been established, particularly in low- and middle-income countries. This formative research study aims to systematically develop an educational intervention for management of post-stroke disability for stroke survivors in India, and evaluate the feasibility and acceptability of delivering the intervention using Smartphones and with caregiver support. The research study will be conducted in Chennai, India, and will be organised in three different phases. Phase 1: Development of the intervention. Phase 2: Field testing and finalising the intervention. Phase 3: Piloting of the intervention and assessment of feasibility and acceptability. A mixed-methods approach will be used to develop and evaluate the intervention. If successful, it will help realise the potential of using Smartphone-enabled, carer-supported educational intervention to bridge the gaps in service access for rehabilitation of individuals with stroke-related disability in India. The proposed research will also provide valuable information for clinicians and policymakers.

'Care for Stroke', a web-based, smartphone-enabled educational intervention for management of physical disabilities following stroke: feasibility in the Indian context

INTRODUCTION

Stroke rehabilitation is a process targeted towards restoration or maintenance of the physical, mental, intellectual and social abilities of an individual affected by stroke. Unlike high-income countries, the resources for stroke rehabilitation are very limited in many low-income and middle-income countries (LMICs). Provision of cost-effective, post-stroke multidisciplinary rehabilitation services for the stroke survivors therefore becomes crucial to address the unmet needs and growing magnitude of disability experienced by the stroke survivors in LMICs. In order to meet the growing need for post-stroke rehabilitation services in India, we developed a web-based Smartphone-enabled educational intervention for management of physical disabilities following a stroke.

METHODS

On the basis of the findings from the rehabilitation needs assessment study, guidance from the expert group and available evidence from systematic reviews, the framework of the intervention content was designed. Web-based application designing and development by Professional application developers were subsequently undertaken.

RESULTS

The application is called 'Care for Stroke'. It is a web-based educational intervention for management of physical disabilities following a stroke. This intervention is developed for use by the Stroke survivors who have any kind of rehabilitation needs to independently participate in his/her family and social roles.

DISCUSSION

'Care for stroke' is an innovative intervention which could be tested not just for its feasibility and acceptability but also for its clinical and cost-effectiveness through rigorously designed, randomised clinical trials. It is very important to test this intervention in LMICs where the rehabilitation and information needs of the stroke survivors seem to be substantial and largely unmet.

Questions people ask about stroke: What's changed in 20 years?

OBJECTIVES

Care for patients after stroke has been transformed over the last two decades. We explored one patient-centred outcome: the type and range of questions asked after stroke through a publically available helpline. We compared data from 1990 to 2013 to see whether the positive changes in stroke care are reflected in the types and quantity of inquiries from patients and their families.

METHODS

All of the inquiries received by the UK Stroke Association helpline between 1 April 2013 and 31 March 2014 were collated and compared to the data collected and previously reported by Hanger and Mulley between May and September 1990.

RESULTS

In 1990, the most common inquiry was for more information about stroke (22.5% (429/1908)). In 2013, the most common question remained the same, with 25.4% (2601/10,233) of all callers asking what is a stroke. Specific medical questions increased from 4.2% (80/1908) in 1990 to 10.5% (1074/10,233) in 2013. Queries about support with home care reduced from 9.4% (180/1908) in 1990 to 2.6% (257/10,233) in 2013. Questions about recovery and rehabilitation were frequent in both 1990 (11.1% (212/1908)) and 2013 (13.2% (1353/10,233)).

CONCLUSION

The transformation in stroke services has not been reflected in this patient-level outcome in the United Kingdom. Many stroke survivors and their families still struggle with understanding their condition and treatment options.

Ability in daily activities after early supported discharge models of stroke rehabilitation

More knowledge is needed about how different rehabilitation models in the municipality influence stroke survivors' ability in activities of daily living (ADL).

OBJECTIVES

To compare three models of outpatient rehabilitation; early supported discharge (ESD) in a day unit, ESD at home and traditional treatment in the municipality (control group), regarding change in ADL ability during the first three months after stroke.

METHODS

A group comparison study was designed within a randomized controlled trial. Included participants were tested with the Assessment of Motor and Process Skills (AMPS) at baseline and discharged directly home. Primary and secondary outcomes were the AMPS and the modified Rankin Scale (mRS).

