Early supported discharge of patients with acute stroke: a randomized controlled trial

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.

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.

Korean Model for Post-acute Comprehensive rehabilitation (KOMPACT): The Study Protocol for a Pragmatic Multicenter Randomized Controlled Study on Early Supported Discharge

Introduction: Early supported discharge (ESD) is a transitional care model aimed at facilitating post-acute stroke patients' discharge to home. Previous studies have demonstrated that ESD provides equivalent patient and caregiver outcomes with superior cost-effectiveness compared to conventional rehabilitation (CR). This study intends to examine the feasibility of ESD in Korea.

Methods and Analysis: This study is designed as a multicenter assessor-blinded, randomized controlled trial. Ninety post-acute stroke patients with mild to moderate disability (modified Rankin Scale 1–3) will be recruited from three university hospitals (30 patients per hospital) in Korea and allocated to either the ESD group or the CR group in a 1:1 ratio. Patients in the ESD group will receive individualized discharge planning and goal setting, a 4-week home-based rehabilitation program, and liaison service to community-based resources by a multidisciplinary team. Patients in the CR group will receive rehabilitation practices according to their current hospital policy.

Outcomes: The primary outcome is the Korean version of the modified Barthel Index, and the primary endpoint was post-onset 3 months. Clinical outcomes, patient/caregiver reported outcomes, and socioeconomic outcomes will be measured at baseline, 1 month after discharge, 2 months after discharge, and 3 months after onset.

Discussion: The efficacy and cost-effectiveness of ESD can vary according to the healthcare system and sociocultural aspects. To establish ESD as an alternative transitional care model for post-acute stroke patients in Korea, its feasibility needs to be examined in prior. This study will add evidence on the applicability of ESD in Korea.

Ethical Considerations: The study protocol was reviewed and approved by the Institutional Review Board of Seoul National University Bundang Hospital (IRB number B-2012/654-308). The study protocol was registered at ClinicalTrials.gov (Identifier NCT04720820). Disseminations will include submission to peer-reviewed journals and presentations at conferences.

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.

Changes in social participation and life-space mobility in newly enrolled home-based rehabilitation users over 6 months

[Purpose] This study aimed to examine whether we were able to measure changes in social participation and life-space mobility of newly enrolled home-based rehabilitation (HR) users by using the activities and participation components of the International Classification of Functioning, Disability and Health (ICF) and Life-Space Assessment (LSA) over a 6-months period. [Participants and Methods] We enrolled 47 HR users who had suffered from a stroke or other condition within the previous year. A 6-month prospective cohort study was conducted. The performance qualifiers “d6 domestic life” and “d9 community, social and civic life” in the activities and participation components of the ICF and LSA were used. [Results] We observed significant improvements in the performance qualifier “d9 community, social and civic life” of the ICF over 3 months, and the LSA over a 6-months period. We also identified significant improvements in “d910 community life” and “d920 recreation and leisure” of the ICF. The LSA results showed that HR users had more frequent mobility within the neighborhood. [Conclusion] This study showed that newly enrolled HR users improved their social activities in the community, recreational activities, and life-space mobility over a 6-months period. These were measured using performance qualifiers from the ICF and LSA.

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.

Emergency Department Patient Satisfaction with Treatment of Low-risk Pulmonary Embolism

Introduction

Many emergency department (ED) patients with acute pulmonary embolism (PE) who meet low-risk criteria may be eligible for a short length of stay (LOS) (<24 hours), with expedited discharge home either directly from the ED or after a brief observation or hospitalization. We describe the association between expedited discharge and site of discharge on care satisfaction and quality of life (QOL) among patients with low-risk PE (PE Severity Index [PESI] Classes I-III).

Methods

This phone survey was conducted from September 2014 through April 2015 as part of a retrospective cohort study across 21 community EDs in Northern California. We surveyed low-risk patients with acute PE, treated predominantly with enoxaparin bridging and warfarin. All eligible patients were called 2-8 weeks after their index ED visit. PE-specific, patient-satisfaction questions addressed overall care, discharge instruction clarity, and LOS. We scored physical and mental QOL using a modified version of the validated Short Form Health Survey. Satisfaction and QOL were compared by LOS. For those with expedited discharge, we compared responses by site of discharge: ED vs. hospital, which included ED-based observation units. We used chi-square and Wilcoxon rank-sum tests as indicated.

Results

Survey response rate was 82.3% (424 of 515 eligible patients). Median age of respondents was 64 years; 47.4% were male. Of the 145 patients (34.2%) with a LOS<24 hours, 65 (44.8%) were discharged home from the ED. Of all patients, 89.6% were satisfied with their overall care and 94.1% found instructions clear. Sixty-six percent were satisfied with their LOS, whereas 17.5% would have preferred a shorter LOS and 16.5% a longer LOS. There were no significant differences in satisfaction between patients with LOS<24 hours vs. ≥24 hours (p>0.13 for all). Physical QOL scores were significantly higher for expedited-discharge patients (p=0.01). Patients with expedited discharge home from the ED vs. the hospital had no significant difference in satisfaction (p>0.20 for all) or QOL (p>0.19 for all).

