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Meta-Analysis
. 2017 Jul 13;7(7):CD000443.
doi: 10.1002/14651858.CD000443.pub4.

Early supported discharge services for people with acute stroke

Peter Langhorne  1 , Satu Baylan; Early Supported Discharge Trialists
Affiliations
Meta-Analysis

Early supported discharge services for people with acute stroke

Peter Langhorne et al. Cochrane Database Syst Rev. .

Abstract

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 In an effort to identify further published, unpublished, and ongoing trials we searched six trial registries (March 2017).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.

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Conflict of interest statement

Peter Langhorne co‐authored one trial and the ESD trialists conducted the original randomised trials (see 'Potential biases in the review process'). Otherwise no relevant conflicts are known for Peter Langhorne and Satu Baylan.

Figures

1
1
Flow diagram illustrating the results of the updated searches
2
2
'Risk of bias' graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
3
3
'Risk of bias' summary: review authors' judgements about each risk of bias item for each included study.
1.1
1.1. Analysis
Comparison 1 Early supported discharge service versus conventional care: patient outcomes, Outcome 1 Death.
1.2
1.2. Analysis
Comparison 1 Early supported discharge service versus conventional care: patient outcomes, Outcome 2 Death or requiring institutional care.
1.3
1.3. Analysis
Comparison 1 Early supported discharge service versus conventional care: patient outcomes, Outcome 3 Death or dependency.
1.4
1.4. Analysis
Comparison 1 Early supported discharge service versus conventional care: patient outcomes, Outcome 4 Activities of daily living (Barthel ADL) score.
1.5
1.5. Analysis
Comparison 1 Early supported discharge service versus conventional care: patient outcomes, Outcome 5 Extended activities of daily living (EADL) score.
1.6
1.6. Analysis
Comparison 1 Early supported discharge service versus conventional care: patient outcomes, Outcome 6 Subjective health status.
1.7
1.7. Analysis
Comparison 1 Early supported discharge service versus conventional care: patient outcomes, Outcome 7 Mood status.
1.8
1.8. Analysis
Comparison 1 Early supported discharge service versus conventional care: patient outcomes, Outcome 8 Satisfaction with services.
2.1
2.1. Analysis
Comparison 2 Early supported discharge service versus conventional care: duration of follow‐up, Outcome 1 Death or dependency: within 6 months.
2.2
2.2. Analysis
Comparison 2 Early supported discharge service versus conventional care: duration of follow‐up, Outcome 2 Death or dependency: at 6 to 12 months.
2.3
2.3. Analysis
Comparison 2 Early supported discharge service versus conventional care: duration of follow‐up, Outcome 3 Death or dependency: within 5 years.
3.1
3.1. Analysis
Comparison 3 Early supported discharge service versus conventional care: carer outcomes, Outcome 1 Subjective health status.
3.2
3.2. Analysis
Comparison 3 Early supported discharge service versus conventional care: carer outcomes, Outcome 2 Mood status.
3.3
3.3. Analysis
Comparison 3 Early supported discharge service versus conventional care: carer outcomes, Outcome 3 Satisfaction with services.
4.1
4.1. Analysis
Comparison 4 Early supported discharge service versus conventional care: resource use, Outcome 1 Length of initial hospital stay (days).
4.2
4.2. Analysis
Comparison 4 Early supported discharge service versus conventional care: resource use, Outcome 2 Readmission to hospital.
5.1
5.1. Analysis
Comparison 5 Early supported discharge service versus conventional care: age subgroups, Outcome 1 Death or dependency.
5.2
5.2. Analysis
Comparison 5 Early supported discharge service versus conventional care: age subgroups, Outcome 2 Length of stay (days).
6.1
6.1. Analysis
Comparison 6 Early supported discharge service versus conventional care: gender subgroups, Outcome 1 Death or dependency.
6.2
6.2. Analysis
Comparison 6 Early supported discharge service versus conventional care: gender subgroups, Outcome 2 Length of stay (days).
7.1
7.1. Analysis
Comparison 7 Early supported discharge service versus conventional care: stroke severity subgroups, Outcome 1 Death or dependency.
7.2
7.2. Analysis
Comparison 7 Early supported discharge service versus conventional care: stroke severity subgroups, Outcome 2 Length of stay (days).
8.1
8.1. Analysis
Comparison 8 Early supported discharge service versus conventional care: carer subgroups, Outcome 1 Death or dependency.
8.2
8.2. Analysis
Comparison 8 Early supported discharge service versus conventional care: carer subgroups, Outcome 2 Length of stay (days).
9.1
9.1. Analysis
Comparison 9 Early supported discharge service versus conventional care: conventional service subgroups, Outcome 1 Death or dependency.
9.2
9.2. Analysis
Comparison 9 Early supported discharge service versus conventional care: conventional service subgroups, Outcome 2 Length of stay (days).
10.1
10.1. Analysis
Comparison 10 Early supported discharge service versus conventional care: ESD service subgroups: service base, Outcome 1 Death or dependency.
10.2
10.2. Analysis
Comparison 10 Early supported discharge service versus conventional care: ESD service subgroups: service base, Outcome 2 Length of stay (days).
11.1
11.1. Analysis
Comparison 11 Early supported discharge service versus conventional care: ESD service subgroups: MDT co‐ordination, Outcome 1 Death.
11.2
11.2. Analysis
Comparison 11 Early supported discharge service versus conventional care: ESD service subgroups: MDT co‐ordination, Outcome 2 Death or requiring institutional care.
11.3
11.3. Analysis
Comparison 11 Early supported discharge service versus conventional care: ESD service subgroups: MDT co‐ordination, Outcome 3 Death or dependency.
11.4
11.4. Analysis
Comparison 11 Early supported discharge service versus conventional care: ESD service subgroups: MDT co‐ordination, Outcome 4 Length of stay (days).
See this image and copyright information in PMC