RESULTS AND CONCLUSIONS

Included were 154 participants (57% men, median age 73 years), and 103 participants completed the study. There were no significant group differences in pre-post changed ADL ability measured by the AMPS. To find the best rehabilitation model to improve the quality of stroke survivors' motor and process skills needs further research. Patients participating in the ESD rehabilitation models were, compared with traditional treatment, significantly associated with improved ADL ability measured by the mRS when controlling for confounding factors, indicating that patients with social needs and physical impairment after stroke may benefit from ESD rehabilitation models.

Evaluating an extended rehabilitation service for stroke patients (EXTRAS): study protocol for a randomised controlled trial

BACKGROUND

Development of longer term stroke rehabilitation services is limited by lack of evidence of effectiveness for specific interventions and service models. We describe the protocol for a multicentre randomised controlled trial which is evaluating an extended stroke rehabilitation service. The extended service commences when routine 'organised stroke care' (stroke unit and early supported discharge (ESD)) ends.

METHODS/DESIGN

This study is a multicentre randomised controlled trial with health economic and process evaluations. It is set within NHS stroke services which provide ESD. Participants are adults who have experienced a new stroke (and carer if appropriate), discharged from hospital under the care of an ESD team. The intervention group receives an extended stroke rehabilitation service provided for 18 months following completion of ESD. The extended rehabilitation service involves regular contact with a senior ESD team member who leads and coordinates further rehabilitation. Contact is usually by telephone. The control group receives usual stroke care post-ESD. Usual care may involve referral of patients to a range of rehabilitation services upon completion of ESD in accordance with local clinical practice. Randomisation is via a central independent web-based service. The primary outcome is extended activities of daily living (Nottingham Extended Activities of Daily Living Scale) at 24 months post-randomisation. Secondary outcomes (at 12 and 24 months post-randomisation) are health status, quality of life, mood and experience of services for patients, and quality of life, experience of services and carer stress for carers. Resource use and adverse events are also collected. Outcomes are undertaken by a blinded assessor. Implementation and delivery of the extended stroke rehabilitation service will also be described. Semi-structured interviews will be conducted with a subsample of participants and staff to gain insight into perceptions and experiences of rehabilitation services delivered or received. Allowing for 25% attrition, 510 participants are needed to provide 90% power to detect a difference in mean Nottingham Extended Activities of Daily Living Scale score of 6 with a 5% significance level.

DISCUSSION

The provision of longer term support for stroke survivors is currently limited. The results from this trial will inform future stroke service planning and configuration.

TRIAL REGISTRATION

This trial was registered with ISRCTN (identifier: ISRCTN45203373 ) on 9 August 2012.

Is Stroke Early Supported Discharge still effective in practice? A prospective comparative study

Objective:

Randomised controlled trials have shown the benefits of Early Supported Discharge (ESD) of stroke survivors. Our aim was to evaluate whether ESD is still beneficial when operating in the complex context of frontline healthcare provision.

Design:

We conducted a cohort study with quasi experimental design. A total of 293 stroke survivors (transfer independently or with assistance of one, identified rehabilitation goals) within two naturally formed groups were recruited from two acute stroke units: ‘ESD’ n=135 and ‘Non ESD’ n=158 and 84 caregivers. The ‘ESD’ group accessed either of two ESD services operating in Nottinghamshire, UK. The ‘Non ESD’ group experienced standard practices for discharge and onward referral. Outcome measures (primary: Barthel Index) were administered at baseline, 6 weeks, 6 months and 12 months.

Results:

The ESD group had a significantly shorter length of hospital stay ( P=0.029) and reported significantly higher levels of satisfaction with services received ( P<0.001). Following adjustment for age differences at baseline, participants in the ESD group ( n=71) had significantly higher odds (compared to the Non ESD group, n=85) of being in the ⩾90 Barthel Index category at 6 weeks (OR = 1.557, 95% CI 2.579 to 8.733), 6 months (OR = 1.541, 95% CI 2.617 to 8.340) and 12 months (OR 0.837, 95% CI 1.306 to 4.087) respectively in relation to baseline. Carers of patients accessing ESD services showed significant improvement in mental health scores ( P<0.01).