Conclusion

ED patients with low-risk PE reported high satisfaction with their care in follow-up surveys. Expedited discharge (<24 hours) and site of discharge were not associated with differences in patient satisfaction.

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.

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.

Well-being and instrumental activities of daily living after stroke

Objective: To explore the relationship between subjective well-being and competence in instrumental activities of daily living after stroke.

Design: Cross-sectional with evaluation at six months post stroke.

Subjects: Eighty-two patients admitted to an acute stroke unit, of whom 64 were seen at six months. The mean age was 77.5 years, 55% were females and 55% were living alone. Main outcome measures: The General Health Questionnaire (GHQ-20 version), a well-being scale, was factor analysed and yielded three dimensions, named ‘coping’, ‘anxiety’ and ‘satisfaction’ that served as main outcomes.

Results: Explanatory variables were the four subscales of the Nottingham IADL scale, the Ullevaal Aphasia Screening test, urinary continence and demographics. Structural equation modelling showed that the GHQ dimension ‘satisfaction’ related significantly to the Nottingham subscale ‘leisure activities’ (β = -0.38, p= 0.01), whereas ‘coping’ was indirectly associated with ‘leisure activities’ by its correlation with ‘satisfaction’ (R= 0.26, p= 0.01). None of the outcomes were statistically associated with aphasia, continence or the background variables.

Conclusion: ‘Leisure activities’ demonstrated the strongest association to subjective well-being as expressed by the ‘satisfaction’ dimension. In stroke rehabilitation leisure activities should be addressed when assessing function and planning intervention.

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.

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.

Ottawa Panel Evidence-Based Clinical Practice Guidelines for Post-Stroke Rehabilitation

BACKGROUND AND PURPOSE

The purpose of this project was to create guidelines for 13 types of physical rehabilitation interventions used in the management of adult patients (>18 years of age) presenting with hemiplegia or hemiparesis following a single clinically identifiable ischemic or hemorrhagic cerebrovascular accident (CVA).

METHOD

Using Cochrane Collaboration methods, the Ottawa Methods Group identified and synthesized evidence from comparative controlled trials. The group then formed an expert panel, which developed a set of criteria for grading the strength of the evidence and the recommendation. Patient-important outcomes were determined through consensus, provided that these outcomes were assessed with a validated and reliable scale.

RESULTS

The Ottawa Panel developed 147 positive recommendations of clinical benefit concerning the use of different types of physical rehabilitation interventions involved in post-stroke rehabilitation.

DISCUSSION AND CONCLUSION

The Ottawa Panel recommends the use of therapeutic exercise, task-oriented training, biofeedback, gait training, balance training, constraint-induced movement therapy, treatment of shoulder subluxation, electrical stimulation, transcutaneous electrical nerve stimulation, therapeutic ultrasound, acupuncture, and intensity and organization of rehabilitation in the management of post stroke.

Sense of well-being 10 years after stroke

AIMS AND OBJECTIVES

To describe factors that promote subjective well-being in a long-time perspective of 10 years after stroke.

BACKGROUND

The research literature describes circumstances that are difficult to deal with after a stroke, but there is relatively little knowledge of factors that contribute to well-being in a longer-time perspective than two years after the incident. This study focuses on such conditions in a 10-year perspective.

DESIGN

Qualitative study

METHODS

Qualitative in-depth interviews were carried out with nine stroke survivors. The interviews addressed their description of factors accounting for adaptation and subjective well-being after the stroke. Kvale and Brinkmann's (2008, Interview. Sage Publications, Inc., København) guidelines for qualitative research informed the analysis.

RESULTS

Six major themes emerged from these analyses: (1) personal characteristics as the cause of positive adaptation to the new situation, (2) new meaningful activities, (3) new health habits, (4) social networks and family, (5) economical resources and (6) public help. Only a few of the survivors had received any home-based nursing care or health assistance, but they were nevertheless mainly satisfied with their rehabilitation outcome. Self-care, health literacy, stamina, a positive way of thinking and attention from family and friends seemed to be of immense importance for adaptation and well-being.

CONCLUSION

Personal characteristics and synergy with significant others seem to be the most important factors for having a good and long life after a stroke.

RELEVANCE TO CLINICAL PRACTICE

The results of this study will contribute to rehabilitation planning and to understanding, assisting and supporting stroke survivors in restoring a good life despite disabilities after the stroke.

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.

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 METHODS

We searched the trials registers of the Cochrane Stroke Group (January 2012) and the Cochrane Effective Practice and Organisation of Care (EPOC) Group, MEDLINE (2008 to 7 February 2012), EMBASE (2008 to 7 February 2012) and CINAHL (1982 to 7 February 2012). In an effort to identify further published, unpublished and ongoing trials we searched 17 trial registers (February 2012), performed citation tracking of included studies, checked reference lists of relevant articles and contacted 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

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 and categorised them on their eligibility. We then sought standardised individual patient 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.

MAIN RESULTS

Outcome data are currently available for 14 trials (1957 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 seven 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 0.91 (95% CI 0.67 to 1.25, P = 0.58), OR 0.78 (95% CI 0.61 to 1.00, P = 0.05) and OR 0.80 (95% CI 0.67 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 to 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. The apparent benefits were no longer statistically significant at five-year follow-up.

