Economic consequences of early inpatient discharge to community-based rehabilitation for stroke in an inner-London teaching hospital

International depiction of the cost of functional independence limitations among older adults living in the community: a systematic review and cost-of-impairment study

BACKGROUND

Functional independence limitations restrict older adult self-sufficiency and can reduce quality of life. This systematic review and cost of impairment study examined the costs of functional independence limitations among community dwelling older adults to society, the health care system, and the person.

METHODS

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines this systematic review included community dwelling older adults aged 60 years and older with functional independence limitations. Databases (Cochrane Database of Systematic Reviews, EconLit, NHS EED, Embase, CINAHL, AgeLine, and MEDLINE) were searched between 1990 and June 2020. Two reviewers extracted information on study characteristics and cost outcomes including mean annual costs of functional independence limitations per person for each cost perspective (2020 US prices). Quality was assessed using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist.

RESULTS

85 studies were included. The mean annual total costs per person (2020 US prices) were: $27,380.74 (95% CI: [$4075.53, $50,685.96]) for societal, $24,195.52 (95% CI: [$9679.77, $38,711.27]) for health care system, and $7455.49 (95% CI: [$2271.45, $12,639.53]) for personal. Individuals with cognitive markers of functional independence limitations accounts for the largest mean costs per person across all perspectives. Variations across studies included: cost perspective, measures quantifying functional independence limitations, cost items reported, and time horizon.

CONCLUSIONS

This study sheds light on the importance of targeting cognitive markers of functional independence limitations as they accounted for the greatest costs across all economic perspectives.

A qualitative study of hospital and community providers’ experiences with digitalization to facilitate hospital-to-home transitions during the COVID-19 pandemic

Background

The COVID-19 pandemic has triggered substantial changes to the healthcare context, including the rapid adoption of digital health to facilitate hospital-to-home transitions. This study aimed to: i) explore the experiences of hospital and community providers with delivering transitional care during the COVID-19 pandemic; ii) understand how rapid digitalization in healthcare has helped or hindered hospital-to-home transitions during the COVID-19 pandemic; and, iii) explore expectations of which elements of technology use may be sustained post-pandemic.

Methods

Using a pragmatic qualitative descriptive approach, remote interviews with healthcare providers involved in hospital-to-home transitions in Ontario, Canada, were conducted. Interviews were analyzed using a team-based rapid qualitative analysis approach to generate timely results. Visual summary maps displaying key concepts/ideas were created for each interview and revised based on input from multiple team members. Maps that displayed similar concepts were then combined to create a final map, forming the themes and subthemes.

Results

Sixteen healthcare providers participated, of which 11 worked in a hospital, and five worked in a community setting. COVID-19 was reported to have profoundly impacted healthcare providers, patients, and their caregivers and influenced the communication processes. There were several noted opportunities for technology to support transitions.

Interpretation

Several challenges with technology use were highlighted, which could impact post-pandemic sustainability. However, the perceived opportunities for technology in supporting transitions indicate the need to investigate the optimal role of technology in the transition workflow.

Community-Based Rehabilitation Promotes the Functional Recovery of Patients After Intracerebral Hemorrhage

BACKGROUND

Intracerebral hemorrhage (ICH), a severe disorder with the high death rate, high recurrence rate and high disability rate, affected the quality of human life. Community-based rehabilitation (CBR) helps disabled people at both community and family levels. However, the effect of CBR on the recovery of people after ICH remains unclear.

METHODS

Patients were treated with the CBR training program, subsequently, medication compliance test, clinical neural impairment measurements, functional comprehensive assessments, improved Barthel index score, and life qualities assessments were to performed at 3-month or 6-month intervention of CBR to evaluate the influence of CBR on the medication compliance, physical function and life quality of patients after ICH.

RESULTS

After the treatment of CBR, we observed that, the rate of medication compliance, motor function, functional comprehensive rating scale score, modified Barthel index score, and generic quality of life inventory-74 in the CBR-treated group were significantly higher than that in the control group; the neural impairment measure score in the CBR-treated group was significantly decreased in comparison to the control group.

CONCLUSION

CBR increased the medication compliance, promoted the recovery of the neurological function and improved the life qualities of ICH patients.

Internet+Continuing Nursing (ICN) Program Promotes Motor Function Rehabilitation of Patients With Ischemic Stroke

BACKGROUND AND PURPOSE

Ischemic stroke is a severe disorder with high rates of death and recurrence that causes disability in patients and for which there is currently no effective treatment. Internet-based rehabilitation helps patients with disability recover at home with the help of their household or family members in a nonclinical setting. However, the effects of the internet+continuing nursing (ICN) program on the recovery of patients after ischemic stroke remains unknown.

METHODS

In the present study, patients were treated with an ICN-based rehabilitation training program; subsequently, the Self-efficacy Scale for Chronic Disease, Questionnaire of Exercise Adherence, Motor Assessment Scale, Activities of Daily Living, and Stroke-specific Quality of Life were performed to evaluate the effects of the ICN program on patient self-confidence to persist with rehabilitation, functional exercise compliance, motor function, ability to live independently and quality of life following ischemic stroke.

RESULTS

We observed that, after the ICN intervention for 6 weeks and 3 months, the scores of Self-efficacy Scale for Chronic Disease, Questionnaire of Exercise Adherence, Motor Assessment Scale, Activities of Daily Living, and Stroke-specific Quality of Life in the ICN-treated group were significantly higher compared with those in the control group.

CONCLUSION

These results suggested that the ICN program may promote the recovery of patients after ischemic stroke.

Renal dysfunction is associated with lower odds of home discharge for patients with stroke

OBJECTIVES

Studies on the association of estimated glomerular filtration rate (eGFR) levels with hospital discharge disposition after stroke are limited with inconsistent results. This study investigated the odds of home discharge with eGFR levels at admission for patients with stroke using the Taiwan Stroke Registry (TSR) data.

