Comparison of short (3-day) hospitalization followed by home care treatment and conventional (10-day) hospitalization for acute ischemic stroke. A randomized controlled trial of rehabilitation at home after stroke in southwest Stockholm. Outcome of subacute stroke rehabilitation: a randomized controlled trial. Benefit of an extended stroke unit service with early supported discharge: A randomized, controlled trial. There's no place like home : an evaluation of early supported discharge for stroke. Home or hospital for stroke rehabilitation? results of a randomized controlled trial : I: health outcomes at 6 months. Randomised controlled trial to evaluate early discharge scheme for patients with stroke. Early supported discharge of patients with acute stroke: a randomized controlled trial. Randomized controlled trial of an early discharge rehabilitation service: the Belfast Community Stroke Trial. Model of hospital-supported discharge after stroke. Early supported hospital discharge following acute stroke: pilot study results. Evaluation of an extended stroke unit service with early supported discharge for patients living in a rural community. A randomized controlled trial.
This prospective randomized controlled study was designed to compare the treatment efficacy, safety and quality of life of ischemic stroke patients treated with conventional (10-day) hospitalization or short (3-day) hospitalization followed by home care treatment. One hundred and two patients with acute ischemic stroke who arrived within 48 h after symptom onset and met the inclusion criteria were studied. Patients were randomly assigned to either of two groups of treatment. Patients in the 'hospitalization' group were hospitalized for 10 days, whereas those in the 'home care' group were admitted only for the first 3 days and were followed at home under the home care program. The baseline characteristics were similar in the two groups. There was no difference in the number of deaths or dependency defined by the Modified Rankin scale more than or equal to 3 between the two groups at 6 months. The relative risk was 0.85 with a 95% confidence interval between 0.35 and 2.04. There was also no difference in the number of patients who had good outcome (NIHSS between 0 and 2 and Barthel index between 75 and 100) at 6 months. One patient in the home care group died due to massive intracerebral hemorrhage. Seventy-nine percent of patients in the home care group were satisfied with the home treatment program.
                Copyright 2002 S. Karger AG, Basel This study describes the methodology, patient outcome, and use of hospital and rehabilitation services at 3 months of a population-based randomized controlled trial. The purpose was to evaluate rehabilitation at home after early supported discharge from the Department of Neurology, Huddinge Hospital, for moderately disabled stroke patients in southwest Stockholm.
                The patients were eligible if they were continent, independent in feeding, had mental function within normal limits, and had impaired motor function and/or aphasia 1 week after stroke. Patients were randomized either to early supported discharge with continuity of rehabilitation at home for 3 to 4 months or to routine rehabilitation service in a hospital, day care, and/or outpatient care. The home rehabilitation team consisted of two physical therapists, two occupational therapists, and one speech therapist; one of the therapists was assigned as case manager for the patient. The rehabilitation program at home emphasized a task- and context-oriented approach. The activities were chosen on the basis of the patient's personal interests. Spouses were offered education and individual counseling. A total of 81 patients were followed up for a minimum of 3 months. Patient outcome was assessed by the Frenchay Social Activity Index, Extended Katz Index, Barthel Index, Lindmark Motor Capacity Assessment, Nine-Hole Peg Test, walking speed over 10 m, reported falls, and subjective dysfunction according to the Sickness Impact Profile. Patient use of hospital and home rehabilitation service and patient satisfaction with care were studied.
                Overall there were no statistical significant differences in outcome. Multivariate logistic regression analysis suggested a systematic positive effect for the home rehabilitation group in social activity, activities of daily living, motor capacity, manual dexterity, and walking. A considerable difference in resource use during such a 3-month period was seen. A 52% reduction in hospitalization was observed: from 29 days in the routine rehabilitation group to 14 days in the home rehabilitation group. Patient satisfaction was in favor of the latter group.
                Early supported discharge with continuity of home rehabilitation services for the majority of moderately disabled stroke patients during the first 3-month period after acute stroke is not less beneficial than routine rehabilitation and can be a rehabilitation service of choice if follow-up at 6 and 12 months confirms the suggested effectiveness and considerable reduction in use of health care. Organized acute stroke treatment reduces mortality, functional deficits, and the need of institutionalization after stroke. It is largely unknown whether the effects of treatment are due to early or subacute efforts. The aim of this randomized, controlled study was to test the hypothesis that rehabilitation of stroke patients in the subacute phase in a hospital rehabilitation unit is beneficial in reducing death and dependency and increasing health-related quality of life.
                251 patients initially treated in the hospital were randomized to subacute rehabilitation in a hospital rehabilitation unit (n = 127) or to the health services in the municipality (n = 124) and were followed up for 7 months.
                The combined outcome of patients being dead or dependent (Barthel Index score of < 75) was 23% in the hospital group and 38% in the municipality group (P=.01). Seven-month survival rates were 90.6% and 83.9% (P=.11), respectively. Dependency in activities of daily living was 12.6% in the hospital group and 25.0% in the municipality group (P=.07). Patients with a BI score of < 50 before rehabilitation had significantly better outcome in the hospital rehabilitation unit, with fewer patients becoming dependent (P=.005) and patients having higher Scandinavian Stroke Scale (P=.026) and BI scores (P=.005). No significant differences in health-related quality of life were found. Many patients treated in the municipalities (30%) did not receive any organized rehabilitation in this study.