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. We observed no adverse impact on the mood or subjective health status of patients or carers.

Early Supported Discharge after Stroke in Bergen (ESD Stroke Bergen): A Randomized Controlled Trial Comparing Rehabilitation in a Day Unit or in the Patients' Homes with Conventional Treatment

Rationale

As a result of demographic changes with a presumed rapidly increasing number of older people during the coming decades, a strong increase in the incidence and prevalence of stroke should be expected. Early supported discharge implies that the patients are discharged to their homes as soon as feasible and that rehabilitative treatment is offered after the discharge, with the patients being home-dwelling. This has proved beneficial in previous studies.

Aims

The main objective of this study is to further characterize the important components of early supported discharge and to confirm superiority of early supported discharge over conventional treatment. The secondary aim will be to compare two different early supported discharge schemes. These early supported discharge schemes are composed of intensive rehabilitation treatment given by a multidisciplinary team in a day unit and, alternatively, the same treatment given in the patients' homes.

Design

The study is conducted as a randomized controlled trial with three arms: two different forms of early supported discharge and a control arm with conventional treatment. Patients with acute stroke admitted to our hospital's stroke unit and living in the Municipality of Bergen are considered for inclusion. A total of 350 stroke patients are expected.

Study outcomes

Primary outcome is modified Rankin Scale six-months after inclusion. Secondary outcomes include Barthel Index and National Institute of Health Stroke Scale at several points in time after inclusion, as well as many other schemes, questionnaires and physical tests. The study is registered in ClinicalTrials.gov registration number NCT00771771.

Interprofessional stroke rehabilitation for stroke survivors using home care

OBJECTIVE

To compare a specialized interprofessional team approach to community-based stroke rehabilitation with usual home care for stroke survivors using home care services.

METHODS

Randomized controlled trial of 101 community-living stroke survivors (<18 months post-stroke) using home care services. Subjects were randomized to intervention (n=52) or control (n=49) groups. The intervention was a 12-month specialized, evidence-based rehabilitation strategy involving an interprofessional team. The primary outcome was change in health-related quality of life and functioning (SF-36) from baseline to 12 months. Secondary outcomes were number of strokes during the 12-month follow-up, and changes in community reintegration (RNLI), perceived social support (PRQ85-Part 2), anxiety and depressive symptoms (Kessler-10), cognitive function (SPMSQ), and costs of use of health services from baseline to 12 months.

RESULTS

A total of 82 subjects completed the 12-month follow-up. Compared with the usual care group, stroke survivors in the intervention group showed clinically important (although not statistically significant) greater improvements from baseline in mean SF-36 physical functioning score (5.87, 95% CI -3.98 to 15.7; p=0.24) and social functioning score (9.03, CI-7.50 to 25.6; p=0.28). The groups did not differ for any of the secondary effectiveness outcomes. There was a higher total per-person costs of use of health services in the intervention group compared to usual home care although the difference was not statistically significant (p=0.76).

CONCLUSIONS

A 12-month specialized, interprofessional team is a feasible and acceptable approach to community-based stroke rehabilitation that produced greater improvements in quality of life compared to usual home care. Clinicaltrials.gov identifier: NCT00463229.

Avoiding hospital admission through provision of hospital care at home: a systematic review and meta-analysis of individual patient data

BACKGROUND

Avoidance of admission through provision of hospital care at home is a scheme whereby health care professionals provide active treatment in the patient's home for a condition that would otherwise require inpatient treatment in an acute care hospital. We sought to compare the effectiveness of this method of caring for patients with that type of in-hospital care.

METHODS

We searched the MEDLINE, EMBASE, CINAHL and EconLit databases and the Cochrane Effective Practice and Organisation of Care Group register from the earliest date in each database until January 2008. We included randomized controlled trials that evaluated a service providing an alternative to admission to an acute care hospital. We excluded trials in which the program did not offer a substitute for inpatient care. We performed meta-analyses for trials for which the study populations had similar characteristics and for which common outcomes had been measured.

RESULTS

We included 10 randomized trials (with a total of 1327 patients) in our systematic review. Seven of these trials (with a total of 969 patients) were deemed eligible for meta-analysis of individual patient data, but we were able to obtain data for only 5 of these trials (with a total of 844 patients [87%]). There was no significant difference in mortality at 3 months for patients who received hospital care at home (adjusted hazard ratio [HR] 0.77, 95% confidence interval [CI] 0.54-1.09, p = 0.15). However, at 6 months, mortality was significantly lower for these patients (adjusted HR 0.62, 95% CI 0.45-0.87, p = 0.005). Admissions to hospital were greater, but not significantly so, for patients receiving hospital care at home (adjusted HR 1.49, 95% CI 0.96-2.33, p = 0.08). Patients receiving hospital care at home reported greater satisfaction than those receiving inpatient care. These programs were less expensive than admission to an acute care hospital ward when the analysis was restricted to treatment actually received and when the costs of informal care were excluded.

INTERPRETATION

For selected patients, avoiding admission through provision of hospital care at home yielded similar outcomes to inpatient care, at a similar or lower cost.