METHODS

From the TSR database, a total of 51,338 stroke patients from 2006 to 2015 were categorized into five groups based on eGFR levels at admission. The proportion of home discharge by the eGFR levels was calculated and logistic regression analysis was used to estimate the related odds ratio (OR) and 95% confidence interval.

RESULTS

Near 85% of stroke patients were discharged to home. The proportion of home discharges decreased as the eGFR level declined. Compared to patients with eGFR ≥90 mL/min/1.73 m², the adjusted ORs of home discharge were 0.91, 0.85, 0.63, 0.56 for patients with eGFR 60-89, eGFR 30-59, eGFR 15-29, and eGFR < 15 mL/min/1.73 m² or on dialysis, respectively, in a graded relationship. The trends were consistent in the ischemic stroke and hemorrhagic stroke patients. The areas under the receiver operating characteristic curve for all stroke patients, ischemic stroke patients, and hemorrhagic stroke patients were 0.801, 0799, 0.815, respectively.

CONCLUSION

The odds of home discharge for stroke patients decreased with a significant independent graded association with declining eGFR levels. Renal function could predict home discharge after stroke.

Costs and length of stay associated with early supported discharge for moderate and severe stroke survivors

GOAL

This study aimed to compare the length of stay, saved days and service costs associated with an early supported discharge model of care for mild, moderate and severe stroke survivors, to standard treatment.

MATERIALS AND METHODS

A two centre cohort study, employing a quasi-experimental design with a control group of convenience. Forty-four participants were recruited when they were deemed suitable for discharge home with intensive rehabilitation and services, with three dropouts from the treatment group (treatment n = 28, control n = 13). There were no significant differences between the groups for gender, age, Functional Independence Measure, Berg Balance Test and Modified Ranking Scale total scores at baseline. There were also no significant differences between the groups for subsequent readmissions or complications. Length of stay was measured by the days between admission and discharge from both inpatient and community services. Costs were measured by daily amounts calculated for this service.

FINDINGS

The treatment group spent significantly fewer days on the acute and inpatient rehabilitation wards, with over half avoiding subacute admission altogether. However, the control group spent significantly fewer days receiving intensive rehabilitation. The treatment group cost less on average per patient, but was not significantly different in terms of overall costs per admission.

CONCLUSION

Stroke survivors receiving an early supported discharge model of care spent fewer days in hospital, frequently avoided subacute admission and incurred less cost per patient than those receiving standard treatment. These findings indicate that early supported discharge reduces length of inpatient stay, for a similar cost to standard treatment.

Economic evaluation of a phase III international randomised controlled trial of very early mobilisation after stroke (AVERT)

OBJECTIVES

While very early mobilisation (VEM) intervention for stroke patients was shown not to be effective at 3 months, 12 month clinical and economical outcomes remain unknown. The aim was to assess cost-effectiveness of a VEM intervention within a phase III randomised controlled trial (RCT).

DESIGN

An economic evaluation alongside a RCT, and detailed resource use and cost analysis over 12 months post-acute stroke.

SETTING

Multi-country RCT involved 58 stroke centres.

PARTICIPANTS

2104 patients with acute stroke who were admitted to a stroke unit.

INTERVENTION

A very early rehabilitation intervention within 24 hours of stroke onset METHODS: Cost-utility analyses were undertaken according to pre-specified protocol measuring VEM against usual care (UC) based on 12 month outcomes. The analysis was conducted using both health sector and societal perspectives. Unit costs were sourced from participating countries. Details on resource use (both health and non-health) were sourced from cost case report form. Dichotomised modified Rankin Scale (mRS) scores (0 to 2 vs 3 to 6) and quality adjusted-life years (QALYs) were used to compare the treatment effect of VEM and UC. The base case analysis was performed on an intention-to-treat basis and 95% CI for cost and QALYs were estimated by bootstrapping. Sensitivity analysis were conducted to examine the robustness of base case results.

RESULTS

VEM and UC groups were comparable in the quantity of resource use and cost of each component. There were no differences in the probability of achieving a favourable mRS outcome (0.030, 95% CI -0.022 to 0.082), QALYs (0.013, 95% CI -0.041 to 0.016) and cost (AUD1082, 95% CI -$2520 to $4685 from a health sector perspective or AUD102, 95% CI -$6907 to $7111, from a societal perspective including productivity cost). Sensitivity analysis achieved results with mostly overlapped CIs.

CONCLUSIONS

VEM and UC were associated with comparable costs, mRS outcome and QALY gains at 12 months. Compared with to UC, VEM is unlikely to be cost-effective. The long-term data collection during the trial also informed resource use and cost of care post-acute stroke across five participating countries.

TRIAL REGISTRATION NUMBER

ACTRN12606000185561; Results.

Reablement services for people at risk of needing social care: the MoRe mixed-methods evaluation

Background

Reablement is an intensive, time-limited intervention for people at risk of needing social care or an increased intensity of care. Differing from home care, it seeks to restore functioning and self-care skills. In England, it is a core element of intermediate care. The existing evidence base is limited.

Objectives

To describe reablement services in England and develop a service model typology; to conduct a mixed-methods comparative evaluation of service models investigating outcomes, factors that have an impact on outcomes, costs and cost-effectiveness, and user and practitioner experiences; and to investigate specialist reablement services/practices for people with dementia.

Methods

Work package (WP) 1, which took place in 2015, surveyed reablement services in England. Data were collected on organisational characteristics, service delivery and practice, and service costs and caseload. WP2 was an observational study of three reablement services, each representing a different service model. Data were collected on health (EuroQol-5 Dimensions, five-level version) and social care related (Adult Social Care Outcomes Toolkit – self-completed) quality of life, practitioner (Barthel Index of Activities of Daily Living) and self-reported (Nottingham Extended Activities of Daily Living scale) functioning, individual and service characteristics, and resource use. They were collected on entry into reablement (n = 186), at discharge (n = 128) and, for those reaching the point on the study timeline, at 6 months post discharge (n = 64). Interviews with staff and service users explored experiences of delivering or receiving reablement and its perceived impacts. In WP3, staff in eight reablement services were interviewed to investigate their experiences of reabling people with dementia.

