Benefit of an extended stroke unit service with early supported discharge: A randomized, controlled trial

Discharge to Assess: an evaluation of three case studies in the southeast of England to inform service improvement

BACKGROUND

Discharge to Assess (D2A) emerged as a critical process during the COVID-19 pandemic facilitating patient flow within hospitals, however research on the post-discharge community services of this pathway remains limited. We conducted an evaluation to examine the impacts, capacity, processes and barriers associated with D2A and to identify best practice across three sites in the southeast of England.

METHODS

We interviewed 29 commissioners, providers and staff members involved in the delivery of D2A pathways within three Health and Care Partnerships. Framework analysis of the collected data revealed three prominent themes: the commissioning of services encompassing funding, structure, culture, and expected outcomes; multidisciplinary collaboration including staff skills, team connections, and coordination; and information and knowledge exchange such as assessment methods, record management, and availability of operational insights.

RESULTS

62 specific enablers and blockers to effective D2A practice emerged.

DISCUSSION

These findings supported the development of a comprehensive service improvement toolkit.

CONCLUSION

Five recommendations are proposed: 1. Examination of pathways against the 62 enablers and blockers to identify and resolve pathway obstacles; 2. Establish a local operational policy accessible to all providers; 3. Enhance coordination and communication among service providers, patients and carers; 4. Strengthen oversight of service user flow; 5. Develop a consistent Patient Reported Outcomes Measure to facilitate feedback and service enhancements for individuals discharged from urgent care pathways.

Effectiveness of outpatient geriatric rehabilitation after inpatient geriatric rehabilitation or hospitalisation: a systematic review and meta-analysis

BACKGROUND

Due to the increasing number of older people with multi-morbidity, the demand for outpatient geriatric rehabilitation (OGR) will also increase.

OBJECTIVE

To assess the effects of OGR on the primary outcome functional performance (FP) and secondary outcomes: length of in-patient stay, re-admission rate, patients' and caregivers' quality of life, mortality and cost-effectiveness. We also aim to describe the organisation and content of OGR.

METHODS

Systematic review and meta-analysis. Five databases were queried from inception to July 2022. We selected randomised controlled trials written in English, focusing on multidisciplinary interventions related to OGR, included participants aged ≥65 and reported one of the main outcomes. A meta-analysis was performed on FP, patients' quality of life, length of stay and re-admissions. The structural, procedural and environmental aspects of OGR were systematically mapped.

RESULTS

We selected 24 studies involving 3,405 participants. The meta-analysis showed no significant effect on the primary outcome FP (activity). It demonstrated a significant effect of OGR on shortening length of in-patient stay (P = 0.03, MD = -2.41 days, 95%CI: [-4.61-0.22]). Frequently used elements of OGR are: inpatient start of OGR with an interdisciplinary rehabilitation team, close cooperation with primary care, an OGR coordinator, individual goal setting and education for both patient and caregiver.

CONCLUSION

This review showed that OGR is as effective as usual care on FP activity. It shows low certainty of evidence for OGR being effective in reducing the length of inpatient stay. Further research is needed on the various frequently used elements of OGR.

Organization of rehabilitation services in randomized controlled trials - which factors influence functional outcome? A systematic review

Objective

To identify factors related to the organization of rehabilitation services that may influence patients’ functional outcome and make recommendations for categories to be used in the reporting of rehabilitation interventions.

Data Sources

A systematic review based on a search in MEDLINE indexed journals (MEDLINE [OVID], Cumulative Index of Nursing and Allied Health Literature, PsycINFO, Cochrane Central Register of Controlled Trials) until June 2019.

Study Selection

In total 8587 candidate randomized controlled trials reporting on organizational factors of multidisciplinary rehabilitation interventions and their associations with functional outcome. An additional 1534 trials were identified from June 2019 to March 2021. Data Extraction: Quality evaluation was conducted by 2 independent researchers. The organizational factors were classified according to the International Classification for Service Organization in Health-related Rehabilitation 2.0.

Data Synthesis

In total 80 articles fulfilled the inclusion criteria. There was a great heterogeneity in the terminology and reporting of service organization across all studies. Aspects of Settings including the Mode of Service Delivery was the most explicitly analyzed organizational category (44 studies). The importance of the integration of rehabilitation in the inpatient services was supported. Furthermore, several studies documented a lack of difference in outcome between outpatient vs inpatient service delivery. Patient Centeredness, Integration of Care, and Time and Intensity factors were also analyzed, but heterogeneity of interventions in these studies prohibited aggregation of results.

Conclusions

Settings and in particular the way the services were delivered to the users influenced functional outcome. Hence, it should be compulsory to include a standardized reporting of aspects of service delivery in clinical trials. We would also advise further standardization in the description of organizational factors in rehabilitation interventions to build knowledge of effective service organization.

Early Supported Discharge and Transitional Care Management After Stroke: A Systematic Review and Meta-Analysis

Objective

To investigate the available evidence on early supported discharge (ESD) and transitional care (TC) delivery service in patients with cerebrovascular disease.

Methods

A systematic literature search was conducted to collect all available evidence on the use of ESD and TC services. We included cluster-randomized pragmatic trials or randomized controlled trials (RCTs) that recruited patients with stroke or transient ischemic attack to receive either conventional care or any care service intervention that included rehabilitation or support provided by professional medical personnel with the aim of accelerating and supporting home discharge. Relevant data were electronically searched through international databases (Cochrane Library, EMBASE, and PubMed) and incorporated into a summary grid to investigate research outcomes and provide a narrative synthesis. Furthermore, we compared the outcomes in terms of length of hospital stay, patient and caregiver outcomes, and mortality through meta-analysis.

Results

We identified and included a total of 20 publications of various original randomized studies. There were 18 studies conducted in western countries and 2 in eastern countries. The meta-analysis revealed a tendency that ESD or TC could decrease the length of hospital stay more than the usual care [standardized mean difference (SMD) -0.13; 95% confidence interval (CI) -0.31 to 0.04 days; P = 0.14]. Moreover, there was a tendency that ESD resulted in better activities of daily living (ADL) than usual care (SMD 0.29; 95% CI -0.04 to 0.61; P = 0.08). Patient outcome based on modified Rankin scale (mRS) score (SMD -0.11; 95% CI -0.38 to 0.17; P = 0.45] and mortality (odds ratio 0.80; 95% CI 0.56-1.17; P = 0.25) did not reveal any significant difference. The Caregiver Strain Index revealed no difference.

Conclusion

We did not find a large effect size for the use of TC and ESD. When implementing the TC and ESD model from western to Asian countries, services should be prepared and implemented in accordance with national medical rehabilitation pathways for cerebrovascular disease.

Large-scale implementation of stroke early supported discharge: the WISE realist mixed-methods study

Background

In England, the provision of early supported discharge is recommended as part of an evidence-based stroke care pathway.

Objectives

To investigate the effectiveness of early supported discharge services when implemented at scale in practice and to understand how the context within which these services operate influences their implementation and effectiveness.

Design

A mixed-methods study using a realist evaluation approach and two interlinking work packages was undertaken. Three programme theories were tested to investigate the adoption of evidence-based core components, differences in urban and rural settings, and communication processes.

Setting and interventions

Early supported discharge services across a large geographical area of England, covering the West and East Midlands, the East of England and the North of England.

Participants

Work package 1: historical prospective patient data from the Sentinel Stroke National Audit Programme collected by early supported discharge and hospital teams. Work package 2: NHS staff (n = 117) and patients (n = 30) from six purposely selected early supported discharge services.

Data and main outcome

Work package 1: a 17-item early supported discharge consensus score measured the adherence to evidence-based core components defined in an international consensus document. The effectiveness of early supported discharge was measured with process and patient outcomes and costs. Work package 2: semistructured interviews and focus groups with NHS staff and patients were undertaken to investigate the contextual determinants of early supported discharge effectiveness.

Results

A variety of early supported discharge service models had been adopted, as reflected by the variability in the early supported discharge consensus score. A one-unit increase in early supported discharge consensus score was significantly associated with a more responsive early supported discharge service and increased treatment intensity. There was no association with stroke survivor outcome. Patients who received early supported discharge in their stroke care pathway spent, on average, 1 day longer in hospital than those who did not receive early supported discharge. The most rural services had the highest service costs per patient. NHS staff identified core evidence-based components (e.g. eligibility criteria, co-ordinated multidisciplinary team and regular weekly multidisciplinary team meetings) as central to the effectiveness of early supported discharge. Mechanisms thought to streamline discharge and help teams to meet their responsiveness targets included having access to a social worker and the quality of communications and transitions across services. The role of rehabilitation assistants and an interdisciplinary approach were facilitators of delivering an intensive service. The rurality of early supported discharge services, especially when coupled with capacity issues and increased travel times to visit patients, could influence the intensity of rehabilitation provision and teams’ flexibility to adjust to patients’ needs. This required organising multidisciplinary teams and meetings around the local geography. Findings also highlighted the importance of good leadership and communication. Early supported discharge staff highlighted the need for collaborative and trusting relationships with patients and carers and stroke unit staff, as well as across the wider stroke care pathway.