Stressful Situations the First Six Months after a Stroke

The main purpose of this study is to categorize and analyze the most stressful situations perceived by stroke patients during a period of 6 months after experiencing a stroke. The events that have an impact on the subjective well-being and the intensity of the stress are also investigated. A clinic-based sample of 82 hospitalized stroke patients were studied 4 times after the stroke incident. They were asked to describe and appraise the most stressful event or situation that had affected them during the last 3 days. The data analysis was conducted according to phenomenological and hermeneutical methods. The study was approved by the Regional Committee for Ethics in Medical Research. The reported difficulties after a stroke have been separated into 5 categories: 1) impairments and disabilities in bodily functions; 2) communication and memory problems; 3) negative thoughts, depression and loneliness; 4) anxiety, fear, and worries; and 5) anger. Stressful situations in the first category were the most frequently reported, while those in the fourth category increased during the first 2 weeks after discharge, but decreased again within 3 months after the stroke. Encounters in the second category were less reported over time while those in the third category tended to become a more stable emotional state. Some interviewees expressed anger (category five). Few described relief or no difficulties at all. In total, the intensity of the stressful events decreased strongly. The increased occurrence of anxiety, fear, and worries during the first weeks after discharge from hospital gives rise to concern. These strains coincide with the withdrawal of health services.

Early discharge hospital at home

BACKGROUND

'Early discharge hospital at home' is a service that provides active treatment by health care professionals in the patient's home for a condition that otherwise would require acute hospital in-patient care. If hospital at home were not available then the patient would remain in an acute hospital ward.

OBJECTIVES

To determine, in the context of a systematic review and meta-analysis, the effectiveness and cost of managing patients with early discharge hospital at home compared with in-patient hospital care.

SEARCH STRATEGY

We searched the Cochrane Effective Practice and Organisation of Care (EPOC) Group Register , MEDLINE (1950 to 2008), EMBASE (1980 to 2008), CINAHL (1982 to 2008) and EconLit through to January 2008. We checked the reference lists of articles identified for potentially relevant articles.

SELECTION CRITERIA

Randomised controlled trials recruiting patients aged 18 years and over. Studies comparing early discharge hospital at home with acute hospital in-patient care. Evaluations of obstetric, paediatric and mental health hospital at home schemes are excluded from this review.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted data and assessed study quality. Our statistical analyses were done on an intention-to-treat basis. We requested individual patient data (IPD) from trialists, and relied on published data when we did not receive trial data sets or the IPD did not include the relevant outcomes. For the IPD meta-analysis, where at least one event was reported in both study groups in a trial, Cox regression models were used to calculate the log hazard ratio and its standard error for mortality and readmission separately for each data set. The calculated log hazard ratios were combined using fixed-effect inverse variance meta-analysis.

MAIN RESULTS

Twenty-six trials were included in this review [n = 3967]; 21 were eligible for the IPD meta-analysis and 13 of the 21 trials contributed data [1899/2872; 66%]. For patients recovering from a stroke and elderly patients with a mix of conditions there was insufficient evidence of a difference in mortality between groups (adjusted HR 0.79, 95% CI 0.32 to 1.91; N = 494; and adjusted HR 1.06, 95% CI 0.69 to 1.61; N = 978). Readmission rates were significantly increased for elderly patients with a mix of conditions allocated to hospital at home (adjusted HR 1.57; 95% CI 1.10 to 2.24; N = 705). For patients recovering from a stroke and elderly patients with a mix of conditions respectively, significantly fewer people allocated to hospital at home were in residential care at follow up (RR 0.63; 95% CI 0.40 to 0.98; N = 4 trials; RR 0.69, 95% CI 0.48 to 0.99; N =3 trials). Patients reported increased satisfaction with early discharge hospital at home. There was insufficient evidence of a difference for readmission between groups in trials recruiting patients recovering from surgery. Evidence on cost savings was mixed.

AUTHORS' CONCLUSIONS

Despite increasing interest in the potential of early discharge hospital at home services as a cheaper alternative to in-patient care, this review provides insufficient objective evidence of economic benefit or improved health outcomes.

Interventions for treating depression after stroke

BACKGROUND

Depression is an important consequence of stroke that impacts on recovery yet is often not detected or inadequately treated. This is an update of a Cochrane review first published in 2004.

OBJECTIVES

To determine whether pharmaceutical, psychological, or electroconvulsive treatment (ECT) of depression in patients with stroke can improve outcome.

SEARCH STRATEGY

We searched the trials registers of the Cochrane Stroke Group (last searched October 2007) and the Cochrane Depression Anxiety and Neurosis Group (last searched February 2008). In addition, we searched the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 1, 2008), MEDLINE (1966 to May 2006), EMBASE (1980 to May 2006), CINAHL (1982 to May 2006), PsycINFO (1967 to May 2006) and other databases. We also searched reference lists, clinical trials registers, conference proceedings and dissertation abstracts, and contacted authors, researchers and pharmaceutical companies.

SELECTION CRITERIA

Randomised controlled trials comparing pharmaceutical agents with placebo, or various forms of psychotherapy or ECT with standard care (or attention control), in patients with stroke, with the intention of treating depression.