Results

A total of 201 services in 139 local authorities took part in the survey. Services varied in their organisational base, their relationship with other intermediate care services, their use of outsourced providers, their skill mix and the scope of their reablement input. These characteristics influenced aspects of service delivery and practice. The average cost per case was £1728. Lower than expected sample sizes meant that a comparison of service models in WP2 was not possible. The findings are preliminary. At discharge (T1), significant improvements in mean score on outcome measures, except self-reported functioning, were observed. Further improvements were observed at 6 months post discharge (T2), but these were significant for self-reported functioning only. There was some evidence that individual (e.g. engagement, mental health) and service (e.g. service structure) characteristics were associated with outcomes and resource use at T1. Staff’s views on factors affecting outcomes typically aligned with, or offered possible explanations for, these associations. However, it was not possible to establish the significance of these findings in terms of practice or commissioning decisions. Service users expressed satisfaction with reablement and identified two core impacts: regained independence and, during reablement, companionship. Staff participating in WP3 believed that people with dementia can benefit from reablement, but objectives may differ and expectations for regained independence may be inappropriate. Furthermore, staff believed that flexibility in practice (e.g. duration of home visits) should be incorporated into delivery models and adequate provision made for specialist training of staff.

Conclusions

The study contributes to our understanding of reablement, and what the impacts are on outcomes and costs. Staff believe that reablement can be appropriate for people with dementia. Findings will be of interest to commissioners and service managers. Future research should further investigate the factors that have an impact on outcomes, and reabling people with dementia.

Funding

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

From Hospital to Home to Participation: A Position Paper on Transition Planning Poststroke

Based on a review of the evidence, members of the American Congress of Rehabilitation Medicine Stroke Group's Movement Interventions Task Force offer these 5 recommendations to help improve transitions of care for patients and their caregivers: (1) improving communication processes; (2) using transition specialists; (3) implementing a patient-centered discharge checklist; (4) using standardized outcome measures; and (5) establishing partnerships with community wellness programs. Because of changes in health care policy, there are incentives to improve transitions during stroke rehabilitation. Although transition management programs often include multidisciplinary teams, medication management, caregiver education, and follow-up care management, there is a lack of a comprehensive and standardized approach to implement transition management protocols during poststroke rehabilitation. This article uses the Transitions of Care (TOC) model to conceptualize how to facilitate a comprehensive patient-centered hand off at discharge to maximize patient functioning and health. Specifically, this article reviews current guidelines and provides an evidence summary of several commonly cited approaches (Early Supported Discharge, planned predischarge home visits, discharge checklists) to manage TOC, followed by a description of documented barriers to effective transitions. Patient-centered and standardized transition management may improve community integration, activities of daily living performance, and quality of life for stroke survivors while also decreasing hospital readmission rates during the transition from hospital to home to community.

Hospital Discharge Disposition of Stroke Patients in Tennessee

OBJECTIVES

Early determination of hospital discharge disposition status at an acute admission is extremely important for stroke management and the eventual outcomes of patients with stroke. We investigated the hospital discharge disposition of patients with stroke residing in Tennessee and developed a predictive tool for clinical adoption. Our investigational aims were to evaluate the association of selected patient characteristics with hospital discharge disposition status and predict such status at the time of an acute stroke admission.

METHODS

We analyzed 127,581 records of patients with stroke hospitalized between 2010 and 2014. Logistic regression was used to generate odds ratios with 95% confidence intervals to examine the factor outcome association. An easy-to-use clinical predictive tool was built by using integer-based risk scores derived from coefficients of multivariable logistic regression.

RESULTS

Among the 127,581 records of patients with stroke, 86,114 (67.5%) indicated home discharge and 41,467 (32.5%) corresponded to facility discharge. All considered patient characteristics had significant correlations with hospital discharge disposition status. Patients were at greater odds of being discharged to another facility if they were women; older; black; patients with a subarachnoid or intracerebral hemorrhage; those with the comorbidities of diabetes mellitus, heart disease, hypertension, chronic kidney disease, arrhythmia, or depression; those transferred from another hospital; or patients with Medicare as the primary payer. A predictive tool had a discriminatory capability with area under the curve estimates of 0.737 and 0.724 for derivation and validation cohorts, respectively.

CONCLUSIONS

Our investigation revealed that the hospital discharge disposition pattern of patients with stroke in Tennessee was associated with the key patient characteristics of selected demographics, clinical indicators, and insurance status. These analyses resulted in the development of an easy-to-use predictive tool for early determination of hospital discharge disposition status.

Potential role of tele-rehabilitation to address barriers to implementation of physical therapy among West African stroke survivors: A cross-sectional survey

BACKGROUND

The greatest burden from stroke-related disability is borne by Low-and-Middle Income countries (LMICs) where access to rehabilitation after stroke is severely challenged. Tele-rehabilitation could be a viable avenue to address unmet rehabilitation needs in LMICs.

OBJECTIVES

To assess the burden of post-stroke physical deficits, rates of utilization of physiotherapy services, and perceptions of tele-rehabilitation among recent Ghanaian stroke survivors.

METHODS

Using a consecutive sampling strategy, 100 stroke survivors attending an outpatient Neurology clinic in a Ghanaian tertiary medical center were enrolled into this cross-sectional study. After collecting basic demographic data, clinical history on stroke type, severity and level of disability, we administered the validated 20-item Functional Independence Measure questionnaire to evaluate functional status of study participants and an 8-item questionnaire to assess participants' attitudes towards telemedicine administered rehabilitation intervention.