Conclusion:

The health benefits of ESD are still evident when evidence based models of these services are implemented in practice.

Insights from the clinical assurance of service reconfiguration in the NHS: the drivers of reconfiguration and the evidence that underpins it – a mixed-methods study

Background

Over the life of the NHS, hospital services have been subject to continued reconfiguration. Yet it is rare for the reconfiguration of clinical services to be evaluated, leaving a deficit in the evidence to guide local reconfiguration of services.

Objectives

The objectives of this research are to determine the current pressures for reconfiguration within the NHS in England and the solutions proposed. We also investigate the quality of evidence used in making the case for change, any key evidence gaps, and the opportunities to strengthen the clinical case for change and how it is made.

Methods

We have drawn on two key sources of evidence. First, we reviewed the reports produced by the National Clinical Advisory Team (NCAT) documenting its reviews of reconfiguration proposals. An in-depth multilevel qualitative analysis was conducted of 123 NCAT reviews published between 2007 and 2012. Second, we carried out a search and synthesis of the literature to identify the key evidence available to support reconfiguration decisions. The findings from this literature search were integrated with the analysis of the reviews to develop a narrative for each specialty and the process of reconfiguration as a whole.

Results

The evidence from the NCAT reviews shows significant pressure to reconfigure services within the NHS in England. We found that the majority of reconfiguration proposals are driving an increasing concentration of hospital services, with some accompanying decentralisation and, for some specialist services, the development of supporting clinical networks. The primary drivers of reconfiguration have been workforce (in particular the medical workforce) and finance. Improving outcomes and safety issues have been subsidiary drivers, though many make the link between staffing and clinical safety. Policy has also been a notable driver. Access has been notable by its absence as a driver. Despite significant pressures to reconfigure services, many proposals fail to be implemented owing to public and/or clinical opposition. We found strong evidence that some specialist service reconfiguration including vascular surgery and major trauma can significantly improve clinical outcomes. However, there are notable evidence gaps. The most significant is the absence of evidence that service reconfiguration can deliver significant savings. There is also an absence of evidence about safe staffing models and the interplay between staff numbers, skill mix and outcomes. We found that the advice provided by the NCAT reflects the current evidence, but one of the NCAT’s most valuable contributions has been to encourage greater clinical engagement in service change.

Conclusions

The NHS is continuing to concentrate many district general hospital services to resolve financial and workforce pressures. However, many proposals are not implemented owing to public opposition. We also found no evidence to suggest that this will deliver the savings anticipated. There is a significant gap in the evidence about safe staffing models and the appropriate balance of junior and senior medical as well as other clinical staff. There is an urgent need to carry out research that will help to fill the current evidence gap. There is also a need to retain some national clinical expertise to work alongside Clinical Senates in supporting local service reconfiguration.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

The influence of an intermediate care hospital on health care utilization among elderly patients--a retrospective comparative cohort study

BACKGROUND

An intermediate care hospital (ICH) was established in a municipality in Central Norway in 2007 to improve the coordination of services and follow-up among elderly and chronically ill patients after hospital discharge. The aim of this study was to compare health care utilization by elderly patients in a municipality with an ICH to that of elderly patients in a municipality without an ICH.

METHODS

This study was a retrospective comparative cohort study of all hospitalized patients aged 60 years or older in two municipalities. The data were collected from the national register of hospital use from 2005 to 2012, and from the local general hospital and two primary health care service providers from 2008 to 2012 (approx. 1,250 patients per follow-up year). The data were analyzed using descriptive statistics and analysis of covariance (ANCOVA).

RESULTS

The length of hospital stay decreased from the time the ICH was introduced and remained between 10% and 22% lower than the length of hospital stay in the comparative municipality for the next five years. No differences in the number of readmissions or admissions during one year follow-up after the index stay at the local general hospital or changes in primary health care utilization were observed. In the year after hospital discharge, the municipality with an ICH offered more hour-based care to elderly patients living at home (estimated mean = 234 [95% CI 215-252] versus 175 [95% CI 154-196] hours per person and year), while the comparative municipality had a higher utilization of long-term stays in nursing homes (estimated mean = 33.3 [95% CI 29.0-37.7] versus 21.9 [95% CI 18.0-25.7] days per person and year).