DATA COLLECTION AND ANALYSIS

Two review authors selected trials for inclusion and assessed methodological quality; three review authors extracted, cross-checked and entered data. Primary analyses were the prevalence of diagnosable depressive disorder at the end of treatment. Secondary outcomes included depression scores on standard scales, physical function, death, recurrent stroke and adverse effects.

MAIN RESULTS

Sixteen trials (17 interventions), with 1655 participants, were included in the review. Data were available for 13 pharmaceutical agents, and four trials of psychotherapy. There were no trials of ECT. The analyses were complicated by the lack of standardised diagnostic and outcome criteria, and differing analytic methods. There was some evidence of benefit of pharmacotherapy in terms of a complete remission of depression and a reduction (improvement) in scores on depression rating scales, but there was also evidence of an associated increase in adverse events. There was no evidence of benefit of psychotherapy.

AUTHORS' CONCLUSIONS

A small but significant effect of pharmacotherapy (not psychotherapy) on treating depression and reducing depressive symptoms was found, as was a significant increase in adverse events. More research is required before recommendations can be made about the routine use of such treatments.

Care home versus hospital and own home environments for rehabilitation of older people

BACKGROUND

Rehabilitation for older people has acquired an increasingly important profile for both policy-makers and service providers within health and social care agencies. This has generated an increased interest in the use of alternative care environments including care home environments. Yet, there appears to be limited evidence on which to base decisions.This review is the first update of the Cochrane review which was published in 2003.

OBJECTIVES

To compare the effects of care home environments (e.g. nursing home, residential care home and nursing facilities) versus hospital environments and own home environments in the rehabilitation of older people.

SEARCH STRATEGY

We searched the Cochrane Effective Practice and Organisation of Care Specialised Register and Pending Folder, MEDLINE (1950 to March Week 3 2007), EMBASE (1980 to 2007 Week 13), CINAHL (1982 to March, Week 4, 2007), other databases and reference lists of relevant review articles were additionally reviewed. Date of most recent search: March 2007.

SELECTION CRITERIA

Randomised controlled trials (RCTs), controlled clinical trials (CCTs), controlled before and after studies (CBAs) and interrupted time series (ITS) that compared rehabilitation outcomes for persons 60 years or older who received rehabilitation whilst residing in a care home with those who received rehabilitation in hospital or own home environments.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted data.

MAIN RESULTS

In this update, 8365 references were retrieved. Of these, 339 abstracts were independently assessed by 2 review authors, and 56 studies and 5 review articles were subsequently obtained. Full text papers were independently assessed by two or three review authors and none of these met inclusion criteria.

AUTHORS' CONCLUSIONS

There is insufficient evidence to compare the effects of care home environments versus hospital environments or own home environments on older persons rehabilitation outcomes. Although the authors acknowledge that absence of effect is not no effect. There are three main reasons; the first is that the description and specification of the environment is often not clear; secondly, the components of the rehabilitation system within the given environments are not adequately specified and; thirdly, when the components are clearly specified they demonstrate that the control and intervention sites are not comparable with respect to the methodological criteria specified by Cochrane EPOC group. The combined effect of these factors resulted in the comparability between intervention and control groups being very weak.

Interventions for preventing depression after stroke

BACKGROUND

Depression is an important consequence of stroke that impacts on recovery yet often is not detected or is inadequately treated.

OBJECTIVES

To determine if pharmaceutical or psychological interventions can prevent depression and improve physical and psychological outcomes in patients with stroke.

SEARCH STRATEGY

We searched the Trials Registers of the Cochrane Stroke Group (October 2007) and the Cochrane Depression Anxiety and Neurosis Group (February 2008). In addition, we searched the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 1, 2008), MEDLINE (1966 to May 2006), EMBASE (1980 to May 2006), CINAHL (1982 to May 2006), PsycINFO (1967 to May 2006), Applied Science and Technology Plus (1986 to May 2006), Arts and Humanities Index (1991 to September 2002), Biological Abstracts (1969 to September 2002), BIOSIS Previews (2002 to May 2006), General Science Plus (1994 to September 2002), Science Citation Index (1992 to May 2006), Social Sciences Citation Index (1991 to May 2006), SocioFile (1974 to May 2006) ISI Web of Science (2002 to February 2008), reference lists, trial registers, conference proceedings and dissertation abstracts, and contacted authors, researchers and pharmaceutical companies.

SELECTION CRITERIA

Randomised controlled trials comparing pharmaceutical agents with placebo, or psychotherapy against standard care (or attention control) to prevent depression in patients with stroke.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials, extracted data and assessed trial quality. Primary analyses were the proportion of patients who met the standard diagnostic criteria for depression applied in the trials at the end of follow up. Secondary outcomes included depression scores on standard scales, physical function, death, recurrent stroke and adverse effects.

MAIN RESULTS

Fourteen trials involving 1515 participants were included. Data were available for 10 pharmaceutical trials (12 comparisons) and four psychotherapy trials. The time from stroke to entry ranged from a few hours to seven months, but most patients were recruited within one month of acute stroke. The duration of treatment ranged from two weeks to one year. There was no clear effect of pharmacological therapy on the prevention of depression or other endpoints. A significant improvement in mood and the prevention of depression was evident for psychotherapy, but the treatment effects were small.