RESULTS

Mean±SD age of study participants was 57.2±13.3years of which 51.0% were males with a mean duration of stroke of 1.3±2.2years. 53% had Modified Rankin scores of ≥3, 57% were fully independent and only 27% reported utilizing any physiotherapy services. Barriers to access to physiotherapy included financial constraints due to cost of physiotherapy services and transportation as well as premature discharge from physiotherapy to avoid overburdening of available physiotherapy services. These factors led to the limited provision of rehabilitative therapy. Participants held positive views of the potential for tele-rehabilitation interventions (80-93%). However, while 85% owned mobile phones, only 35% had smart phones.

CONCLUSION

Despite, a high burden of residual disability, only about 1 out of 4 stroke patients in this Ghanaian cohort was exposed to post-stroke physiotherapy services, largely due to relatively high costs and limited health system resources. These Ghanaian stroke patients viewed the potential role of Tele-rehabilitation as positive, but this promising intervention needs to be formally tested for feasibility, efficacy and cost-effectiveness.

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.

Should There Be an Age Split for Stroke DRGs? Analysing a Large Clinical Data Set of a Principal Teaching Hospital over a Five-Year Period

The aim of this study was to analyse the inpatient statistics collection relating to stroke patients admitted to a major teaching hospital, with particular reference to length of stay, and to assess the adequacy of the diagnosis related group (DRG) as a predictor of length of stay. The study subjects were selected by DRG to identify all stroke inpatients admitted and discharged between 1 July 1995 and 30 June 2000. There were 1365 stroke discharges (half of whom were over 75 years of age at discharge) over the period of the study. The median length of stay was 8 days, and 67% of the subjects experienced complications and/or comorbidities. Age was significantly associated with increased length of stay of stroke patients, independent of complications or comorbidities.

These findings raise the question of whether casemix-based funding should be based solely on DRGs for complicated conditions such as stroke, or whether additional measures such as age should be used for funding allocation. This study provides a model that health information managers and other researchers could use to analyse inpatient statistics collections at state, territory or national levels.

Instruments for assessing the burden of informal caregiving for stroke patients in clinical practice: a comparison of CSI, CRA, SCQ and self-rated burden

Objective: To compare the feasibility, convergent and clinical validity of three commonly used burden scales: Caregiver Strain Index (CSI), Caregiver Reaction Assessment (CRA) and Sense of Competence Questionnaire (SCQ), with a self-developed single question on self-rated burden (SRB).

Subjects: Stroke patients receiving support from an informal caregiver ( n=148) and their caregivers were followed up to six months after stroke.

Intervention: Feasibility was assessed with several measures of missing values. Convergent validity was assessed on the basis of the correlation patterns between the burden scales, and clinical validity through evaluation of expected associations between levels of burden and explanatory patients' and caregivers' characteristics.

Results: Missing values were less often observed on CSI and SRB than SCQ and CRA. Significant correlation coefficients ( p<0.05) could be demonstrated between all burden scales, except for one subscale of CRA. Evidence for clinical validity was strongest for CSI and SRB, based on associations between higher burden scores and patients' disability, and patients' and caregivers' poor level of health-related quality of life (all p<0.05).

Conclusions: A concise and simple measure would facilitate early detection of caregivers at risk in clinical practice and research. CSI and SRB are more feasible and at least as valid instruments for assessment of caregiver burden in stroke than the longer and more complex SCQ and CRA. SRB could be used for quick screening of caregivers at risk. CSI is indicated for further diagnosis of the burden of informal caregivers.

Cost of post-stroke outpatient care in Malaysia

INTRODUCTION

This study aimed to investigate the direct cost of outpatient care for patients with stroke, as well as the relationship between the aforementioned cost and the sociodemographic and stroke characteristics of the patients.

METHODS

This was a cross-sectional study involving patients with first-ever stroke who were attending outpatient stroke rehabilitation, and their family members. Participants were interviewed using a structured questionnaire designed to obtain information regarding the cost of outpatient care. Stroke severity was measured using the National Institute of Health Stroke Scale.

RESULTS

This study comprised 49 patients (28 men, 21 women) with a mean age of 60.2 (range 35-80) years. The mean total cost incurred was USD 547.10 (range USD 53.50-4,591.60), of which 36.6% was spent on attendant care, 25.5% on medical aids, 15.1% on travel expenses, 14.1% on medical fees and 8.5% on out-of-pocket expenses. Stroke severity, age > 70 years and haemorrhagic stroke were associated with increased cost. The mean cost of attending outpatient therapy per patient was USD 17.50 per session (range USD 6.60-30.60), with travelling expenses (41.8%) forming the bulk of the cost, followed by medical fees (38.1%) and out-of-pocket expenses (10.9%). Multiple regression analysis showed that stroke severity was the main determinant of post-stroke outpatient care cost (p < 0.001).

CONCLUSION

Post-stroke outpatient care costs are significantly influenced by stroke severity. The cost of attendant care was the main cost incurred during the first three months after hospital discharge, while travelling expenses was the main cost incurred when attending outpatient stroke rehabilitation therapy.

Post-stroke care: an alternative model to reduce stroke related morbidity in sub-Saharan Africa

Stroke is a leading cause of death and disability in adults in sub-Saharan Africa (SSA). Despite its considerable burden, there has been limited progress to properly cater for and rehabilitate stroke survivors. Scarcity of rehabilitation services and grossly inadequate skilled personnel for post stroke care are distressing realities for stroke victims in SSA. There is growing evidence suggesting that home-based rehabilitation for stroke can have functional outcomes similar to patients who receive inpatient neuro-rehabilitation. The acute phase of treatment during hospitalization could be an opportunity to educate families and caregivers on how to care for stroke victims at home and provide home-based rehabilitation and care tailored to their disability. Interventions to vulgarize home-based post-stroke care could be more acceptable, affordable and accessible for victims and families. This could go a long way to palliate to the scarcity of rehabilitation services and reduce stroke related morbidity. We suggest that further research be carried out to ascertain the feasibility of this model in SSA settings, with greater emphasis on the cost effectiveness and sustainability arms of such an intervention.