Limitations

Work package 1: possible influence of unobserved variables and we were unable to determine the effect of early supported discharge on patient outcomes. Work package 2: the pragmatic approach led to ‘theoretical nuggets’ rather than an overarching higher-level theory.

Conclusions

The realist evaluation methodology allowed us to address the complexity of early supported discharge delivery in real-world settings. The findings highlighted the importance of context and contextual features and mechanisms that need to be either addressed or capitalised on to improve effectiveness.

Trial registration

Current Controlled Trials ISRCTN15568163.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 22. See the NIHR Journals Library website for further project information.

The value of caregiver inclusive practices in geriatric transitions of care: A systematic review

Globally, hospital length of stay is decreasing, yet the number of aged patients requiring complex care is increasing. This causes more patients, and their informal caregivers, to self-manage in the community following acute care discharge. This study aims to assess whether transitional care programs that integrate caregivers provide better value care than routine care. In this systematic review, Medline Ovid, EMBASE Ovid, CINAHL EbscoHOST, Scopus, and Proquest were searched for any study design that investigated a caregiver inclusive transitional care intervention in a population of people with geriatric syndrome, enroled a comparator group, and assessed population health, experience, and/or cost related outcomes. Risk of bias was assessed by two reviewers using ROBINS I and RoB 2. The review included 23 studies and results were mixed. Consistently positive results occurred for patient and caregiver satisfaction. Cost tended to increase with caregiver inclusive practices. Most studies found no difference in population health outcomes. There was insufficient evidence on healthcare professional experience. Currently, there is insufficient evidence to determine whether caregiver inclusive transitions of care provide better value care than routine care. Studies that rigorously implement and evaluate caregiver inclusive care models are urgently required to inform future policy.

Bridging the Gap: A Mixed Methods Study Investigating Caregiver Integration for People with Geriatric Syndrome

Introduction

Transitions of care between acute hospital and community settings are points of vulnerability for people with geriatric syndrome. Routinely including informal caregivers into the transition processes may mitigate risk. Guidance for operational aspects of caregiver inclusion is currently lacking in healthcare policy and fails to address the barriers faced by caregivers and healthcare professionals.

Methods

A questionnaire and a semi-structured interview were piloted with acute care physiotherapists who facilitate patient discharge into community settings. The questionnaire was analysed using summary statistics and interviews were thematically analysed by researchers, using NVivo 12 software.

Results

Questionnaire responses indicated mixed satisfaction with current caregiver integration by the multidisciplinary team. Four themes were shaped in the interviews: inconsistent caregiver engagement, individuals working in a system, an outdated model of care, and invisible care gaps.

Discussion

Feedback loops constructed from participant questionnaires and interview responses informed the identification of barriers and solutions. These are system wide and address automated integration, cultural shift, reimbursement models, and flexible structures to enhance informal caregiver participation. Future research is urgently required to translate, implement, and evaluate enhanced caregiver integration to ensure sustainable, person-centred healthcare delivery.

Early Supported Discharge for Neurorehabilitation Following Acquired Brain Injury

Introduction: Early Supported Discharge (ESD) is a clinical flow management service offering interdisciplinary rehabilitation, wherein patients are provided supported in-home rehabilitation treatment; in comparison to conventional hospital-based rehabilitation model of service delivery. There has been little research into the functional outcomes for other types of acquired brain injury (ABI).

Methods: In this prospective cohort study, ABI patients presenting at a level I trauma center in Calgary, Canada were placed in either an ESD program or conventional inpatient rehabilitation (IPR) program based on their medical history and presentation. A small number of patients completed both programs (ESD+IPR group). ESD therapies were designed to emulate IPR. Participants completed professionally-rated Mayo-Portland Adaptability Index-4 (MPAI), Quality of Life after Brain Injury (QOLIBRI), Generalized Anxiety Questionnaire-7 (GAD7), Montreal Cognitive Assessment (MoCA), and Patient Health Questionnaire-9 (PHQ9) surveys at 1, 3, and 6 months following initial assessment pre-rehabilitation. Caregivers completed the Zarit Burden Interview (ZBI) at the same time points. The Supervision Rating Scale (SRS) and Disability Rating Scale (DRS) were completed at admission to rehabilitation and all follow-ups. Generalized estimate equations models were used to describe the three groups over time, including age as a covariate.

Results: Significant effects of time were reported in the MPAI participant sub-score in the ESD and IPR groups (χ(2)2 = 42.429, p < 0.000; χ(2)2 = 9.773, p = 0.008), showing significantly higher scores between 1 and 3 month timepoints for both groups. ZBI scores were significantly lower in the ESD group at 1 month compared to 3 and 6 months (χ(2)2 = 31.252, p < 0.001). The proportion of patients with medical complications during rehabilitation was 25.3% in ESD compared to 74.7% patients in IPR.

Conclusions: Improvements in functional outcomes were evident in patients participating in ESD and IPR, with more medical complications reported in the IPR group. Caregiver burden lessened over time in the ESD group but not in the IPR group. Both ESD and ESD+IPR groups can be considered viable alternatives to traditional inpatient rehabilitation. A randomized control trial would be required to properly compare rehabilitation streams. Further investigation into affective and lifestyle elements of ABI recovery would also improve our understanding of targeted neurorehabilitation in this population.

A protocol for a qualitative synthesis exploring people with stroke, family members, caregivers and healthcare professionals experiences of early supported discharge (ESD) after stroke

Early supported discharge (ESD) facilitates a person with a stroke to be discharged from the acute hospital environment earlier than conventional care to continue their rehabilitation within the home with members of the multi-disciplinary team. A number of quantitative studies have highlighted benefits of ESD including a reduction in the length of inpatient stay, cost savings, as well as reducing long term dependency. This systematic review and qualitative synthesis explores the perspectives and experiences of those involved in ESD including people with stroke, family members, caregivers as well as the healthcare professionals involved in the delivery of the service. A comprehensive literature search will be completed in the following databases CINAHL, PubMed Central, Embase, Medline, PsycINFO, Sage, Academic Search Complete, Directory of Open Access Journals, The Cochrane Library, PsycARTICLES and Scopus. Qualitative or mixed methods studies that include qualitative data on the perspectives and experiences of people with stroke, family members, caregivers and healthcare professionals of an ESD service will be included. Methodological quality will be appraised using the ten-item Critical Appraisal Skills Programme checklist for qualitative research by two independent reviewers with a third reviewer involved should differences of opinion arise. Findings will be synthesised using thematic synthesis.    It is anticipated that the qualitative synthesis will provide a deeper understanding of the experiences of ESD which may serve to inform practice as well as assist in the development of new ESD services. PROSPERO registration: CRD42020135197 - 28/04/2020.

General practice nurses and physicians and end of life: a systematic review of models of care

BACKGROUND

General practitioners (GPs) and general practice nurses (GPNs) face increasing demands to provide palliative care (PC) or end-of-life care (EoLC) as the population ages. In order to maximise the impact of GPs and GPNs, the impact of different models of care that have been developed to support their practice of EoLC needs to be understood.

OBJECTIVE

To examine published models of EoLC that incorporate or support GP and GPN practice, and their impact on patients, families and the health system.

METHOD

Systematic literature review. Data included papers (2000 to 2017) sought from Medline, Psychinfo, Embase, Joanna Briggs Institute and Cochrane databases.

RESULTS

From 6209 journal articles, 13 papers reported models of care supporting the GP and GPN's role in EoLC or PC practice. Services and guidelines for clinical issues have mixed impact on improving symptoms, but improved adherence to clinical guidelines. National Frameworks facilitated patients being able to die in their preferred place. A single specialist PC-GP case conference reduced hospitalisations, better maintained functional capacity and improved quality of life parameters in both patients with cancer and without cancer. No studies examined models of care aimed at supporting GPNs.

CONCLUSIONS

Primary care practitioners have a natural role to play in EoLC, and most patient and health system outcomes are substantially improved with their involvement. Successful integrative models need to be tested, particularly in non-malignant diseases. Such models need to be explored further. More work is required on the role of GPNs and how to support them in this role.

Cost-effectiveness of an intervention to improve the quality of nursing care among immobile patients with stroke in China: A multicenter study

BACKGROUND

While a nursing intervention program for immobile patients with stroke can improve clinic outcomes, less is known about the cost-effectiveness of these interventions.