CONCLUSIONS

This study indicates that the introduction of an ICH rapidly reduces the length of hospital stay without exposing patients to an increased health risk. The ICH appears to operate as an extension of the general hospital, with only a minor impact on the pattern of primary health care utilization.

Early supported discharge after stroke in Bergen (ESD Stroke Bergen): three and six months results of a randomised controlled trial comparing two early supported discharge schemes with treatment as usual

BACKGROUND

Stroke causes lasting disability and the burden of stroke is expected to increase substantially during the next decades. Optimal rehabilitation is therefore mandatory. Early supported discharge (ESD) has previously shown beneficial, but all major studies were carried out more than ten years ago. We wanted to implement and study the results of ESD in our community today with comparisons between ESD and treatment as usual, as well as between two different ESD models.

METHODS

Patients with acute stroke were included during a three year period (2008-11) in a randomised controlled study comparing two different ESD models to treatment as usual. The two ESD models differed by the location of treatment: either in a day unit or in the patients' homes. Patients in the ESD groups were followed by a multi-disciplinary ambulatory team in the stroke unit and discharged home as early as possible. The ESD models also comprised treatment by a multi-disciplinary community health team for up to five weeks and follow-up controls after 3 and 6 months. Primary outcome was modified Rankin Scale (mRS) at six months.

RESULTS

Three-hundred-and-six patients were included. mRS scores and change scores were non-significantly better in the two ESD groups at 3 and 6 months. Within-group improvement from baseline to 3 months was significant in the ESD 1 (p = 0.042) and ESD 2 (p = 0.001) groups, but not in the controls. More patients in the pooled ESD groups were independent at 3 (p = 0.086) and 6 months (p = 0.122) compared to controls and there also was a significant difference in 3 month change score between them (p = 0.049). There were no differences between the two ESD groups. Length of stay in the stroke unit was 11 days in all groups.

CONCLUSIONS

Patients in the ESD groups tended to be more independent than controls at 3 and 6 months, but no clear statistically significant differences were found. The added effect of supported discharge and improved follow-up seems to be rather modest. The improved stroke treatment of today may necessitate larger patient samples to demonstrate additional benefit of ESD.

CLINICAL TRIAL REGISTRATION

Unique identifier: NCT00771771.

Prevalence of self-reported stroke and disability in the French adult population: a transversal study

In France, the prevalence of stroke and the level of disability of stroke survivors are little known. The aim of this study was to evaluate functional limitations in adults at home and in institutions, with and without self-reported stroke. A survey named “the Disability Health survey” was carried out in people's homes (DHH) and in institutions (DHI). Medical history and functional level (activities-of-daily-living, ADL and instrumented-activities-of-daily-living IADL) were collected through interviews. The modified Rankin score (mRS) and the level of dependence and disability were compared between participants with and without stroke. 33896 subjects responded. The overall prevalence of stroke was 1.6% (CI95% [1.4%–1.7%]). The mRS was over 2 for 34.4% of participants with stroke (28.7% of participants at home and 87.8% of participants in institutions) versus respectively 3.9%, 3.1% and 71.6% without stroke. Difficulty washing was the most frequently reported ADL for those with stroke (30.6% versus 3% for those without stroke). Difficulty with ADL and IADL increased with age but the relative risk was higher below the age of 60 (17 to 25) than over 85 years (1.5 to 2.2), depending on the ADL. In the overall population, 22.6% of those confined to bed or chair reported a history of stroke. These results thus demonstrate a high national prevalence of stroke. Older people are highly dependent, irrespective of stroke history and the relative risk of dependence in young subjects with a history of stroke is high compared with those without.

Organisational interventions to reduce length of stay in hospital: a rapid evidence assessment

Background

Available evidence on effective interventions to reduce length of stay in hospital is wide-ranging and complex, with underlying factors including those acting at the health system, organisational and patient levels, and the interface between these. There is a need to better understand the diverse literature on reducing the length of hospital stay.