Update of

References

References to studies included in this review

Adelaide 2000 {published and unpublished data}
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Adelaide 2016 {published data only}
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Aveiro 2016 {unpublished data only}
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Bangkok 2002 {published data only}
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Bergen 2014 {unpublished data only}
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Bergen 2014 ‐ Day unit {published data only}
    1. Hofstad H, Gjelsvik BEB, Næss H, Eide GE, Skouen JS. Early supported discharge after stroke in Bergen (ESD Stroke Bergen): three and six months results of a randomised controlled trial comparing two early supported discharge schemes with treatment as usual. BMC Neurology 2014;14:239. - PMC - PubMed
Bergen 2014 ‐ Home care {published data only}
    1. Hofstad H, Gjelsvik BEB, Næss H, Eide GE, Skouen JS. Early supported discharge after stroke in Bergen (ESD Stroke Bergen): three and six months results of a randomised controlled trial comparing two early supported discharge schemes with treatment as usual. BMC Neurology 2014;14:239. - PMC - PubMed
Copenhagen 2009 {unpublished data only}
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London 1997 {published data only}
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Manchester 2001 {unpublished data only}
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Montreal 2000 {unpublished data only}
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Newcastle 1997 {published data only (unpublished sought but not used)}
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Oslo 2000 {published and unpublished data}
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Stockholm 1998 {published and unpublished data}
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Trondheim 2000 {published and unpublished data}
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Trondheim 2004 {published and unpublished data}
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References to studies excluded from this review

Asplund 2000 {published data only}
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Auckland 1999 {unpublished data only}
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Ayrshire 2000 {unpublished data only}
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Challis 1991 {published data only}
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Cumbria 2004 {unpublished data only}
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Donald 1995 {published data only}
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Dunn 1994 {published data only}
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EXTRAS {published data only}
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Gladman 2001 {published data only}
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Glostrup 2006 {published and unpublished data}
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Grasel 2005 {published data only}
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Hirano 2012 {published data only}
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LHEC 1997 {published data only}
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Lincoln 2004 {published data only}
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Mackay 1995 {published data only}
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Martin 1994 {published data only}
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Ricauda 2004 {published data only}
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Victor 1988 {published data only}
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References to studies awaiting assessment