OBJECTIVES

The goal of this study was to evaluate the cost-effectiveness of the intervention program for immobile patients with stroke in China.

DESIGN

A cost-effectiveness analysis alongside a pre-test/post-test (before and after) study was undertaken from a health care perspective.

SETTINGS

Participants were recruited from 25 hospitals among six provinces or municipal cities in eastern (Guangdong province, Zhejiang province, and Beijing municipal city), western (Sichuan province), and central (Henan province and Hubei province) China.

PARTICIPANTS

A total of 7,653 immobile stroke patients were included in our sample. Patients in routine care settings were recruited from November 2015 to June 2016, and the recruitment of the intervention group patients was from November 2016 to July 2017.

METHODS

To adjust for potential bias from confounding variables, the 1:1 propensity score matching yielded matched pairs of 2,966 patients in the routine care group and 2,966 patients in the intervention group, with no significant differences in sociodemographic or clinical characteristics between two groups. All patients were followed-up 3 months after enrolment in the study. Total healthcare costs were extracted from the hospital information system, with the health outcome effectiveness of the intervention program measured using the EuroQol five-dimensional questionnaire (EQ-5D) instrument and the cost-effectiveness of the intervention measured by the incremental cost-effectiveness ratio with a time horizon of 3 months.

RESULTS

Compared to routine care, the intervention program decreased the total costs of stroke patients by CN¥4,600 (95% confidence interval [CI]: [-7050, -2151]), while increasing quality-adjusted life year 0.009 (95% CI: [0.005, 0.013]). The incremental cost-effectiveness ratios over 3 months was CN¥-517,011 per quality-adjusted life year (95% CI: [-1,111,442, -203,912]). Subgroup analysis reveals that both the health-related quality of life and cost effectiveness improved significantly for ischemic patients and tertiary hospitals patients while for hemorrhagic patients and non-tertiary hospital patients only the health-related quality of life improved significantly.

CONCLUSIONS

Findings from this first cost-effectiveness analysis in immobile stroke patients provide evidence that an intervention program provided significant cost saving, but mainly in ischemic patients and tertiary hospital patients. Wider adoption of such programs may be a sensible approach to reducing the burden of stroke and for immobile patients more generally.

Organised inpatient (stroke unit) care for stroke: network meta-analysis

BACKGROUND

Organised inpatient (stroke unit) care is provided by multi-disciplinary teams that manage stroke patients. This can been provided in a ward dedicated to stroke patients (stroke ward), with a peripatetic stroke team (mobile stroke team), or within a generic disability service (mixed rehabilitation ward). Team members aim to provide co-ordinated multi-disciplinary care using standard approaches to manage common post-stroke problems.

OBJECTIVES

• To assess the effects of organised inpatient (stroke unit) care compared with an alternative service. • To use a network meta-analysis (NMA) approach to assess different types of organised inpatient (stroke unit) care for people admitted to hospital after a stroke (the standard comparator was care in a general ward). Originally, we conducted this systematic review to clarify: • The characteristic features of organised inpatient (stroke unit) care? • Whether organised inpatient (stroke unit) care provide better patient outcomes than alternative forms of care? • If benefits are apparent across a range of patient groups and across different approaches to delivering organised stroke unit care? Within the current version, we wished to establish whether previous conclusions were altered by the inclusion of new outcome data from recent trials and further analysis via NMA.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register (2 April 2019); the Cochrane Central Register of Controlled Trials (CENTRAL; 2019, Issue 4), in the Cochrane Library (searched 2 April 2019); MEDLINE Ovid (1946 to 1 April 2019); Embase Ovid (1974 to 1 April 2019); and the Cumulative Index to Nursing and Allied Health Literature (CINAHL; 1982 to 2 April 2019). In an effort to identify further published, unpublished, and ongoing trials, we searched seven trial registries (2 April 2019). We also performed citation tracking of included studies, checked reference lists of relevant articles, and contacted trialists.

SELECTION CRITERIA

Randomised controlled clinical trials comparing organised inpatient stroke unit care with an alternative service (typically contemporary conventional care), including comparing different types of organised inpatient (stroke unit) care for people with stroke who are admitted to hospital.

DATA COLLECTION AND ANALYSIS

Two review authors assessed eligibility and trial quality. We checked descriptive details and trial data with co-ordinators of the original trials, assessed risk of bias, and applied GRADE. The primary outcome was poor outcome (death or dependency (Rankin score 3 to 5) or requiring institutional care) at the end of scheduled follow-up. Secondary outcomes included death, institutional care, dependency, subjective health status, satisfaction, and length of stay. We used direct (pairwise) comparisons to compare organised inpatient (stroke unit) care with an alternative service. We used an NMA to confirm the relative effects of different approaches.

MAIN RESULTS

We included 29 trials (5902 participants) that compared organised inpatient (stroke unit) care with an alternative service: 20 trials (4127 participants) compared organised (stroke unit) care with a general ward, six trials (982 participants) compared different forms of organised (stroke unit) care, and three trials (793 participants) incorporated more than one comparison. Compared with the alternative service, organised inpatient (stroke unit) care was associated with improved outcomes at the end of scheduled follow-up (median one year): poor outcome (odds ratio (OR) 0.77, 95% confidence interval (CI) 0.69 to 0.87; moderate-quality evidence), death (OR 0.76, 95% CI 0.66 to 0.88; moderate-quality evidence), death or institutional care (OR 0.76, 95% CI 0.67 to 0.85; moderate-quality evidence), and death or dependency (OR 0.75, 95% CI 0.66 to 0.85; moderate-quality evidence). Evidence was of very low quality for subjective health status and was not available for patient satisfaction. Analysis of length of stay was complicated by variations in definition and measurement plus substantial statistical heterogeneity (I² = 85%). There was no indication that organised stroke unit care resulted in a longer hospital stay. Sensitivity analyses indicated that observed benefits remained when the analysis was restricted to securely randomised trials that used unequivocally blinded outcome assessment with a fixed period of follow-up. Outcomes appeared to be independent of patient age, sex, initial stroke severity, stroke type, and duration of follow-up. When calculated as the absolute risk difference for every 100 participants receiving stroke unit care, this equates to two extra survivors, six more living at home, and six more living independently. The analysis of different types of organised (stroke unit) care used both direct pairwise comparisons and NMA. Direct comparison of stroke ward versus general ward: 15 trials (3523 participants) compared care in a stroke ward with care in general wards. Stroke ward care showed a reduction in the odds of a poor outcome at the end of follow-up (OR 0.78, 95% CI 0.68 to 0.91; moderate-quality evidence). Direct comparison of mobile stroke team versus general ward: two trials (438 participants) compared care from a mobile stroke team with care in general wards. Stroke team care may result in little difference in the odds of a poor outcome at the end of follow-up (OR 0.80, 95% CI 0.52 to 1.22; low-quality evidence). Direct comparison of mixed rehabilitation ward versus general ward: six trials (630 participants) compared care in a mixed rehabilitation ward with care in general wards. Mixed rehabilitation ward care showed a reduction in the odds of a poor outcome at the end of follow-up (OR 0.65, 95% CI 0.47 to 0.90; moderate-quality evidence). In a NMA using care in a general ward as the comparator, the odds of a poor outcome were as follows: stroke ward - OR 0.74, 95% CI 0.62 to 0.89, moderate-quality evidence; mobile stroke team - OR 0.88, 95% CI 0.58 to 1.34, low-quality evidence; mixed rehabilitation ward - OR 0.70, 95% CI 0.52 to 0.95, low-quality evidence.

AUTHORS' CONCLUSIONS

We found moderate-quality evidence that stroke patients who receive organised inpatient (stroke unit) care are more likely to be alive, independent, and living at home one year after the stroke. The apparent benefits were independent of patient age, sex, initial stroke severity, or stroke type, and were most obvious in units based in a discrete stroke ward. We observed no systematic increase in the length of inpatient stay, but these findings had considerable uncertainty.

Effects of an integrated transitional care program for stroke survivors living in a rural community: a randomized controlled trial

OBJECTIVE

To evaluate the effect of an integrated transitional care program on health outcomes in stroke survivors based on an original community for healthcare.

DESIGN

A pilot randomized controlled trial with blinded assessment. Randomization by statistician using computer-generated, random numbers concealed in opaque envelopes.

SETTING

A tertiary hospital and participants' home across Lishui, China.

SUBJECTS

A total of 98 people with acute cerebral hemorrhage or cerebral infarction, eight weeks following discharge from our hospital.