Objectives

This study sought to (i) describe the nature of interventions that have been used to reduce length of stay in acute care hospitals; (ii) identify the factors that are known to influence length of stay; and (iii) assess the impact of interventions on patient outcomes, service outcomes and costs.

Data sources

We searched MEDLINE (Ovid), EMBASE, the Health Management Information Consortium and System for Information on Grey Literature in Europe for the period January 1995 to January 2013 with no limitation of publication type.

Methods

We conducted a rapid evidence synthesis of the peer-reviewed literature on organisational interventions set in or initiated from acute hospitals. We considered evidence published between 2003 and 2013. Data were analysed drawing on the principles of narrative synthesis. We also carried out interviews with eight NHS managers and clinical leads in four sites in England.

Results

A total of 53 studies met our inclusion criteria, including 19 systematic reviews and 34 primary studies. Although the overall evidence base was varied and frequently lacked a robust study design, we identified a range of interventions that showed potential to reduce length of stay. These were multidisciplinary team working, for example some forms of organised stroke care; improved discharge planning; early supported discharge programmes; and care pathways. Nursing-led inpatient units were associated with improved outcomes but, if anything, increased length of stay. Factors influencing the impact of interventions on length of stay included contextual factors and the population targeted. The evidence was mixed with regard to the extent to which interventions seeking to reduce length of stay were associated with cost savings.

Limitations

We only considered assessments of interventions which provided a quantitative estimate of the impact of the given organisational intervention on length of hospital stay. There was a general lack of robust evidence and poor reporting, weakening the conclusions that can be drawn from the review.

Conclusions

The design and implementation of an intervention seeking to reduce (directly or indirectly) the length of stay in hospital should be informed by local context and needs. This involves understanding how the intervention is seeking to change processes and behaviours that are anticipated, based on the available evidence, to achieve desired outcomes (‘theory of change’). It will also involve assessing the organisational structures and processes that will need to be put in place to ensure that staff who are expected to deliver the intervention are appropriately prepared and supported. With regard to future research, greater attention should be given to the theoretical underpinning of the design, implementation and evaluation of interventions or programmes. There is a need for further research using appropriate methodology to assess the effectiveness of different types of interventions in different settings. Different evaluation approaches may be useful, and closer relationships between researchers and NHS organisations would enable more formative evaluation. Full economic costing should be undertaken where possible, including considering the cost implications for the wider local health economy.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Feasibility and efficacy of cognitive telerehabilitation in early Alzheimer's disease: a pilot study

BACKGROUND

This pilot study compared the effects of lexical-semantic stimulation through telecommunication technology (LSS-tele) with in-person LSS (LSS-direct) and unstructured cognitive treatment (UCS) in patients with early Alzheimer's disease.

METHODS

Twenty-seven patients with Alzheimer's disease in the very early stage (Mini-Mental State Examination [MMSE] >26/30) were divided into three groups: seven patients received LSS-tele treatment, ten received standard LSS-direct intervention, and ten participants underwent UCS as control condition. Intervention treatments consisted of two weekly sessions of LSS (through teleconference or face to face depending on group assignment) or UCS exercises administered to small groups throughout a 3-month period. The main outcome measures were changes of global cognitive performance, language abilities, and memory function. Secondary outcome measures were changes in attention, working memory, executive functions, and visual-spatial abilities tests.

RESULTS

The mean MMSE score improved significantly in LSS-tele and LSS-direct treatments; LSS-tele improved language abilities, both phonemic and semantic, and stabilized delayed verbal episodic memory with respect to an improved performance after the LSS-direct intervention and to a memory decline observed in the control group. Improvement was not achieved in any neuropsychological test score after UCS.

CONCLUSION

Clinical application of telecommunication technology to cognitive rehabilitation of elderly patients with neurodegenerative cognitive impairment is feasible and may improve global cognitive performance. Technical aspects to ameliorate efficacy of delivery may further improve its impact on domain-specific cognitive abilities.

Organising health care services for people with an acquired brain injury: an overview of systematic reviews and randomised controlled trials

BACKGROUND

Acquired brain injury (ABI) is the leading cause of disability worldwide yet there is little information regarding the most effective way to organise ABI health care services. The aim of this review was to identify the most up-to-date high quality evidence to answer specific questions regarding the organisation of health care services for people with an ABI.