AUTHORS' CONCLUSIONS

A small but significant effect of psychotherapy on improving mood and preventing depression was identified. More evidence is required before recommendations can be made about the routine use of such treatments after stroke.

Older people's satisfaction with intermediate care: a systematic review

Although intermediate care takes a variety of different forms and has developed somewhat differently in different countries, we believe that intermediate-care schemes have enough in common to make it meaningful to examine the relationship between this method of care and the views of older patients receiving either it or its alternatives. This is particularly important as one of the underlying principles of intermediate care is to extend patient choice; furthermore, most intermediate-care services target older people. In this review we examine evidence about whether older people prefer intermediate or hospital care, and what they like and dislike about intermediate care.

Early home-supported discharge of stroke patients: a health technology assessment

OBJECTIVES

A comprehensive and systematic assessment (HTA) of early home-supported discharge by a multidisciplinary team that plans, coordinates, and delivers care at home (EHSD) was undertaken and the results were compared with that of conventional rehabilitation at stroke units.

METHODS

A systematic literature search for randomized trials (RCTs) on "early supported discharge" was closed in April 2005. RCTs on EHSD without information on (i) death or institution at follow-up, (ii) change in Barthél Index, (iii) length of hospital stay, (iv) intensity of home rehabilitation, or (v) baseline data are excluded. Seven RCTs on EHSD with 1,108 patients followed 3-12 months after discharge are selected for statistical meta-analysis of outcomes. The costs are calculated as a function of the average number of home training sessions. Economic evaluation is organized as a test of dominance (both better outcomes and lower costs).

RESULTS

The odds ratio (OR) for "Death or institution" is reduced significantly by EHSD: OR = .75 (confidence interval [CI], .46-.95), and number needed to treat (NNT) = 14. Referrals to institution have OR = .45 (CI, .31-.96) and NNT = 20. The reduction of the rate of death is not significant. Length of stay is significantly reduced by 10 days (CI, 2.6-18 days). All outcomes have a nonsignificant positive covariance. The median number of home sessions is eleven, and the average cost per EHSD is 1,340 USD. The "action mechanism" and financial barriers to EHSD are discussed.

CONCLUSIONS

EHSD is evidenced as a dominant health intervention. However, financial barriers between municipalities and health authorities have to be overcome. For qualitative reasons, a learning path of implementation is recommended where one stroke unit in a region initiates EHSD for dissemination of new experience to the other stroke units.

Review of randomised trials using the post-randomised consent (Zelen's) design

BACKGROUND

In 1979, Zelen described a trial method of randomising participants before acquiring consent in order to enhance recruitment to clinical trials. The method has been criticised ethically due to lack of consent and scientifically due to high crossover rates. This paper reviews recent published trials using this method and describes the reasons authors gave for using the method, examines the crossover rates, and looks at the quality of identified trials.

METHODS

Literature review searching for all citations to the relevant Zelen's papers of trials published since 1990 plus inclusion of trials from personal knowledge.

RESULTS

We identified 58 relevant trials. The most common justification for the use of Zelen method was to avoid the introduction of bias (e.g., to avoid the Hawthorne effect). Few trialists had explicitly used the design to enhance participant recruitment. Most trials (n=41) experienced some crossover from one group to the other (median crossover=8.9%, mean=13.8%, IQR 2.6% to 15%) although this was usually within acceptable limits.

CONCLUSION

The most important reason stated by authors for using Zelen's method was to limit bias. Zelen's method, if carefully used, can avoid 'resentful demoralisation' and the Hawthorne effect biasing a trial. Unlike a previous review, we found that crossover was not a problem for most trials.

Exploring the Content of Physiotherapeutic Home-Based Stroke Rehabilitation in New Zealand

OBJECTIVE

To address the paucity of information on the content of home interventions for people with stroke by reporting on the practice of physiotherapeutic home-based stroke rehabilitation in New Zealand.

DESIGN

Qualitative research methodology comprising a series of semi-structured interviews.

SETTING

Community setting in 6 cities in New Zealand.

PARTICIPANTS

A purposeful sampling strategy recruited 20 physiotherapists working in home-based stroke rehabilitation.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Not applicable.

RESULTS

Participants described patients as being fatigued, frustrated, depressed, and scared once discharged home and said that the primary aim of rehabilitation in the home environment is preparation for life after stroke. Physiotherapists aimed at optimal independent functioning by building patients' confidence, self-responsibility, and problem-solving skills while ensuring patient safety. Participants, illustrating the complexities of stroke rehabilitation, described a wide range of interventions. We identified a number of factors that influenced the practice decisions made by participants. The success of intervention was measured more by the successful attainment of carefully set patient-centered goals than by the use of validated outcome measures.

CONCLUSIONS

This study presents a conceptual model or framework for physiotherapy practice for people with stroke living in the community.

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.

Early supported discharge services for stroke patients: a meta-analysis of individual patients' data

BACKGROUND

Stroke patients conventionally undergo a substantial part of their rehabilitation in hospital. Services have been developed that offer patients early discharge from hospital with rehabilitation at home (early supported discharge [ESD]). We have assessed the effects and costs of such services.