INTERVENTIONS

Each participant received stroke unit-based treatment including acute medical treatment, early rehabilitation and health education. Patients in the intervention group received ongoing rehabilitation at home through multidisciplinary team, while patients in the control group received secondary stroke prevention.

MAIN MEASURES

Short-Form Health Survey-36, Modified Barthel Index and Caregiver Strain Index at four and eight weeks, respectively, after discharged.

RESULTS

A total of 98 participants were recruited (intervention n = 49, control n = 49). Patients had an average age of 61.4 years (61.4 ± 18.3). Mean values of Physical Components Summary and Mental Components Summary, integral components of Short-Form Health Survey-36, were significantly better in the intervention group at four and eight weeks (40.2 ± 6.3 and 42.9 ± 3.7 for the former; 43.9 ± 2.6 and 46.1 ± 1.8 for the later). The same trend was observed in Modified Barthel Index (87.1 ± 9.2 and 92.5 ± 6.7 at four and eight weeks, respectively). But the significant improvement in Caregiver Strain Index was only observed at four weeks. There were significant differences between groups in these scores.

CONCLUSION

The transitional care program has been proven to be feasible and improve health-related outcomes.

Feasibility and preliminary effects of an integrated hospital-to-home transitional care intervention for older adults with stroke and multimorbidity: A study protocol

BACKGROUND

Stroke is a major life-altering event and the leading cause of death and disability in Canada. Most older adults who have suffered a stroke will return home and require ongoing rehabilitation in the community. Transitioning from hospital to home is reportedly very stressful and challenging, particularly if stroke survivors have multiple chronic conditions. New interventions are needed to improve the quality of transitions from hospital to home for this vulnerable population.

OBJECTIVES

The primary objective of this study is to examine the feasibility of implementing a new 6-month transitional care intervention supported by a web-based app. The secondary objective is to explore its preliminary effects.

DESIGN

A single arm, pre/post, pragmatic feasibility study of 20-40 participants in Ontario, Canada. Participants will be community-dwelling older adults (≥55 years) with a confirmed stroke diagnosis, ≥2 co-morbid conditions, and referred to a hospital-based outpatient stroke rehabilitation centre. The 6-month transitional care intervention will be delivered by an interprofessional (IP) team and involve care coordination/system navigation, self-management education and support, home visits, telephone contacts, IP team meetings and a web-based app. Primary evaluation of the intervention will be based on feasibility outcomes (e.g. acceptability, fidelity). Preliminary intervention effects will be based on 6-month changes in health outcomes, patient experience, provider experience and cost.

CONCLUSIONS

Information on the feasibility and preliminary effects of this newly-developed intervention will be used to optimize the design and methods for a future pragmatic trial to test the effectiveness and implementation of the intervention in other contexts and settings.

Functional outcome and survival following spontaneous intracerebral hemorrhage: A retrospective population-based study

BACKGROUND

Accurate and reliable clinical and radiological predictors of intracerebral hemorrhage (ICH) outcomes are needed to optimize treatment of ICH. The aim of this study was to investigate functional outcome and identify predictors of severe disability or death following ICH.

MATERIALS AND METHODS

Retrospective population-based study of spontaneous ICH. Clinical and radiological data were obtained from electronic medical records, and functional outcome estimated using the modified Rankin Scale (mRS) before ICH and at 3 and 12 months after ICH.

RESULTS

Four hundred and fifty-two patients were included (mean age 74.8 years, 45.6% females). Proportion of fatal outcome at 1 week was 22.1%, at 3 months 39.2%, and at 12 months 44.9%. Median mRS score before the ICH was 1 (interquartile range [IQR] 2); for survivors at 3 months, it was 5 (IQR 3); and at 12 months, it was 3 (IQR 2). Independent predictors of severe disability (mRS of 5) or death (mRS of 6) were use of oral antithrombotic drugs (OR 2.2, 95% CI 1.3-3.8, p = 0.04), mRS score before the ICH (OR 1.8, 95% CI 1.4-2.2, p < 0.001), Glasgow Coma Scale (GCS) on admission (OR 8.3, 95% CI 3.5-19.7, p < 0.001), hematoma volume >60 ml (OR 4.5, 05% CI 2.0-10.2, p < 0.001), and intraventricular hematoma extension (OR 1.8, 95% CI 0.8-4.2, p < 0.001).

CONCLUSION

Intracerebral hemorrhage is associated with high mortality, and more than one third of survivors end up with severe disability or death 3 months later. Predictors of severe disability or death were use of oral antithrombotic drugs, functional disability prior to ICH, low GCS on admission, larger hematoma volume, and intraventricular hematoma extension.

Association Between Early Outpatient Visits and Readmissions After Ischemic Stroke

BACKGROUND

Reducing hospital readmission is an important goal to optimize poststroke care and reduce costs. Early outpatient follow-up may represent one important strategy to reduce readmissions. We examined the association between time to first outpatient contact and readmission to inform postdischarge transitions.

METHODS AND RESULTS

We performed a retrospective cohort study of all Medicare fee-for-service patients discharged home after an acute ischemic stroke in 2012 identified by the InternationalClassification of Diseases, Ninth Revision, Clinical Modification codes. Our primary predictor variable was whether patients had a primary care or neurology visit within 30 days of discharge. Our primary outcome variable was all-cause 30-day hospital readmission. We used separate multivariable Cox models with primary care and neurology visits specified as time-dependent covariates, adjusted for numerous patient- and systems-level factors. The cohort included 78 345 patients. Sixty-one percent and 16% of patients, respectively, had a primary care and neurology visit within 30 days of discharge. Visits occurred a median (interquartile range) 7 (4-13) and 15 (5-22) days after discharge for primary care and neurology, respectively. Thirty-day readmission occurred in 9.4% of patients. Readmissions occurred a median 14 (interquartile range, 7-21) days after discharge. Patients who had a primary care visit within 30 days of discharge had a slightly lower adjusted hazard of readmission than those who did not (hazard ratio, 0.98; 95% confidence interval, 0.97-0.98). The association was nearly identical for 30-day neurology visits (hazard ratio, 0.98; 95% confidence interval, 0.97-0.98).

CONCLUSIONS

Thirty-day outpatient follow-up was associated with a small reduction in hospital readmission among elderly patients with stroke discharged home. Further work should assess how outpatient care may be improved to further reduce readmissions.

Early supported discharge services for people with acute stroke

BACKGROUND

People with stroke conventionally receive a substantial part of their rehabilitation in hospital. Services have now been developed that offer people in hospital an early discharge with rehabilitation at home (early supported discharge: ESD).

OBJECTIVES

To establish if, in comparison with conventional care, services that offer people in hospital with stroke a policy of early discharge with rehabilitation provided in the community (ESD) can: 1) accelerate return home, 2) provide equivalent or better patient and carer outcomes, 3) be acceptable satisfactory to patients and carers, and 4) have justifiable resource implications use.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register (January 2017), Cochrane Central Register of Controlled Trials (CENTRAL 2017, Issue 1) in the Cochrane Library (searched January 2017), MEDLINE in Ovid (searched January 2017), Embase in Ovid (searched January 2017), CINAHL in EBSCO (Cumulative Index to Nursing and Allied Health Literature; 1937 to December 2016), and Web of Science (to January 2017). In an effort to identify further published, unpublished, and ongoing trials we searched six trial registries (March 2017). We also performed citation tracking of included studies, checked reference lists of relevant articles, and contacted trialists.

SELECTION CRITERIA

Randomised controlled trials (RCTs) recruiting stroke patients in hospital to receive either conventional care or any service intervention that has provided rehabilitation and support in a community setting with an aim of reducing the duration of hospital care.

DATA COLLECTION AND ANALYSIS

The primary patient outcome was the composite end-point of death or long-term dependency recorded at the end of scheduled follow-up. Two review authors scrutinised trials, categorised them on their eligibility and extracted data. Where possible we sought standardised data from the primary trialists. We analysed the results for all trials and for subgroups of patients and services, in particular whether the intervention was provided by a co-ordinated multidisciplinary team (co-ordinated ESD team) or not. We assessed risk of bias for the included trials and used GRADE to assess the quality of the body of evidence.

