Services for reducing duration of hospital care for acute stroke patients

BACKGROUND: Stroke patients conventionally receive a substantial part of their rehabilitation in hospital. Services have now been developed which offer patients in hospital an early discharge with rehabilitation at home (early supported discharge (ESD)). OBJECTIVES: To establish the effects and costs of ESD services compared with conventional services. SEARCH STRATEGY: We searched the Cochrane Stroke Group's trials register (last searched August 2004) and obtained further information from individual trialists. SELECTION CRITERIA: Randomised controlled trials recruiting stroke patients in hospital to receive either conventional care or any service intervention which has provided rehabilitation and support in a community setting with an aim of reducing the duration of hospital care. DATA COLLECTION AND ANALYSIS: Two reviewers scrutinised trials and categorised them on their eligibility. Standardised individual patient data was then sought from the primary trialists. Results were analysed 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. MAIN RESULTS: Outcome data are currently available for 11 trials (1597 patients). Patients tended to be a selected elderly group with moderate disability. The ESD group showed significant reductions (P < 0.0001) in the length of hospital stay equivalent to approximately 8 days. Overall, the odds ratios (OR) (95% confidence interval (CI)) for death, death or institutionalisation, death or dependency at the end of scheduled follow up were OR 0.90, 95% CI 0.64 to 1.27, P = 0.56, OR 0.74, 95% CI 0.56 to 0.96, P = 0.02 and OR 0.79, 95% CI 0.64 to 0.97, P = 0.02, respectively. The greatest benefits were seen in the trials evaluating a co-ordinated ESD team and in stroke patients with mild-moderate disability. Improvements were also seen in patients' extended activities of daily living scores (standardised mean difference 0.12, 95% CI 0.00 to 0.25, P = 0.05) and satisfaction with services (OR 1.60, 95% CI 1.08 to 2.38, P = 0.02) but no statistically significant differences were seen in carers' subjective health status, mood or satisfaction with services. AUTHORS' CONCLUSIONS: Appropriately resourced ESD services 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. No adverse impact was observed on the mood or subjective health status of patients or carers.