METHODS

We did a meta-analysis of data from individual patients who took part in randomised trials that recruited patients with stroke in hospital to receive either conventional care or any ESD service intervention that provided rehabilitation and support in a community setting with the aim of shortening the duration of hospital care. The primary outcome was death or dependency at the end of scheduled follow-up.

FINDINGS

Outcome data were available for 11 trials (1597 patients). ESD services were mostly provided by specialist multidisciplinary teams to a selected group (median 41%) of stroke patients admitted to hospital. There was a reduced risk of death or dependency equivalent to six (95% CI one to ten) fewer adverse outcomes for every 100 patients receiving an ESD service (p=0.02). The hospital stay was 8 days shorter for patients assigned ESD services than for those assigned conventional care (p<0.0001). There were also significant improvements in scores on the extended activities of daily living scale and in the odds of living at home and reporting satisfaction with services. The greatest benefits were seen in the trials evaluating a coordinated multidisciplinary ESD team and in stroke patients with mild to moderate disability.

INTERPRETATION

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 shortening hospital stays.

Acute stroke unit care combined with early supported discharge. Long-term effects on quality of life. A randomized controlled trial

OBJECTIVES

The aim of the present trial was to compare the effects of an extended stroke unit service (ESUS) with the effects of an ordinary stroke unit service (OSUS) on long-term quality of life (QoL).

DESIGN

One year follow-up of a randomized controlled trial with 320 acute stroke patients allocated either to OSUS (160 patients) or ESUS (160 patients) with early supported discharge and follow-up by a mobile team. The intervention was a mobile team and close co-operation with the primary health care service. All assessments were blinded.

MAIN OUTCOME MEASURE

Primary outcome of QoL in this paper was measured by the Nottingham Health Profile (NHP) at 52 weeks. Secondary outcomes measured at 52 weeks were differences between the groups measured by the Frenchay Activity Index, Montgomery-Asberg Depression Scale, Mini-Mental State Score and the Caregivers Strain Index.

RESULTS

The ESUS group had a significantly better QoL (mean score 78.9) assessed by global NHP after one year than the OSUS group (mean score 75.2) (p =0.048). There were no significant differences between the groups in the secondary outcomes, but a trend in favour of ESUS. Caregivers Strain Index showed a mean score of 23.3 in the ESUS group and 22.6 in the OSUS group (p=0.089).

CONCLUSION

It seems that stroke unit treatment combined with early supported discharge in addition to reducing the length of hospital stay can improve long-term QoL. However, similar trials are necessary to confirm the benefit of this type of service.

Effectiveness of home rehabilitation after stroke in Israel

On discharge from an acute general hospital after a stroke, 191 patients were in need of, and were appropriate for, multidisciplinary rehabilitation. One-hundred-and-one patients (52.4%) received it in a rehabilitation institution as inpatients (the institutional rehabilitation group (IR) group) and 91 patients received it at home (the home rehabilitation (HR) group). Patients in the HR group had their mobility, activities of daily living (ADL), range of movements, tonus, coordination and sensation determined on admission to home rehabilitation and on discharge from it, 6 weeks to 2 months later. This group contained more women and more patients able to walk with devices and who were partially independent in ADL. The IR group consisted of more men and more patients with diabetes and marked difficulties in ADL and ambulation. In both groups the Barthel index and the Frenchay activities index were determined 1 year after the stroke by way of a telephone interview and no meaningful differences were found between the two groups. IR was considerably more expensive than HR. In Israel there exists a subpopulation of acute stroke survivors in need of, and appropriate for, multidisciplinary rehabilitation that can be provided at home; such rehabilitation was found to be effective in the short and long term, as well as cost effective.

Interventions for treating depression after stroke

BACKGROUND

Depressive and anxiety disorders following stroke are often undiagnosed or inadequately treated. This may reflect difficulties with the diagnosis of abnormal mood among older people with stroke-related disability, but may also reflect uncertainty about the effectiveness of such therapies in this setting.

OBJECTIVES

To determine whether pharmacological, psychological, or electroconvulsive treatment (ECT) of depression in patients with stroke can improve outcome.

SEARCH STRATEGY

The Cochrane Stroke Group Trials Register (last searched June 2003). The Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 3, 2002), MEDLINE (1966 to September 2002), EMBASE (1980 to September 2002), CINAHL (1982 to September 2002), PsychINFO (1967 to September 2002), Applied Science and Technology Plus (1986 to September 2002), Arts and Humanities Index (1991 to September 2002), Biological Abstracts (1969 to September 2002), General Science Plus (1994 to September 2002), Science Citation Index (1992 to September 2002), Social Sciences Citation Index (1991 to September 2002), and Sociofile (1974 to September 2002). Reference lists from relevant articles and textbooks were searched, and authors of known studies and pharmaceutical companies who manufacture psychotropic medications were contacted.

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials comparing different types of pharmaceutical agents with placebo, or various forms of psychotherapy with standard care (or attention control), in patients with recent, clinically diagnosed, acute stroke, where treatment was explicitly intended of treat depression.