MAIN RESULTS

We included 17 trials, recruiting 2422 participants, for which outcome data are currently available. Participants tended to be a selected elderly group of stroke survivors with moderate disability. The ESD group showed reductions in the length of hospital stay equivalent to approximately six days (mean difference (MD) -5.5; 95% confidence interval (CI) -3 to -8 days; P < 0.0001; moderate-grade evidence). The primary outcome was available for 16 trials (2359 participants). Overall, the odds ratios (OR) for the outcome of death or dependency at the end of scheduled follow-up (median 6 months; range 3 to 12) was OR 0.80 (95% CI 0.67 to 0.95, P = 0.01, moderate-grade evidence) which equates to five fewer adverse outcomes per 100 patients receiving ESD. The results for death (16 trials; 2116 participants) and death or requiring institutional care (12 trials; 1664 participants) were OR 1.04 (95% CI 0.77 to 1.40, P = 0.81, moderate-grade evidence) and OR 0.75 (95% CI 0.59 to 0.96, P = 0.02, moderate-grade evidence), respectively. Small improvements were also seen in participants' extended activities of daily living scores (standardised mean difference (SMD) 0.14, 95% CI 0.03 to 0.25, P = 0.01, low-grade evidence) and satisfaction with services (OR 1.60, 95% CI 1.08 to 2.38, P = 0.02, low-grade evidence). We saw no clear differences in participants' activities of daily living scores, patients subjective health status or mood, or the subjective health status, mood or satisfaction with services of carers. We found low-quality evidence that the risk of readmission to hospital was similar in the ESD and conventional care group (OR 1.09, 95% CI 0.79 to 1.51, P = 0.59, low-grade evidence). The evidence for the apparent benefits were weaker at one- and five-year follow-up. Estimated costs from six individual trials ranged from 23% lower to 15% greater for the ESD group in comparison to usual care.In a series of pre-planned analyses, the greatest reductions in death or dependency were seen in the trials evaluating a co-ordinated ESD team with a suggestion of poorer results in those services without a co-ordinated team (subgroup interaction at P = 0.06). Stroke patients with mild to moderate disability at baseline showed greater reductions in death or dependency than those with more severe stroke (subgroup interaction at P = 0.04).

AUTHORS' CONCLUSIONS

Appropriately resourced ESD services with co-ordinated multidisciplinary team input provided for a selected group of stroke patients can reduce long-term dependency and admission to institutional care as well as reducing the length of hospital stay. Results are inconclusive for services without co-ordinated multidisciplinary team input. We observed no adverse impact on the mood or subjective health status of patients or carers, nor on readmission to hospital.

Early discharge hospital at home

BACKGROUND

Early discharge hospital at home is a service that provides active treatment by healthcare professionals in the patient's home for a condition that otherwise would require acute hospital inpatient care. This is an update of a Cochrane review.

OBJECTIVES

To determine the effectiveness and cost of managing patients with early discharge hospital at home compared with inpatient hospital care.

SEARCH METHODS

We searched the following databases to 9 January 2017: the Cochrane Effective Practice and Organisation of Care Group (EPOC) register, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, CINAHL, and EconLit. We searched clinical trials registries.

SELECTION CRITERIA

Randomised trials comparing early discharge hospital at home with acute hospital inpatient care for adults. We excluded obstetric, paediatric and mental health hospital at home schemes.   DATA COLLECTION AND ANALYSIS: We followed the standard methodological procedures expected by Cochrane and EPOC. We used the GRADE approach to assess the certainty of the body of evidence for the most important outcomes.

MAIN RESULTS

We included 32 trials (N = 4746), six of them new for this update, mainly conducted in high-income countries. We judged most of the studies to have a low or unclear risk of bias. The intervention was delivered by hospital outreach services (17 trials), community-based services (11 trials), and was co-ordinated by a hospital-based stroke team or physician in conjunction with community-based services in four trials.Studies recruiting people recovering from strokeEarly discharge hospital at home probably makes little or no difference to mortality at three to six months (risk ratio (RR) 0.92, 95% confidence interval (CI) 0.57 to 1.48, N = 1114, 11 trials, moderate-certainty evidence) and may make little or no difference to the risk of hospital readmission (RR 1.09, 95% CI 0.71 to 1.66, N = 345, 5 trials, low-certainty evidence). Hospital at home may lower the risk of living in institutional setting at six months (RR 0.63, 96% CI 0.40 to 0.98; N = 574, 4 trials, low-certainty evidence) and might slightly improve patient satisfaction (N = 795, low-certainty evidence). Hospital at home probably reduces hospital length of stay, as moderate-certainty evidence found that people assigned to hospital at home are discharged from the intervention about seven days earlier than people receiving inpatient care (95% CI 10.19 to 3.17 days earlier, N = 528, 4 trials). It is uncertain whether hospital at home has an effect on cost (very low-certainty evidence).Studies recruiting people with a mix of medical conditionsEarly discharge hospital at home probably makes little or no difference to mortality (RR 1.07, 95% CI 0.76 to 1.49; N = 1247, 8 trials, moderate-certainty evidence). In people with chronic obstructive pulmonary disease (COPD) there was insufficient information to determine the effect of these two approaches on mortality (RR 0.53, 95% CI 0.25 to 1.12, N = 496, 5 trials, low-certainty evidence). The intervention probably increases the risk of hospital readmission in a mix of medical conditions, although the results are also compatible with no difference and a relatively large increase in the risk of readmission (RR 1.25, 95% CI 0.98 to 1.58, N = 1276, 9 trials, moderate-certainty evidence). Early discharge hospital at home may decrease the risk of readmission for people with COPD (RR 0.86, 95% CI 0.66 to 1.13, N = 496, 5 trials low-certainty evidence). Hospital at home may lower the risk of living in an institutional setting (RR 0.69, 0.48 to 0.99; N = 484, 3 trials, low-certainty evidence). The intervention might slightly improve patient satisfaction (N = 900, low-certainty evidence). The effect of early discharge hospital at home on hospital length of stay for older patients with a mix of conditions ranged from a reduction of 20 days to a reduction of less than half a day (moderate-certainty evidence, N = 767). It is uncertain whether hospital at home has an effect on cost (very low-certainty evidence).Studies recruiting people undergoing elective surgeryThree studies did not report higher rates of mortality with hospital at home compared with inpatient care (data not pooled, N = 856, low-certainty evidence; mainly orthopaedic surgery). Hospital at home may lead to little or no difference in readmission to hospital for people who were mainly recovering from orthopaedic surgery (N = 1229, low-certainty evidence). We could not establish the effects of hospital at home on the risk of living in institutional care, due to a lack of data. The intervention might slightly improve patient satisfaction (N = 1229, low-certainty evidence). People recovering from orthopaedic surgery allocated to early discharge hospital at home were discharged from the intervention on average four days earlier than people allocated to usual inpatient care (4.44 days earlier, 95% CI 6.37 to 2.51 days earlier, , N = 411, 4 trials, moderate-certainty evidence). It is uncertain whether hospital at home has an effect on cost (very low-certainty evidence).

AUTHORS' CONCLUSIONS

Despite increasing interest in the potential of early discharge hospital at home services as a less expensive alternative to inpatient care, this review provides insufficient evidence of economic benefit (through a reduction in hospital length of stay) or improved health outcomes.

Hospital readmission within 10 years post stroke: frequency, type and timing

BACKGROUND

The aim of this study was to examine the hospital readmissions in a 10 year follow-up of a stroke cohort previously studied for acute and subacute complications and to focus on their frequency, their causes and their timing.

METHODS

The hospital records of 243 patients, 50% of a cohort of 489 patients acutely and consecutively admitted to our stroke unit in 2002/3, were subjected to review 10 years after the incidental stroke and all acute admissions were examined. The main admitting diagnoses were attributed to one of 18 predefined categories of illness. Additionally, the occurrence of death was registered.

RESULTS

After 10 years 68.9% of patients had died and 72.4% had been readmitted to the hospital with a mean number of readmissions of 3.4 (+15.1 SD). 20% of the readmissions were due to a vascular cause, 17.3% were caused by infection, 9.3% by falls with (6.1%) and without fracture, 5.7% by a hemorrhagic event. The readmission rate was highest in the first 6 months post stroke with a rate of 116.2 admissions/100 live patient-years. Falls with fractures occurred maximally 3-5 years post stroke.

CONCLUSIONS

Hospital readmissions over the 10 years following stroke are caused by vascular events, infections, falls and hemorrhagic events, where the first 6 months are a period of particular vulnerability. The magnitude and the spectrum of these long-term complications suggest the need for a more comprehensive approach to post stroke prophylaxis.