Home-based tele-supervising rehabilitation for brain infarction patients (HTRBIP): study protocol for a randomized controlled trial

Background

With high morbidity, mortality and disability rate, brain infarction brings a huge economic and health burden to the whole society in China. Although some previous studies suggested that telerehabilitation may facilitate rehabilitation for stroke survivors at home, the evidence is insufficient for clinical application; additionally, as yet no trial evaluates efficacy of telerehabilitation for brain infarction patients. Therefore, more high quality trials are needed to provide practice evidence for this novel rehabilitation strategy.

Methods/Design

Based on recruitment criteria, this assessor blinded, paralleled randomized controlled trial will recruit 210 brain infarction patients. After being randomly allocated into two groups, participants will receive home-based tele-supervising rehabilitation or conventional rehabilitation. Outcome measurement will be conducted at the end of intervention and 90-day follow-up. Among which, Barthel index assessment will be considered as primary outcome measurement, secondary outcome measurements include NIHSS score, mRS score, 3-oz water swallow test and surface electromyography. Adverse events will also be recorded during the whole process of the trial for safety assessment.

Discussion

The HTRBIP trial will evaluate efficacy and safety of home-based tele-supervising rehabilitation for brain infarction patients. It is expected to provide new evidence for telerehabilitation application.

Trial registration

Registration date: 17 September 2014; Registration number: ChiCTR-TRC-14005233

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.

Does integrated governance lead to integrated patient care? Findings from the innovation forum

Good integration of services that aim to reduce avoidable acute hospital bed use by older people requires frontline staff to be aware of service options and access them in a timely manner. In three localities where closer inter-organisational integration was taking place, this research sought patients' perceptions of the care received across and within organisational boundaries. Between February and July 2008, qualitative methods were used to map the care journeys of 18 patients (six from each site). Patient interviews (46) covered care received before, at the time of and following a health crisis. Additional interviews (66) were undertaken with carers and frontline staff. Grounded theory-based approaches showed examples of well-integrated care against a background of underuse of services for preventing health crises and a reliance on 'traditional' referral patterns and services at the time of a health crisis. There was scope to raise both practitioner and patient awareness of alternative care options and to expand the availability and visibility of care 'closer to home' services such as rapid response teams. Concerns voiced by patients centred on the adequacy of arrangements for organising ongoing care, while family members reported being excluded from discussions about care arrangements and the roles they were expected to play. The coordination of care was also affected by communication difficulties between practitioners (particularly across organisational boundaries) and a lack of compatible technologies to facilitate information sharing. Finally, closer organisational integration seemed to have limited impact on care at the patient/practitioner interface. To improve care experienced by patients, organisational integration needs to be coupled with vertical integration within organisations to ensure that strategic goals influence the actions of frontline staff. As they experience the complete care journey, feedback from patients can play an important role in the service redesign agenda.

Approaches to economic evaluations of stroke rehabilitation

Many stroke rehabilitation services and interventions are complex in that they involve a number of components, interactions, and outcomes. Much of the onus of stroke care lies with rehabilitation services and because stroke rehabilitation is highly resource intensive, it is important for policy makers to consider the potential trade-offs between all relevant costs and benefits. The primary aim of this systematic review was to assess the methods used to conduct economic evaluations of stroke rehabilitation. Studies that compared two or more alternative stroke rehabilitation interventions or services with the costs and outcomes being examined for each alternative were included. EMBASE, MEDLINE In-Process, and National Health Service's Economic Evaluation Database were searched using search strategies. The methodological quality of the included studies was appraised using a checklist for the conduct and reporting of economic evaluations. Twenty-one studies met the selection criteria. The economic evaluations in the majority of these studies were inadequate based on their ability to identify, measure, and value all resources and benefits pertinent to the complexity of stroke rehabilitation. This study highlights that complex interventions such as stroke rehabilitation have widespread effects, which may not be represented by the changes on a single outcome. This study recommends the adoption of a wider cost and benefit perspective in the economic evaluations of complex interventions. It supports a move away from conventional economic evaluation and decision making, based purely on cost-effectiveness, toward multicriteria decision analysis frameworks for complex interventions, where a broader range of criteria may be assessed by policy makers.

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

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

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

Introduction

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

Methods

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

Results

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

Conclusions

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

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.

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.

Predictive factors for spasticity among ischemic stroke patients

Spasticity is a determining for functional loss following ischemic stroke. OBJECTIVE: To detect possible predictive factors for its occurrence. METHOD: Demographic, clinical and tomographic data on 146 stroke patients were analyzed. RESULTS: Spasticity was noted more frequently among patients who underwent physiotherapy (p<0.0001; OR=19.4; 95% CI: 4.4-84.5), those who underwent such treatment for long periods (p=0.028; OR=4.80; 95% CI: 1.1-8.3) and those with manual work (p=0.041; OR=2.2; 95% CI: 1.02-4.6), lower income (p=0.038), pain complaints (p<0.0001; OR=107.0; 95% CI: 13.5-847.3), appearance of pain at the same time as spasticity (p<0.0001), previous vascular disease (p=0.001; OR=4.2; 95% CI: 1.7-10.3), muscle weakness (p<0.0001; OR=91.9; 95% CI: 12.0-699.4), extensive lesions as seen on tomography (p=0.01) and lesions affecting more than one cerebral lobe (p=0.018). Manual work had a relative risk of 2.9; previous stroke 3.9, and extensive lesion 3.6. CONCLUSION: Spasticity affected 25% of the patients, and was associated with: manual work, previous stroke, extensive lesions, decrease in individual income, underwent physiotherapy, underwent physiotherapy for longer period, pain complaints, the pain started simultaneously with the spasticity, presented changes in strength.