DATA COLLECTION AND ANALYSIS

Primary analyses focussed on the prevalence of diagnosable depressive disorder at the end of treatment. Secondary outcomes included depression or mood scores on standard scales, disability or physical function, death, recurrent stroke, and adverse effects. We did not pool the data for summary scores. We performed meta-analysis for only some binary endpoints and data on adverse events.

MAIN RESULTS

Nine trials, with 780 participants, were included in the review. Data were available for seven trials of pharmaceutical agents, and two trials of psychotherapy. There were no trials of ECT. The analyses were complicated by the lack of standardised diagnostic and outcome criteria, and differing analytic methods. There was no strong evidence of benefit of either pharmacotherapy or psychotherapy in terms of a complete remission of depression following stroke. There was evidence of a reduction (improvement) in scores on depression rating scales, and an increase in the proportion of participants with anxiety at the end of follow up.

REVIEWERS' CONCLUSIONS

This review found no evidence to support the routine use of pharmacotherapeutic or psychotherapeutic treatment for depression after stroke. More research is required before recommendations can be made about the most appropriate management of depression following stroke.

Interventions for preventing depression after stroke

BACKGROUND

Abnormal mood is an important consequence of stroke and may affect recovery and outcome. However, depression and anxiety are often not detected or inadequately treated. This may in part be due to doubts about whether anti-depressant treatments commenced early after the onset of stroke will prevent depression and improve outcome.

OBJECTIVES

To determine if pharmaceutical or psychological interventions can prevent the onset of depression, including depressive illness and abnormal mood, and improve physical and psychological outcomes, in patients with stroke.

SEARCH STRATEGY

We searched the Cochrane Stroke Group trials register (June 2003). In addition we searched the following electronic databases: Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 3, 2002), MEDLINE (1966 to September 2002), EMBASE (1980 to September 2002), CINAHL (1982 to September 2002), PsychINFO (1967 to September 2002), Applied Science and Technology Plus (1986 to September 2002), Arts and Humanities Index (1991 to September 2002), Biological Abstracts (1969 to September 2002), General Science Plus (1994 to September 2002), Science Citation Index (1992 to September 2002), Social Sciences Citation Index (1991 to September 2002), and Sociofile (1974 to September 2002). Reference lists from relevant articles and textbooks were searched, and authors of known studies and pharmaceutical companies who manufacture psychotropic medications were contacted.

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials comparing different types of pharmaceutical agents (eg selective serotonin reuptake inhibitors) with placebo, or various forms of psychotherapy against standard care (or attention control), in patients with a recent clinical diagnosis of stroke, where the treatment was undertaken with the explicit intention of preventing depression.

DATA COLLECTION AND ANALYSIS

The primary analyses focussed on the proportion of patients who met the standard diagnostic criteria for depression applied in the trials at the end of follow-up. Secondary outcomes included depression or mood scores on standard scales, disability or physical function, death, recurrent stroke, and adverse effects.

MAIN RESULTS

Twelve trials involving 1245 participants were included in the review. Data were available for nine trials (11 comparisons) involving different pharmaceutical agents, and three trials of psychotherapy. The time from stroke onset to entry ranged from a few hours to six months, but most patients were recruited within one month of acute stroke. The duration of treatments ranged from two weeks to one year. There was no clear effect of pharmacological therapy on the prevention of depression or on other measures. A significant improvement in mood was evident for psychotherapy, but this treatment effect was small and from a single trial. There was no effect on diagnosed depression.

REVIEWERS' CONCLUSIONS

This review identified a small but significant effect of psychotherapy on improving mood, but no effect of either pharmacotherapy or psychotherapy on the prevention of depressive illness, disability, or other outcomes. More evidence is therefore required before any recommendations can be made about the routine use of such treatments to improve recovery after stroke.

Stroke Unit Care Combined With Early Supported Discharge

Background and Purpose— Early supported discharge from a stroke unit reduces the length of hospital stay. Evidence of a benefit for the patients is still unknown. The aim of this trial was to evaluate the long-term effects of an extended stroke unit service (ESUS), characterized by early supported discharge. The short-term effects were published previously.

Methods— We performed a randomized controlled trial in which 320 acute stroke patients were allocated to either ordinary stroke unit service (OSUS) (160 patients) or stroke unit care with early supported discharge (160 patients). The ESUS consists of a mobile team that coordinates early supported discharge and further rehabilitation. Primary outcome was the proportion of patients who were independent as assessed by modified Rankin Scale (RS) (RS ≤2=global independence). Secondary outcomes measured at 52 weeks were performance on the Barthel Index (BI) (BI ≥95=independent in activities of daily living), differences in final residence, and analyses to identify patients who benefited most from an early supported discharge service. All assessments were blinded.

Results— We found that 56.3% of the patients in the ESUS versus 45.0% in the OSUS were independent (RS ≤2) ( P =0.045). The number needed to treat to achieve 1 independent patient in ESUS versus OSUS was 9. The odds ratio for independence was 1.56 (95% CI, 1.01 to 2.44). There were no significant differences in BI score and final residence. Patients with moderate to severe stroke benefited most from the ESUS.

Conclusions— Stroke service based on treatment in a stroke unit combined with early supported discharge appears to improve the long-term clinical outcome compared with ordinary stroke unit care. Patients with moderate to severe stroke benefit most.