What Type of Transitional Care Effectively Reduced Mortality and Improved ADL of Stroke Patients? A Meta-Analysis

Stroke is a major cause of disability and mortality worldwide; yet; prior to this study; there had been no sufficient evidence to support the effectiveness of various transitional care interventions (TCI) on the disability and mortality of stroke survivors. This meta-analysis aimed to assess the effectiveness of TCI in reducing mortality and improving the activities of daily life (ADL) of stroke patients. PubMed; Web of Science; OVID; EMBASE; CINAHL; and Sino-Med were searched for articles published before November 2016. Thirty-one randomized controlled trials (RCTs) were identified in the study. This analysis showed that the total effect of TCI on reducing mortality was limited (Risk Ratio (RR) = 0.86; 95% Confidence Interval (CI): 0.75-0.98); that only home-visiting programs could reduce mortality rates (RR = 0.34; 95% CI: 0.17-0.67) compared with usual care; and that the best intervention was led by a multidisciplinary team (MT) ≤3 months (RR = 0.19; 95% CI: 0.05-0.71). In addition; home-visiting programs also produced ADL benefit (RR = 0.56; 95% CI: 0.31-0.81). Overall; there was a statistically significant difference in improving patients' independence between TCI and usual care (RR = 1.12; 95% CI: 1.02-1.23). However; none of the interventions was effective when they were differentiated in the analysis. It is the conclusion of this study that home-visiting programs; especially those led by MTs; should receive the greatest consideration by healthcare systems or providers for implementing TCI to stroke survivors.

Where is the idea of Early Supported Discharge after stroke going?

In 2009 and in 2012 we published two articles in “Medical Rehabilitation” regarding the development of idea of Early Home Supported Discharge in stroke rehabilitation. Today, omitting the word “Home”, the abbreviation ESD is more popular. The aim of this article is to present the latest developments around the idea of continuing rehabilitation after early discharge from the hospital in a home setting. We primarily focus on the most recent reports, particularly systematic reviews. Each country has its own eligibility criteria which are different for early hospital discharge and follow-up rehabilitation in the place of residence, and sometimes the rehabilitation team staff also differs. So far, studies have shown that the optimal role of the rehabilitation team is coordination and delivery of rehabilitation in a home setting. It is also clear that the ESD model brings tangible economic benefits, mainly by shortening hospital stays. Specific organizational solutions used in different countries depend on cultural traditions, capabilities and financial sources.

Early home-supported discharge for patients with stroke in Portugal: a randomised controlled trial

OBJECTIVE

To evaluate an early home-supported discharge service for stroke patients.

DESIGN

We carried out a prospective, randomised, open-label, blinded-endpoint trial (allocation ratio of 1:1) with patients assigned to either an early home-supported discharge service or usual care.

SETTING

The study was undertaken in Aveiro, Portugal, between April 2009 and April 2013.

SUBJECTS

We included stroke patients aged 25-85 years admitted to the stroke unit with an initial Functional Independence Measure of up to 100, who gave informed consent.

INTERVENTIONS

Patients in the early home-supported discharge group began their rehabilitation intervention in the stroke unit and the early home-supported discharge team worked with them at home for a maximum of one month. Patients in the control group received usual services.

MAIN MEASURES

The primary outcome measure was the Functional Independence Measure at six months after stroke.

RESULTS

We randomised 190 patients of whom 34 were lost to follow-up. There were no significant differences (p > 0.5) in the average scores of Functional Independence Measure between the early home-supported discharge (69 ±22; mean ±SD) and the control groups (71 ±17) measured at baseline; and between the early home-supported discharge (107 ±20) and the control groups (107 ±25) measured at six months. The number of individuals with a low Functional Independence Measure score (<60) in the early home-supported discharge group compared with the control group was higher at admission (34/95 vs. 26/95) and lower at follow-up (2/74 vs. 5/78).

CONCLUSIONS

It was feasible to implement early home-supported discharge procedures in a Southern European setting, but we have not shown convincing differences in disability at six months.

Evaluation of an extended stroke unit service with early supported discharge for patients living in a rural community. A randomized controlled trial

Objective: To evaluate the effect of an extended stroke unit service (extended service), with early supported discharge and co-ordination of further rehabilitation in co-operation with the primary health care system in three rural municipalities.

Design: A randomized controlled trial comparing extended service with ordinary stroke unit service (ordinary service).

Subjects: Sixty-two eligible patients with acute stroke living in the rural municipalities of Malvik, Melhus and Klñ bu.

Main measures: The primary outcome was the proportion of patients who were independent according to Modified Rankin Scale (mRS) (independence = mRS < 2) 52 weeks after onset of stroke. Secondary outcomes were mRS at 6 and 26 weeks and Barthel Index (BI), Nottingham Health Profile (NHP) and Caregiver Strain Index (CSI) at 6, 26 and 52 weeks. Mortality and length of stay were registered during the 52 weeks.

Results: Twelve patients (39%) in the extended service group versus 16 patients (52%) in the ordinary service group were independent according to mRS at 52 weeks (p= 0.444). The odds ratio for independence (extended service versus ordinary service) was 0.33 (95% confidence interval (CI) 0.088 –1.234). According to outcome by secondary measures there were no significant differences except less social isolation on NHP in the extended service group at 26 weeks (p= 0.046). There were no significant differences in length of stay.

Conclusion: An extended stroke unit service with early supported discharge seems to have no positive effect on functional outcome for patients living in rural communities, but might give a trend toward better quality of life. There were no significant differences in length of stay.

Stroke patients and long-term training: is it worthwhile? A randomized comparison of two different training strategies after rehabilitation

Objective : To find out if there were any differences in improvement and maintenance of motor function, activity of daily living and grip strength between patients with first-ever stroke receiving two different strategies of physical exercise during the first year after stroke.

Design : A longitudinal randomized controlled stratified trial.

Setting : Rehabilitation institutions, community, patients' homes and nursing homes.

Subjects : Seventy-five male and female first-time-ever stroke patients: 35 in an intensive exercise group and 40 in a regular exercise group.

Intervention : The intensive exercise group received physiotherapy with focus on intensive exercises in four periods during the first year after stroke. The regular exercise group patients were followed up according to their subjective needs during the corresponding year.

Main outcome measures : Motor Assessment Scale, Barthel Index of Activities of Daily Living, and grip strength.

Results : Both groups improved significantly up to six months when function stabilized. The groups did not differ significantly on any test occasions. The difference of improvement from admission to discharge was significant in favour of the intensive exercise group, in the Motor Assessment Scale total score (intensive exercise group 7.5; regular exercise group 1.7, P = 0.01), and in the Barthel Index of Activities of Daily Living total score (17.4 versus 8.9, P = 0.04).

Conclusion : Motor function, activities of daily living functions and grip strength improved initially and were maintained during the first year after stroke in all patients irrespective of exercise regime. This indicates the importance of motivation for regular exercise in the first year following stroke, achieved by regular check-ups.

Functional Assessments Used by Occupational Therapists with Older Adults at Risk of Activity and Participation Limitations: A Systematic Review

Introduction

The use of functional assessments to evaluate patient change is complicated by a lack of consensus as to which assessment is most suitable for use with older adults. Objective: To identify and appraise the properties of assessments used to evaluate functional abilities in older adults.

Methods

A systematic review of randomised controlled trials of occupational therapy interventions was conducted up to 2012 to identify assessments used to measure function. Two authors screened and extracted data independently. A second search then identified papers investigating measurement properties of each assessment. Studies from the second search were included if: i) published in English, ii) the assessment was not modified from its original published form, iii) study aim was to evaluate the quality of the tool, iv) and was original research. Translated versions of assessments were excluded. Measurement quality was rated using the COSMIN checklist and Terwee criteria.

Results

Twenty-eight assessments were identified from the systematic search of occupational therapy interventions provided to older adults. Assessments were of varied measurement quality and many had been adapted (although still evaluated as though the original tool had been administered) potentially altering the conclusions drawn about measurement quality. Synthesis of best evidence established 15 functional assessments have not been tested in an older adult population.

Conclusions

The Functional Autonomy Measurement System (SMAF) appears to be a promising assessment for use with older adults. Only two tools (the SMAF and the Assessment of Motor and Process Skills (AMPS)) were deemed to be responsive to change when applied to older adults. Health professionals should use functional assessments that have been validated with their population and in their setting. There are reliable and valid assessments to capture the functional performance of older adults in community and hospital settings, although further refinement of these assessments may be necessary.

Effects of trunk rotation induced treadmill gait training on gait of stroke patients: a randomized controlled trial

[Purpose] This study was conducted to find out the effect of arm swing during treadmill training on the gait of stroke patients. [Subjects and Methods] This study subjects were 20 stroke subjects patients who were randomly assigned to either the experimental group (EG) or the control group (CG), 10 subjects in each group. Therapists induced arm swing of affected side of EG subjects using Nordic poles, while subjects in CG had the affected arm restricted to prevent arm swing. Training was performed for 30 minutes, 3 times a week for 4 weeks. The timed up and go test (TUG), the dynamic gait index (DGI) and the 6-minute walk test (6MWT) were assessed before and after the training. [Results] After the training, there were no significant differences in the TUG times of EG and CG. There were significant differences in the DGI and the 6-minute walking distance of EG, but not of CG. There were also significant differences in the improvements of the DGI and the 6-minute walking distance between the groups. [Conclusion] Arm swing training had a positive effect on patients' gait ability. Further studies are required to generalize the results of this study.