Design and Usability of a Home Telerehabilitation System to Train Hand Recovery Following Stroke

Current theories of stroke rehabilitation point toward paradigms of intense concentrated use of the afflicted limb as a means for motor program reorganization and partial function restoration. A home-based system for stroke rehabilitation that trains recovery of hand function by a treatment of concentrated movement was developed and tested. A wearable goniometer measured finger and wrist motions in both hands. An interface box transmitted sensor measurements in real-time to a laptop computer. Stroke patients used joint motion to control the screen cursor in a one-dimensional tracking task for several hours a day over the course of 10–14 days to complete a treatment of 1800 tracking trials. A telemonitoring component enabled a therapist to check in with the patient by video phone to monitor progress, to motivate the patient, and to upload tracking data to a central file server. The system was designed for use at home by patients with no computer skills. The system was placed in the homes of 20 subjects with chronic stroke and impaired finger motion, ranging from 2–305 mi away from the clinic, plus one that was a distance of 1057 miles. Fifteen subjects installed the system at home themselves after instruction in the clinic, while nine required a home visit to install. Three required follow-up visits to fix equipment. A post-treatment telephone survey was conducted to assess ease of use and most responded that the system was easy to use. Functional improvements were seen in the subjects enrolled in the formal treatment study, although the treatment period was too short to trigger cortical reorganization. We conclude that the system is feasible for home use and that tracking training has promise as a treatment paradigm.

The effects of community-based rehabilitation on stroke patients in China: a single-blind, randomized controlled multicentre trial

OBJECTIVE

To evaluate the effects of community-based rehabilitation therapy on neurological function deficit in stroke patients.

DESIGN

Prospective, single-blind, randomized controlled multicentre trial.

SETTING

At home, in Shanghai, China.

SUBJECTS

A total of 737 stroke patients in the community.

INTERVENTION

The rehabilitation group received additional standardized community-based rehabilitation therapy at home for five months.

MAIN OUTCOME MEASURES

Patients were evaluated using the Clinical Neurological Function Deficit Scale before intervention and at the end of two and five months.

RESULTS

Although both the rehabilitation group and the control group improved over time, the rehabilitation group showed a greater improvement in Clinical Neurological Function Deficit Scale scores. The differences between the groups were significant. After five months, the Clinical Neurological Function Deficit Scale scores of the cerebral infarction rehabilitation group improved by 6.77; the haemorrhage rehabilitation group by 7.99; the total rehabilitation group by 7.03. In comparison, the Clinical Neurological Function Deficit Scale scores of the cerebral infarction control group improved by 1.57; the haemorrhage control group by 5.34; the total control group by 2.43. This implies a difference in improvement of 5.2 in the cerebral infarction group, 2.65 in the haemorrhage group, and 4.6 in the total group in favour of the rehabilitation group between groups.

CONCLUSION

Standardized community-based rehabilitation therapy may help stroke patients to improve their neurological function.

[Needs of the family caregivers of stroke survivors in the home: structured review of the literature from 2000 to 2007]

OBJECTIVE

To perform a structured review of the literature from 2000 to 2007 on the needs of the caregivers of stroke survivors in the postacute phase of the illness process at home.

METHODS

Searches were conducted in the CINAHL, MEDLINE, EMBASE, PSYCHINFO, Cochrane Library Plus, CDSR (coch), DARE, CCTR, ACP Journal Club (ACP), IBECS, LILACS and IME databases using the terms "stroke", "caregiver" and "needs (assessment)".

RESULTS

We selected 270 abstracts for review. Of these, only 53 met the inclusion criteria and just 12 achieved preestablished quality standards. Despite wide variability among the selected studies, the literature reviewed revealed that the two most prevalent needs for the caregivers of stroke survivors were information and support in the development of caregiving skills. Care for the caregiver herself, as well as the development and provision of support services, were defined as the two main areas where these participants seem to need support while adapting to and performing this newly adopted role.

CONCLUSIONS

The studies reviewed show an increasing demand for support and care for stroke survivors' caregivers. Because of the highly diverse contexts of these studies, the lack of an explicit definition on the concept of "need", and the wide heterogeneity in caregivers' situations, summarizing the results of these studies is difficult. New studies are required in our context that take these limitations into account and try to overcome them.

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.

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.

Determinants of variation in the cost of inpatient stays versus outpatient visits in hospitals: A multi-country analysis

Information on hospital costs is key to many types of economic and financial analyses, yet many countries lack reliable estimates due partly to the time and resources required to undertake detailed costing studies. Accordingly, some analysts have used simple rules of thumb to estimate hospital unit costs, e.g., total hospital costs are allocated between departments assuming that the cost of an inpatient day equals a fixed number of outpatient visits. This paper first explores the extent to which these simple rules apply within and across countries. It then identifies determinants of variation in the relationship between the cost of outpatient visits and inpatient days, then uses the estimated relationship to calculate average costs of inpatient and outpatient stays for countries where data are not yet available. Cost information from 832 hospitals in 28 countries are used. We show that simple rules of thumb do not prove to be an accurate basis for cost estimates. The ratio of inpatient to outpatient unit costs varies with GDP per capita, hospital size, ownership, and occupancy rate. We show how the estimated relationship can be used to calculate a mean cost of inpatient stays and outpatient visits, taking into account differences in the levels of key determinants, and argue that, in the absence of a representative sample of hospital costing studies, this method can be used to estimate unit costs in the interim. Moreover, we suggest that the observed great variation in unit costs for similar hospitals in the same country means that this method might well be preferable to basing policy advice on the results of costing studies that cover only one, or a few hospitals, which might well be outliers.

Early Supported Discharge and Continued Rehabilitation at Home After Stroke: 5-Year Follow-up of Resource Use

BACKGROUND

Early supported discharge (ESD) with continued rehabilitation at home has shown a beneficial effect on extended activities of daily living 5 years after stroke. The long-term effect of ESD on resource use has not been explored.