METHODS

We conducted a systematic review of English papers using MEDLINE, EMBASE, PsycINFO, CINAHL and the Cochrane Library. We included the most recently published high quality systematic reviews and any randomised controlled trials, non-randomised controlled trials, controlled before after studies or interrupted time series studies published subsequent to the systematic review. We searched for papers that evaluated pre-defined organisational interventions for adults with an ABI. Organisational interventions of interest included fee-for-service care, integrated care, integrated care pathways, continuity of care, consumer engagement in governance and quality monitoring interventions. Data extraction and appraisal of included reviews and studies was completed independently by two reviewers.

RESULTS

A total of five systematic reviews and 21 studies were included in the review; eight of the papers (31%) included people with a traumatic brain injury (TBI) or ABI and the remaining papers (69%) included only participants with a diagnosis of stroke. We found evidence supporting the use of integrated care to improve functional outcome and reduce length of stay and evidence supporting early supported discharge teams for reducing morbidity and mortality and reducing length of stay for stroke survivors. There was little evidence to support case management or the use of integrated care pathways for people with ABI. We found evidence that a quality monitoring intervention can lead to improvements in process outcomes in acute and rehabilitation settings. We were unable to find any studies meeting our inclusion criteria regarding fee-for-service care or engaging consumers in the governance of the health care organisation.

CONCLUSIONS

The review found evidence to support integrated care, early supported discharge and quality monitoring interventions however, this evidence was based on studies conducted with people following stroke and may not be appropriate for all people with an ABI.

National Institute for Health and Care Excellence stroke rehabilitation guidance – is it useful, usable, and based on best evidence?

In the UK, the National Institute for Health and Care Excellence (NICE) is responsible for producing clinical guidance based on sound evidence. In 2013 they produced guidance on Stroke Rehabilitation and this editorial outlines why this is not a useful guide for clinicians or commissioners. Primarily this is because NICE used inappropriate methods; the methods used are appropriate for evaluating drugs, but are inappropriate when applied to any complex intervention. Moreover, the actual recommendations are written in clinically unhelpful language.

Future rehabilitation guidance should include ensuring that the team responsible for the guidance are all familiar with and understand the biospsychosocial model of illness and the nature of the rehabilitation process (which is not synonymous with therapy), setting a relevant and appropriate scope for a guideline, agreeing to use all evidence relevant to a particular question, and using a more appropriate way to evaluate evidence while recognising that rehabilitation is a complex intervention.

Balance and walking after three different models of stroke rehabilitation: early supported discharge in a day unit or at home, and traditional treatment (control)

OBJECTIVE

To compare the effects on balance and walking of three models of stroke rehabilitation: early supported discharge with rehabilitation in a day unit or at home, and traditional uncoordinated treatment (control).

DESIGN

Group comparison study within a randomised controlled trial.

SETTING

Hospital stroke unit and primary healthcare.

INCLUSION CRITERIA

a score of 2-26 on National Institutes of Health Stroke Scale, assessed with Postural Assessment Scale for Stroke (PASS), and discharge directly home from the hospital stroke unit.

INTERVENTIONS

Two intervention groups were given early supported discharge with treatment in either a day unit or the patient's own home. The controls were offered traditional, uncoordinated treatment.

OUTCOME MEASURES

Primary: PASS. Secondary: Trunk Impairment Scale-modified Norwegian version; timed Up-and-Go; 5 m timed walk; self-reports on problems with walking, balance, ADL, physical activity, pain and tiredness. The patients were tested before randomisation and 3 months after inclusion.

RESULTS

From a total of 306 randomised patients, 167 were tested with PASS at baseline and discharged directly home. 105 were retested at 3 months: mean age 69 years, 63 men, 27 patients in day unit rehabilitation, 43 in home rehabilitation and 35 in a control group. There were no group differences, either at baseline for demographic and test data or for length of stroke unit stay. At 3 months, there was no group difference in change on PASS (p>0.05). Some secondary measures tended to show better outcome for the intervention groups, that is, trunk control, median (95% CI): day unit, 2 (0.28 to 2.31); home rehabilitation, 4 (1.80 to 3.78); control, 1 (0.56 to 2.53), p=0.044; and for self-report on walking, p=0.021 and ADL, p=0.016.