Early Supported Discharge in Stroke Rehabilitation

A systematic review of the randomized controlled trials published from 1970-2002 was conducted to assess the effectiveness of early supported discharge programs in the context of stroke rehabilitation. Ten studies, including 1,286 patients, were selected for detailed review. The methodological quality of the studies was assessed using the PEDro Scale. The outcome assessed included functional outcomes, cost analysis, and length of hospital stay. Although the majority of studies reported no statistically significant differences in functional outcomes between the two groups, there was a reduction in hospital stays for patients receiving home-based therapy. These results suggest that patients with milder strokes who receive home-based therapies have similar functional outcomes to patients who receive traditional inpatient rehabilitation.

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.

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.

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).

Referrer and service provider beliefs and attitudes towards rehabilitation in the home; factors related to utilisation of Early Supported Discharge

PURPOSE

To investigate the attitudes and beliefs held by referrers and service providers of an Australian Early Supported Discharge (ESD) service called "Rehabilitation in the Home" (RITH); with particular consideration of factors that may influence referral to RITH.

METHODS

A cross-sectional online survey based on the Theory of Planned Behaviour was undertaken.

RESULTS

There were 113 respondents; 90 referrers and 23 service providers. Referrers and RITH staff had a moderately favourable attitude towards RITH. The majority of referrers, and, to a greater degree, RITH staff members, understood and appreciated the advantages ascribed to ESD. However, views varied with regard to some of the factors upon which the decision to refer to RITH rests. Two-fifths of referrers did not think that RITH provided hospital equivalent therapy intensity and over one-fifth of referrers had concerns about the capability of the RITH service to provide specialist stroke rehabilitation. Opinion of RITH staff was also varied on these topics.

CONCLUSIONS

This study provides evidence that there was a level of uncertainty amongst referrers and RITH service providers regarding issues directly and indirectly related to patient eligibility and RITH service capability. This uncertainty needs to be explored in future research.

IMPLICATIONS FOR REHABILITATION

Differences in views held by referrers and ESD service providers were identified in this study that could lead to inconsistencies in patient selection for, and under-utilization of, ESD services. Improved communication between referrers and ESD service providers, for instance attendance of RITH staff at inpatient team meetings, could ameliorate some of these misconceptions. On-going education of referrers about service capability is essential to ensure timely transfer of appropriate clients to ESD services.

Care for post-stroke patients at Malaysian public health centres: self-reported practices of family medicine specialists

BACKGROUND

Provision of post stroke care in developing countries is hampered by discoordination of services and limited access to specialised care. Albeit shortcomings, primary care continues to provide post-stroke services in less than favourable circumstances. This paper aimed to review provision of post-stroke care and related problems among Family Medicine Specialists managing public primary health care services.

METHODS

A semi-structured questionnaire was distributed to 121 Family Physicians servicing public funded health centres in a pilot survey focused on improving post stroke care provision at community level. The questionnaire assessed respondents background and practice details i.e. estimated stroke care burden, current service provision and opinion on service improvement. Means and frequencies described quantitative data. For qualitative data, constant comparison method was used until saturation of themes was reached.

RESULTS

Response rate of 48.8% was obtained. For every 100 patients seen at public healthcentres each month, 2 patients have stroke. Median number of stroke patients seen per month is 5 (IQR 2-10). 57.6% of respondents estimated total stroke patients treated per year at each centre was less than 40 patients. 72.4% lacked a standard care plan although 96.6% agreed one was needed. Patients seen were: discharged from tertiary care (88.1%), shared care plan with specialists (67.8%) and patients who developed stroke during follow up at primary care (64.4%). Follow-ups were done at 8-12 weekly intervals (60.3%) with 3.4% on 'as needed' basis. Referrals ranked in order of frequency were to physiotherapy services, dietitian and speech and language pathologists in public facilities. The FMS' perceived 4 important 'needs' in managing stroke patients at primary care level; access to rehabilitation services, coordinated care between tertiary centres and primary care using multidisciplinary care approach, a standardized guideline and family and caregiver support.

CONCLUSIONS

Post discharge stroke care guidelines and access to rehabilitation services at primary care is needed for post stroke patients residing at home in the community.

Physical activity early after stroke and its association to functional outcome 3 months later

BACKGROUND

Early rehabilitation that includes early mobilization and increased amount of motor activity is hypothesized to be one of the most important factors contributing to the beneficial effect of comprehensive stroke unit treatment, whereas too much bed rest is hypothesized to be harmful. The purpose of the present study was to assess the association between early activity/bed rest and functional outcome 3 months later.

METHODS

This was a prospective cohort study including patients with the diagnosis of stroke admitted to Trondheim University Hospital, Norway. Patients were eligible if they were less than 14 days poststroke and did not receive palliative care. Motor activity/bed rest was recorded in the acute phase using a standard method of observation, and the outcome was assessed by the modified Rankin Scale (mRS) score 3 months later. A proportional odds model was used to analyze the association between motor activity/bed rest and outcome. All analyses were adjusted for age, gender, stroke severity, time from stroke to observation, and prestroke function.

RESULTS

A total of 106 patients (mean age 79.0 years, 56.6% men) were included. The odds ratio for a higher mRS score (poor outcome) was 1.04 (95% confidence interval [CI] 1.02-1.07, P = .001) as time in bed increased and .97 (95% CI .93-1.02, P = .283) as time in motor activity increased.

CONCLUSIONS

This study confirms that time in bed in the early phase is associated with poor functional outcome 3 months later, indicating that too much bed rest should be avoided in the early phase after stroke.

Organised inpatient (stroke unit) care for stroke

BACKGROUND

Organised stroke unit care is provided by multidisciplinary teams that exclusively manage stroke patients in a ward dedicated to stroke patients, with a mobile stroke team or within a generic disability service (mixed rehabilitation ward).

OBJECTIVES

To assess the effect of stroke unit care compared with alternative forms of care for people following a stroke.

SEARCH METHODS

We searched the trials registers of the Cochrane Stroke Group (January 2013) and the Cochrane Effective Practice and Organisation of Care (EPOC) Group (January 2013), MEDLINE (2008 to September 2012), EMBASE (2008 to September 2012) and CINAHL (1982 to September 2012). In an effort to identify further published, unpublished and ongoing trials, we searched 17 trial registers (January 2013), performed citation tracking of included studies, checked reference lists of relevant articles and contacted trialists.

SELECTION CRITERIA

Randomised controlled clinical trials comparing organised inpatient stroke unit care with an alternative service. After formal risk of bias assessment, we have now excluded previously included quasi-randomised trials.

DATA COLLECTION AND ANALYSIS

Two review authors initially assessed eligibility and trial quality. We checked descriptive details and trial data with the co-ordinators of the original trials.

MAIN RESULTS

We included 28 trials, involving 5855 participants, comparing stroke unit care with an alternative service. More-organised care was consistently associated with improved outcomes. Twenty-one trials (3994 participants) compared stroke unit care with care provided in general wards. Stroke unit care showed reductions in the odds of death recorded at final (median one year) follow-up (odds ratio (OR) 0.87, 95% confidence interval (CI) 0.69 to 0.94; P = 0.005), the odds of death or institutionalised care (OR 0.78, 95% CI 0.68 to 0.89; P = 0.0003) and the odds of death or dependency (OR 0.79, 95% CI 0.68 to 0.90; P = 0.0007). Sensitivity analyses indicated that the observed benefits remained when the analysis was restricted to securely randomised trials that used unequivocally blinded outcome assessment with a fixed period of follow-up. Outcomes were independent of patient age, sex, initial stroke severity or stroke type, and appeared to be better in stroke units based in a discrete ward. There was no indication that organised stroke unit care resulted in a longer hospital stay.

AUTHORS' CONCLUSIONS

Stroke patients who receive organised inpatient care in a stroke unit are more likely to be alive, independent, and living at home one year after the stroke. The benefits were most apparent in units based in a discrete ward. We observed no systematic increase in the length of inpatient stay.

A survey study to validate a four phases development model for integrated care in the Netherlands

BACKGROUND

The development of integrated care is a complex and long term process. Previous research shows that this development process can be characterised by four phases: the initiative and design phase; the experimental and execution phase; the expansion and monitoring phase and the consolidation and transformation phase. In this article these four phases of the Development Model for Integrated Care (DMIC) are validated in practice for stroke services, acute myocardial infarct (AMI) services and dementia services in the Netherlands.