METHODS

At 5 years, 54 patients with mild to moderate disability, enrolled in a randomized controlled trial of ESD, were followed up. Data were collected from a county register and by interviewing the patient or the patient's spouse.

RESULTS

There were differences in mean length of hospitalization, 51 versus 32 days (P = .02). There was no significant difference between the groups in regard to total outpatient rehabilitation, ESD visits included, but there was a difference in where the services were obtained. The ESD group had more rehabilitation at home (ESD service) and the control group had more outpatient rehabilitation (P = .04), including physiotherapy in primary care (P = .05). There were no other differences.

CONCLUSION

We conclude that, 5 years after stroke, our ESD service was favorable with regard to resource use.

Thai Stroke Patient Caregivers: Who They Are and What They Need

BACKGROUND AND PURPOSES

Primary informal caregivers play a significant role in providing care to stroke survivors after having been discharged from the hospital. Our aims were to describe the characteristics of Thai stroke caregivers and to explore their needs while providing care to their stroke relatives.

METHODS

Using open-ended questions, we individually interviewed 20 caregivers of stroke survivors to identify their characteristics and their own needs. Additional field notes were made during all interviews.

RESULTS

Our findings revealed that the majority of Thai informal stroke caregivers in this study were female, mostly daughters, with the exception of 2 Thai primary stroke caregivers found to be nieces. The majority of caregivers provided care to their stroke relatives 24 h per day. The four major categories of informal rehabilitation were: physical, psychological, social, and spiritual rehabilitation activities. Assistance, information and social support were the three main needs of the caregivers.

CONCLUSION

Based on these findings, appropriate nursing information and assistance focusing on rehabilitation and stroke caregivers' needs should be provided to Thai stroke caregivers performing informal care to ensure that both patients and caregivers have the best possible quality of life.

Cost-effectiveness of losartan-based therapy in patients with hypertension and left ventricular hypertrophy: a UK-based economic evaluation of the Losartan Intervention For Endpoint reduction in hypertension (LIFE) study

The Losartan Intervention for Endpoint reduction in hypertension (LIFE) study demonstrated the clinical benefit of losartan-based therapy in hypertensive patients with left ventricular hypertrophy (LVH), mainly due to a highly significant 25% reduction in the relative risk of stroke compared with an atenolol-based regimen, for a similar reduction in blood pressure. The aim of this economic evaluation was to estimate the cost-effectiveness of losartan compared with atenolol from a UK national health system perspective. Quality-adjusted survival and direct medical costs were modelled beyond the trial using the within-trial incidence of stroke. Survival with stroke, study medication use and quality of life by stroke status were taken directly from the LIFE trial. The LIFE data were supplemented with UK data on lifetime direct medical costs of stroke and life expectancy in individuals without stroke. No additional stroke events or use of study treatment were assumed beyond the trial. Costs and benefits were discounted using current UK Treasury rates. In the base-case analysis, the reduction in stroke-related costs (by 968 sterling pound) offset 86% of the increase in study medication costs (1128 sterling pound) among losartan-treated patients. The incremental cost-effectiveness ratio (ICER) for losartan versus atenolol in hypertensive patients with LVH was 2130 sterling pound per quality-adjusted life year (QALY) gained (3195 Euro/QALY), and this increased to 11,352 sterling pound per QALY gained (16,450 Euro/QALY) when the costs of stroke beyond the first 5 years were excluded. Thus, the clinical benefit of losartan was achieved at a cost well within reported thresholds for cost-effectiveness.

Hospital at home versus in-patient hospital care

BACKGROUND

Hospital at home is defined as a service that provides active treatment by health care professionals, in the patient's home, of a condition that otherwise would require acute hospital in-patient care, always for a limited period.

OBJECTIVES

To assess the effects of hospital at home compared with in-patient hospital care.

SEARCH STRATEGY

We searched the Cochrane Effective Practice and Organisation of Care Group (EPOC) specialised register (November 2004), MEDLINE (1966 to 1996), EMBASE (1980 to 1995), Social Science Citation Index (1992 to 1995), Cinahl (1982 to 1996), EconLit (1969 to 1996), PsycLit (1987 to 1996), Sigle (1980 to 1995) and the Medical Care supplement on economic literature (1970 to 1990).

SELECTION CRITERIA

Randomised trials of hospital at home care compared with acute hospital in-patient care. The participants were patients aged 18 years and over.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data and assessed study quality.

MAIN RESULTS

Twenty two trials are included in this update of the review. Among trials evaluating early discharge hospital at home schemes we found an odds ratio (OR) for mortality of 1.79 95% CI 0.85 to 3.76 for elderly medical patients (age 65 years and over) (n = 3 trials); OR 0.58; 95% CI 0.29 to 1.17 for patients with chronic obstructive pulmonary disease (COPD) (n = 5 trials); and OR 0.78; 95%CI 0.52 to 1.19 for patients recovering from a stroke (n = 4 trials). Two trials evaluating the early discharge of patients recovering from surgery reported an OR 0.43 (95% CI 0.02 to 10.89) for patients recovering from a hip replacement and an OR 1.01 (95% CI 0.37 to 2.81) for patients with a mix of conditions at three months follow-up. For readmission to hospital we found an OR 1.76; 95% CI 0.78 to 3.99 at 3 months follow-up for elderly medical patients (n = 2 trials); OR 0.81; 95% CI 0.55 to 1.19 for patients with COPD (n = 5 trials); and OR 0.96; 95% CI 0.63 to 1.45 for patients recovering from a stroke (n = 3 trials). No significant heterogeneity was observed. One trial recruiting patients following surgery for hernia or varicose veins reported 0/117 versus 2/121 patients were re admitted (Ruckley 1978); another that 2/37 (5%) versus 1/49 (2%) (difference 3%, 95% CI -5% to 12%) of patients recovering from a hip replacement, 4/47 (9%) versus 1/39 (3%) (difference 6%, 95% CI -3% to 15%) of patients recovering from a knee replacement, and 7/114 (6%) versus 13/124 (10%) (difference -4% 95% CI -11% to 3%) of patients recovering from a hysterectomy were readmitted. A third trial analysing surgical and medical patients together reported that 42/159 versus 17/81 patients were readmitted at 3 months (OR 1.34 95% CI 0.66 to 2.20). Allocation to hospital at home resulted in a small reduction in hospital length of stay, but hospital at home increased overall length of care. Patients allocated to hospital at home expressed greater satisfaction with care than those in hospital, while the view of carers was mixed.