CONCLUSIONS

There was no difference in change between the groups for postural balance, but the secondary outcomes indicated that improvement of trunk control and walking was better in the intervention groups than in the control group.

TRIAL REGISTRATION

This study is part of the Early Supported Discharge after Stroke in Bergen, ClinicalTrials.gov (NCT00771771).

Hospital discharge of elderly patients to primary health care, with and without an intermediate care hospital - a qualitative study of health professionals' experiences

Introduction

Intermediate care is an organisational approach to improve the coordination of health care services between health care levels. In Central Norway an intermediate care hospital was established in a municipality to improve discharge from a general hospital to primary health care. The aim of this study was to investigate how health professionals experienced hospital discharge of elderly patients to primary health care with and without an intermediate care hospital.

Methods

A qualitative study with data collected through semi-structured focus groups and individual interviews.

Results

Discharge via the intermediate care hospital was contrasted favourably compared to discharge directly from hospital to primary health care. Although increased capacity to receive patients from hospital and prepare them for discharge to primary health care was viewed as a benefit, professionals still requested better communication with the preceding care level concerning further treatment and care for the elderly patients.

Conclusions

The intermediate care hospital reduced the coordination challenges during discharge of elderly patients from hospital to primary health care. Nevertheless, the intermediate care was experienced more like an extension of hospital than an included part of primary health care and did not meet the need for communication across care levels.

Main barriers to effective implementation of stroke care pathways in France: a qualitative study

Background

Stroke Care Pathways (SCPs) aim to improve quality of care by providing better access to stroke units, rehabilitation centres, and home care for dependent patients. The objective of this study was to identify the main barriers to effective implementation of SCPs in France.

Methods

We selected 4 types of SCPs currently implemented in France that differed in terms of geographical location, population size, socio-economic conditions, and available health care facilities. We carried out 51 semi-structured interviews of 44 key health professionals involved in these SCPs and used the interview data to (i) create a typology of the organisational barriers to effective SCP implementation by axial coding, (ii) define barrier contents by vertical coding. The typology was validated by a panel of 15 stroke care professionals.

Results

Four main barriers to effective SCP implementation were identified: lack of resources (31/44 interviewees), coordination problems among staff (14/44) and among facilities (27/44), suboptimal professional and organisational practices (16/44), and inadequate public education about stroke (13/44). Transposition of the findings onto a generic SCP highlighted alternative care options and identified 10 to 17 barriers that could disrupt continuity of care.

Conclusion

Lack of resources was considered to be the chief obstacle to effective SCP implementation. However, the main weakness of existing SCPs was poor communication and cooperation among health professionals and among facilities. We intend to use this knowledge to construct a robust set of quality indicators for use in SCP quality improvement initiatives, in comparisons between SCPs, and in the assessment of the effective implementation of clinical practice guidelines.

Investigating preferences for support with life after stroke: a discrete choice experiment

Background

There is little evidence of service user preferences to guide the commissioning and improvement of services that support life after stroke. We report the first investigation of patients’ and family carers’ preferences for community services after stroke using a discrete choice experiment (DCE).

Methods

Two workshops with patients and family carers (n = 8) explored stroke experiences, identifying attributes important in shaping views about service design, and piloted data collection strategies. Attributes were group versus individual support; service provider; additional support for social and leisure activities; and the total time required to access services. Patients and family carers were recruited six months post stroke-onset (mean 331 days) from four stroke services, and invited to participate in the DCE. Patients’ general health (EQ5D) and functional dependence (Barthel Index) were also assessed. Of 474 eligible patients, 144 (30%) expressed an interest in the study, and 80 (56%) of these completed the survey questionnaire. 34 of 74 (46%) family carers recruited through patients completed the DCE.