METHODS

Based on the pre-study about the DMIC, a survey was developed for integrated care coordinators. In total 32 stroke, 9 AMI and 43 dementia services in the Netherlands participated (response 83%). Data were collected on integrated care characteristics, planned and implemented integrated care elements, recognition of the DMIC phases and factors that influence development. Data analysis was done by descriptive statistics, Kappa tests and Pearson's correlation tests.

RESULTS

All services positioned their practice in one of the four phases and confirmed the phase descriptions. Of them 93% confirmed to have completed the previous phase. The percentage of implemented elements increased for every further development phase; the percentage of planned elements decreased for every further development phase. Pearson's correlation was .394 between implemented relevant elements and self-assessed phase, and up to .923 with the calculated phases (p < .001). Elements corresponding to the earlier phases of the model were on average older. Although the integrated care services differed on multiple characteristics, the DMIC phases were confirmed.

CONCLUSIONS

Integrated care development is characterised by a changing focus over time, often starting with a large amount of plans which decrease over time when progress on implementation has been made. More awareness of this phase-wise development of integrated care, could facilitate integrated care coordinators and others to evaluate their integrated care practices and guide further development. The four phases model has the potential to serve as a generic quality management tool for multiple integrated care practices.

High-density lipoprotein: a novel marker for risk of in-hospital infection in acute ischemic stroke patients?

BACKGROUND

Several studies have shown that high-density lipoprotein (HDL) cholesterol provides protection against bacterial infections. Our aim was to investigate the influence of HDL cholesterol levels on the risk of developing in-hospital infectious complications after an acute ischemic stroke (IS) as well as the possible effect of prestroke statin treatment on this association.

METHODS AND RESULTS

Observational study that included consecutive IS patients during a 5-year period (2006-2010). We analyzed vascular risk factors, prestroke treatments (including statins), laboratory data (including HDL cholesterol levels), stroke severity, and the development of infectious complications (pneumonia, urinary tract infection and sepsis). A multivariate analysis that included HDL cholesterol levels, prior statin treatment and the interaction between both variables was performed to identify those factors associated with the presence of infectious complications. A total of 1,385 patients were included, 130 of whom (9.4%) developed in-hospital infections. The receiver operating characteristic curve showed the predictive value of HDL cholesterol with an area under the curve of 0.597 (95% CI, 0.526-0.668; p = 0.006) and pointed to 38.5 mg/dl of HDL cholesterol (65.5% sensitivity and 53.4% specificity) as the optimal cutoff level for developing infectious complications during hospitalization. An HDL cholesterol level ≥38.5 mg/dl was an independent predictive factor for lower risk of infection (OR 0.308; 95% CI 0.119-0.795), whereas prestroke statin treatment was not associated with the development of infection.

CONCLUSIONS

An HDL cholesterol level ≥38.5 mg/dl was independently associated with lower risk for developing infectious complications in acute IS patients. Statins do not influence this association.

A qualitative study exploring patients' and carers' experiences of Early Supported Discharge services after stroke

OBJECTIVE

To investigate patients' and carers' experiences of Early Supported Discharge services and inform future Early Supported Discharge service development and provision.

DESIGN AND SUBJECTS

Semi-structured interviews were completed with 27 stroke patients and 15 carers in the Nottinghamshire region who met evidence-based Early Supported Discharge service eligibility criteria. Participants were either receiving Early Supported Discharge or conventional services.

SETTING

Community stroke services in Nottinghamshire, UK.

RESULTS

A thematic analysis process was applied to identify similarities and differences across datasets. Themes specific to participants receiving Early Supported Discharge services were: the home-based form of rehabilitation; speed of response; intensity and duration of therapy; respite time for the carer; rehabilitation exercises and provision of technical equipment; disjointed transition between Early Supported Discharge and ongoing rehabilitation services. Participants receiving Early Supported Discharge or conventional community services experienced difficulties related to: limited support in dealing with carer strain; lack of education and training of carers; inadequate provision and delivery of stroke-related information; disjointed transition between Early Supported Discharge and ongoing rehabilitation services.

CONCLUSIONS

Accelerated hospital discharge and home-based rehabilitation was perceived positively by service users. The study findings highlight the need for Early Supported Discharge teams to address information and support needs of patients and carers and to monitor their impact on carers in addition to patients, using robust outcome measures.

A meta-analysis of "hospital in the home"

OBJECTIVE

To assess the effect of "hospital in the home" (HITH) services that significantly substitute for inhospital time on mortality, readmission rates, patient and carer satisfaction, and costs.

DATA SOURCES

MEDLINE, Embase, Social Sciences Citation Index, CINAHL, EconLit, PsycINFO and the Cochrane Database of Systematic Reviews, from the earliest date in each database to 1 February 2012.

STUDY SELECTION

Randomised controlled trials (RCTs) comparing HITH care with inhospital treatment for patients aged > 16 years.

DATA EXTRACTION

Potentially relevant studies were reviewed independently by two assessors, and data were extracted using a collection template and checklist.

DATA SYNTHESIS

61 RCTs met the inclusion criteria. HITH care led to reduced mortality (odds ratio [OR], 0.81; 95% CI, 0.69 to 0.95; P = 0.008; 42 RCTs with 6992 patients), readmission rates (OR, 0.75; 95% CI, 0.59 to 0.95; P = 0.02; 41 RCTs with 5372 patients) and cost (mean difference, -1567.11; 95% CI, -2069.53 to -1064.69; P < 0.001; 11 RCTs with 1215 patients). The number needed to treat at home to prevent one death was 50. No heterogeneity was observed for mortality data, but heterogeneity was observed for data relating to readmission rates and cost. Patient satisfaction was higher in HITH in 21 of 22 studies, and carer satisfaction was higher in and six of eight studies; carer burden was lower in eight of 11 studies, although not significantly (mean difference, 0.00; 95% CI, -0.19 to 0.19).

CONCLUSION

HITH is associated with reductions in mortality, readmission rates and cost, and increases in patient and carer satisfaction, but no change in carer burden.

A Critical Review of Early Supported Discharge for Stroke Patients: From Evidence to Implementation into Practice

After an acute stroke, a multidimensional approach based on multidisciplinary work and rehabilitation is required in order to promote functional independence and social reinsertion and to maintain medical stability. These activities are usually developed in the hospital setting as a continuum of the acute phase, but hospitalization is resource consuming and resources are limited. Early Support Discharge strategies base postacute care and rehabilitation at home after an early discharge planning and represent possible alternatives to conventional hospitalization. Recent evidence suggests that Early Supported Discharge might be superior to hospitalization from both the clinical-functional and the economic viewpoints. Moreover, home-based rehabilitation might potentiate important determinants of effectiveness, such as patient's motivation and goal-directed rehabilitation. However, hitherto produced evidence and recommendations show a number of limitations related to the organization models, the inclusion/exclusion criteria, and the questionable applicability of results to any healthcare setting worldwide. In this article, we critically review different methodological and organizational aspects of the available studies. For example in the definition of the target population, based mainly on residual disability and medical stability, we suggest that other relevant aspects, such as premorbid functional status, cognitive function, and previous institutionalization, should be better defined. Focusing on the outcomes, we suggest that, besides strong outcomes such as global functioning, surrogate outcomes, such as physical function, could help to refine the specific interventions. Finally, considering that the majority of studies were conducted in northern Europe, further studies are needed to test the implementation of Early Supported Discharge in different regions.

Economic evidence on integrated care for stroke patients; a systematic review

Introduction

Given the high incidence of stroke worldwide and the large costs associated with the use of health care resources, it is important to define cost-effective and evidence-based services for stroke rehabilitation. The objective of this review was to assess the evidence on the relative cost or cost-effectiveness of all integrated care arrangements for stroke patients compared to usual care. Integrated care was defined as a multidisciplinary tool to improve the quality and efficiency of evidence-based care and is used as a communication tool between professionals to manage and standardize the outcome-orientated care.

Methods

A systematic literature review of cost analyses and economic evaluations was performed. Study characteristics, study quality and results were summarized.

Results

Fifteen studies met the inclusion criteria; six on early-supported discharge services, four on home-based rehabilitation, two on stroke units and three on stroke services. The follow-up per patient was generally short; one year or less. The comparators and the scope of included costs varied between studies.

Conclusions

Six out of six studies provided evidence that the costs of early-supported discharge are less than for conventional care, at similar health outcomes. Home-based rehabilitation is unlikely to lead to cost-savings, but achieves better health outcomes. Care in stroke units is more expensive than conventional care, but leads to improved health outcomes. The cost-effectiveness studies on integrated stroke services suggest that they can reduce costs. For future research we recommend to focus on the moderate and severely affected patients, include stroke severity as variable, adopt a societal costing perspective and include long-term costs and effects.