AUTHORS' CONCLUSIONS

Despite increasing interest in the potential of hospital at home services as a cheaper alternative to in-patient care, this review provides insufficient objective evidence of economic benefit. Early discharge schemes for patients recovering from elective surgery and elderly patients with a medical condition may have a place in reducing the pressure on acute hospital beds, providing the views of the carers are taken into account. For these clinical groups hospital length of stay is reduced, although this is offset by the provision of hospital at home. Future primary research should focus on rigorous evaluations of admission avoidance schemes and standards for original research should aim at assisting future meta-analyses of individual patient data from these and future trials.

Costs of a home-based rehabilitation program for older adults after lower limb orthopedic surgery: a pilot study

Little is known about the cost of home-based rehabilitation programs in Quebec, Canada. The objective of this pilot project was to test a cost estimation methodology in the context of rehabilitation services delivered at home and to provide preliminary data on the costs for lower limb orthopedic surgery patients. This pilot study examined a short-term home care program for adults, aged 65 and over who returned home after lower limb surgery and required rehabilitation services. Efficacy was determined as the functional autonomy changes between admission and discharge from home rehabilitation program, as measured by the functional autonomy measurement system (SMAF). Costs of professionals, including direct and indirect time related to the intervention, were also determined in order to document cost-effectiveness of the program. Eighteen subjects were recruited. From those, 14 had complete data available for the analysis. The result shows that costs related to the combined natural improvement and the effect of the home-based rehabilitation program were CAN dollars 419 per unit of change of functional autonomy. The results of this pilot study confirm the feasibility of the cost estimation methodology for a home-based rehabilitation program.

Early supported discharge for stroke patients improves clinical outcome. Does it also reduce use of health services and costs? One-year follow-up of a randomized controlled trial

BACKGROUND

An early supported discharge service (ESD) appears to be a promising alternative to conventional care. The aim of this trial was to compare the use of health services and costs with traditional stroke care during a one-year follow-up.

METHODS

Three hundred and twenty patients were randomly allocated either to ordinary stroke unit care or stroke unit care combined with ESD which was coordinated by a mobile team. The use of all health services was recorded prospectively; its costs were measured as service costs and represent a combination of calculated average costs and tariffs. Hospital expenses were measured as costs per inpatient day and adjusted for the DRG.

RESULTS

There was a reduction in average number of inpatient days at 52 weeks in favour of the ESD group (p = 0.012), and a non-significant reduction in total mean service costs in the ESD group (EUR 18,937/EUR 21,824). ESD service seems to be most cost-effective for patients with a moderate stroke.

CONCLUSION

Acute stroke unit care combined with an ESD programme may reduce the length of institutional stay without increasing the costs of outpatient rehabilitation compared with traditional stroke care.

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.

Care needs and economic consequences after acute ischemic stroke: the Erlangen Stroke Project

The objective was to determine the functional outcome, location of care and economic consequences in the first 3 months after ischemic stroke. As part of the Erlangen Stroke Project, (ESPro) information was collected on patients suffering a first-ever ischemic stroke. Three months after the stroke, location of care, dependence on caregivers and function based on Barthel Index: poor (0-55), moderate (60-90) or good function (95-100) were recorded. Data about health services used were combined with cost estimates for Germany (2000 Euros, undiscounted). Of 491 patients hospitalized, 383 were alive 3 months afterwards, 79% residing in the community. The majority of patients with poor function (60%) were still in institutional care. Patients with good function typically accrued the lowest costs, whether in an institution (17 965) or not (11 032) compared with poorer function who were living in an institution (poor: 26 370; moderate: 28,121), or community (poor: 27,207; moderate: 19,350). Hospitalization and rehabilitation services were the major costs accrued at each level of function. Many patients were left requiring a substantial amount of care and the costs associated with providing institutional care has a major impact on the economic consequences of a stroke.

Systematic review of economic evidence on stroke rehabilitation services

Objectives: Given the resource-intensive nature of stroke rehabilitation, it is important that services be delivered in an evidence-based and cost-efficient manner. The objective of this review was to assess the evidence on the relative cost or cost-effectiveness of three rehabilitation services after stroke: stroke unit care versus care on another hospital ward, early supported discharge (ESD) services versus “usual care,” and community or home-based rehabilitation versus “usual care.”

Methods:A systematic literature review of cost analyses or economic evaluations was performed. Study characteristics and results (including mean total cost per patient) were summarized. The level of evidence concerning relative cost or cost-effectiveness for each service type was determined qualitatively.

Results:Fifteen studies met the inclusion criteria: three on stroke unit care, eight on ESD services, and four on community-based rehabilitation. All were classified as cost-consequences analysis or cost analysis. The time horizon was generally short (1 year or less). The comparators and the scope of costs varied between studies.

Conclusions:There was “some” evidence that the mean total cost per patient of rehabilitation in a stroke unit is comparable to care provided in another hospital ward. There is “moderate” evidence that ESD services provide care at modestly lower total costs than usual care for stroke patients with mild or moderate disability. There was “insufficient” evidence concerning the cost of community-based rehabilitation compared with usual care. Several methodological problems were encountered when analyzing the economic evidence.

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.