Results

All four attributes were significant in shaping patients preferences for stroke support service delivery (p < 0.05), confirming the interpretation of workshop findings. Patients prefer help and support for emotional needs, communication problems and physical difficulties to be provided on an individual basis; and to be offered additional social and leisure activities that they are able to attend on their own. Patients would appear to prefer that voluntary organisations do not provide these services, although this may be linked to lack of experience of these services. Family carers would prefer help and support in their caring role on a one-to-one basis. Whilst health related quality of life is associated with preference for format of service, results were relatively consistent across sub-groups, with the exception of time since stroke, where social and leisure activities had a greater impact on preferences of established service users.

Conclusions

The data provide unique insights into how preferences for community services that support life after stroke are shaped. This information can be used to inform both service re-design, and barriers to implementation that will need to be accounted for in policy shifts towards a more mixed economy of service provision.

Activity limitations experienced by people with stroke who receive inpatient rehabilitation: differences between 2001, 2005, and 2011

OBJECTIVE

To determine whether there were differences in characteristics and activity limitations relevant to physiotherapists among people receiving inpatient rehabilitation after stroke in 2001, 2005, and 2011.

DESIGN

A multicenter observational study of 3 periods.

SETTING

Inpatient rehabilitation units (N=15).

PARTICIPANTS

Adult stroke survivors (N=738) admitted over 3 periods (2001, 2005, 2011).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Characteristics, hospital metrics, and Motor Assessment Scale (MAS) scores were recorded on admission and discharge.

RESULTS

All 3 cohorts were similar in terms of sex, side affected by stroke, and length of time from stroke onset to rehabilitation admission. Stroke participants in the 2005 cohort were older than those in the 2011 and 2001 cohorts. Participants in the 2011 cohort had a longer inpatient rehabilitation length of stay, experienced lower average MAS gains per day (F>3.298, P<.038), and experienced more activity limitations in basic functional tasks involving bed mobility, standing up, and sitting balance on admission and discharge, and in walking and arm function at discharge only compared with earlier cohorts.

CONCLUSIONS

In 2011, on average, people admitted for rehabilitation after stroke were approximately the same age as patients in 2005 and 2001 and it took approximately 2 weeks for all of these patients to be admitted to a rehabilitation unit, but patients in 2011 had a longer inpatient rehabilitation length of stay compared with patients in 2005 and 2001. In addition, activity limitations at inpatient rehabilitation admission and discharge appear to be worse, particularly for activities such as rolling, sitting up over the edge of the bed, and balanced sitting.

The effect of clinical interventions on hospital readmissions: a meta-review of published meta-analyses

BACKGROUND

The economic impact and ease of measurement of all-cause hospital readmission rates (HRR) have led to the current debate as to whether they are reducible, and whether they should be used as a publicly reported quality indicators of medical care.

OBJECTIVE

To assess the efficacy of broad clinical interventions in preventing HRR of patients with chronic diseases

METHOD

A meta-review of published systematic reviews of randomized controlled trials (RCTs) of clinical interventions that have included HRR among the patients' outcomes of interest.

MAIN FINDINGS

Meta-analyses of RCTs have consistently found that, in the community, disease management programs significantly reduced HRR in patients with heart failure, coronary heart disease and bronchial asthma, but not in patients with stroke and in unselected patients with chronic disorders. Inhospital interventions, such as discharge planning, pharmacological consultations and multidisciplinary care, and community interventions in patients with chronic obstructive pulmonary diseases had an inconsistent effect on HRR. MAIN STUDY LIMITATION: Despite their economic impact and ease of measurement, HRR are not the most important outcome of patient care, and efforts aimed at their reduction may compromise patients' health by reducing also justified re-admissions.

CONCLUSIONS

The efficacy of inhospital interventions in reducing HRR is in need of further study. In patients with heart diseases and bronchial asthma, HRR may be considered as a publicly reported quality indicator of community care, provided that future research confirms that efforts to reduce HRR do not adversely affect other patients' outcomes, such as mortality, functional capacity and quality of life. Future research should also focus on the reasons for the higher efficacy of community interventions in patients with heart diseases and bronchial asthma than in those with other chronic diseases.

Communication in a medical setting: can standards be improved?

Do standards exist to improve communication in a medical setting? What are the minimal requirements to make our communication with patients and their family clear and simple? International literature, as well as psychology, philosophy, and even our brain structure offer ways to improve communication. We reflected about what is preventing effective communication in the medical setting and how/from where should we set about improving it.