Shi 2014 {published data only}
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Tian 2015 {published data only}
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References to ongoing studies

ATTEND {published data only}
    1. Alim M, Lindley R, Felix C, Gandhi DBC, Verma SJ, Tugnawat DK, et al. Family‐led rehabilitation after stroke in India: The ATTEND trial, study protocol for a randomized controlled trial. Trials 2016; Vol. 17:13. [DOI: 10.1186/s13063-015-1129-8] - DOI - PMC - PubMed
    1. Billot L, Lindley RI, Harvey LA, Maulik PK, Hackett ML, Murthy GVS, et al. Statistical analysis plan for the family‐led rehabilitation after stroke in India (ATTEND) trial: A multicenter randomized controlled trial of a new model of stroke rehabilitation compared to usual care. International Journal of Stroke 2016. [DOI: 10.1177/1747493016674956] - DOI - PubMed
    1. Felix C, Pandian JD, Alim M, Gandhi DBC, Syrigapu A, Tugnawat DK, et al. Family‐led rehabilitation after stroke in India: ATTEND trial. Proceedings of the International Stroke Conference 2015. 11‐13 February 2015; Nashville, Tennesee, USA. (Abst. CT P26). 2015.
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Care4Stroke {published data only}
    1. Vloothuis J, Mulder M, Nijland RHM, Konijnenbelt M, Mulder H, Hertogh CMPM, et al. Caregiver‐mediated exercises with e‐healthsupport for early supported discharge after stroke (CARE4STROKE): study protocol for a randomized controlled trial. BMC Neurology 2015;15:193. - PMC - PubMed
Gothenburg {published data only}
    1. Sunnerhagen KS, Danielsson A, Rafsten L, Bjorkdahl A, Axelsson AB, Nordin A, et al. Gothenburg very early supported discharge study (GOTVED) NCT01622205: a block randomized trial with superiority design of very early supported discharge for patients with stroke. BMC Neurology 2013;13:66. - PMC - PubMed
    1. Sunnerhagen KT. GOThenburg Very Early Supported Discharged (GOTVED). ClinicalTrials.gov 2012; Vol. [http://www.ClinicalTrials.gov].
Hong Kong {unpublished data only}
    1. Patient Engagement Program for Stroke (PEPS). Ongoing study May 2010.
Perth {unpublished data only}
    1. Jones R. Establishing an effective and efficient early supported discharge (ESD) rehabilitation program for stroke patients in Perth WA. Australian New Zealand Clinical Trials Registry (ANZCTR) 2011, issue [http://www.anzctr.org.au/].
RECOVER {published data only}
    1. Yan LL. Randomized controlled trial on rehabilitation through caregiver‐delivered nurse‐organised service programs for disabled stroke patients in rural China (RECOVER). George Institute for Global Health Neurological and Mental Health. 2016, issue http://www.georgeinstitute.org/units/neurological‐and‐mental‐health. - PubMed
    1. Yan LL. Rehabilitation for disabled stroke patients in rural China (RECOVER). ClinicalTrials.gov 2016; Vol. [http://www.ClinicalTrials.gov].
    1. Yan LL, Chen S, Zhou B, Zhang J, Xie B, Luo R, et al. A randomized controlled trial on rehabilitation through caregiver‐derived nurse‐organized service programs for disabled stroke patients in rural China (the RECOVER trial): design and rationale. International Journal of Stroke 2016;11(7):823‐30. - PubMed
West Denmark {unpublished data only}
    1. RCTComputer‐generated blocks of 10, opaque sealed envelopes. Ongoing study 2009.

Additional references

ESO 2008
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References to other published versions of this review

EDS Trialists 2001
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ESD trialists 2005
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