                Subacute rehabilitation of stroke patients in a hospital-based rehabilitation unit improves outcome. Patients with moderate or severe stroke appear to benefit most. Several trials have shown that stroke unit care improves outcome for stroke patients. The aim of the present trial was to evaluate the effects of an extended stroke unit service (ESUS), with early supported discharge, cooperation with the primary healthcare system, and more emphasis on rehabilitation at home as essential elements.
                In a randomized, controlled trial, 160 patients with acute stroke were allocated to the ESUS and 160 to the ordinary stroke unit service (OSUS). The primary outcome was the proportion of patients who were independent as assessed by the modified Rankin Scale (RS) (RS </=2=global independence) and independent in activities of daily living (ADL) as assessed by Barthel Index (BI) (BI >/=95=independent in ADL) after 26 weeks. Secondary outcomes were RS and BI scores after 6 weeks; the proportion of patients at home, in institutions, and deceased after 6 and 26 weeks; and the length of stay in institutions.
                After 26 weeks, 65.0% in the ESUS versus 51.9% in the OSUS group showed global independence (RS </=2) (P:=0.017), while 60.0% in the ESUS versus 49.4% in the OSUS group were independent in ADL (BI >/=95) (P:=0.056). The odds ratios for independence (ESUS versus OSUS) were as follows: RS, 1.72 (95% CI, 1.10 to 2.70); BI, 1.54 (95% CI, 0.99 to 2.39). At 6 weeks, 54.4% of the ESUS group and 45. 6% of the OSUS group were independent according to RS (P:=0.118), and 56.3% versus 48.8% were independent according to BI (P:=0.179). The proportion of patients at home after 6 weeks was 74.4% for ESUS and 55.6% for OSUS (P:=0.0004), and the proportion in institutions was 23.1% versus 40.0%, respectively (P:=0.001). After 26 weeks, 78. 8% in the ESUS group versus 73.1% in the OSUS were at home (P:=0. 239), while 13.1% versus 17.5% were in institutions (P:=0.277). The mortality in the 2 groups did not differ. Average lengths of stay in an institution were 18.6 days in the ESUS and 31.1 days in the OSUS group (P:=0.0324).
                An ESUS with early supported discharge seems to improve functional outcome and to reduce the length of stay in institutions compared with traditional stroke unit care. Because stroke management is aimed at facilitating community reintegration, it would be logical that the sooner the patient can be discharged home, the sooner reintegration can commence. The purpose of this study was to determine the effectiveness of prompt discharge combined with home rehabilitation on function, community reintegration, and health-related quality of life during the first 3 months after stroke.
                A randomized trial was carried out involving patients who required rehabilitation services and who had a caregiver at home. When medically ready for discharge, persons with stroke were randomized to either the home intervention group (n=58) or the usual care group (n=56). The home group received a 4-week, tailor-made home program of rehabilitation and nursing services; persons randomized to the usual care group received services provided through a variety of mechanisms, depending on institutional, care provider, and personal preference. The main outcome measure was the Physical Health component of the Measuring Outcomes Study Short-Form-36 (SF-36). Associated outcomes measures included the Timed Up & Go (TUG), Barthel Index (BI), the Older Americans Resource Scale for instrumental activities of daily living (OARS-IADL), Reintegration to Normal Living (RNL), and the SF-36 Mental Health component.
                The total length of stay for the home group was, on average, 10 days, 6 days shorter than that for the usual care group. There were no differences between the 2 groups on the BI or on the TUG at either 1 or 3 months after stroke; however, there was a significantly beneficial impact of the home intervention on IADL and reintegration (RNL). By 3 months after stroke, the home intervention group showed a significantly higher score on the SF-36 Physical Health component than the usual care group. The total number of services received by the home group was actually lower than that received by the usual care group.
                Prompt discharge combined with home rehabilitation appeared to translate motor and functional gains that occur through natural recovery and rehabilitation into a greater degree of higher-level function and satisfaction with community reintegration, and these in turn were translated into a better physical health. We wished to examine the effectiveness of an early hospital discharge and home-based rehabilitation scheme for patients with acute stroke.
                This was a randomized, controlled trial comparing early hospital discharge and home-based rehabilitation with usual inpatient rehabilitation and follow-up care. The trial was carried out in 2 affiliated teaching hospitals in Adelaide, South Australia. Participants were 86 patients with acute stroke (mean age, 75 years) who were admitted to hospital and required rehabilitation. Forty-two patients received early hospital discharge and home-based rehabilitation (median duration, 5 weeks), and 44 patients continued with conventional rehabilitation care after randomization. The primary end point was self-reported general health status (SF-36) at 6 months after randomization. A variety of secondary outcome measures were also assessed.
                Overall, clinical outcomes for patients did not differ significantly between the groups at 6 months after randomization, but the total duration of hospital stay in the experimental group was significantly reduced (15 versus 30 days; P<0.001). Caregivers among the home-based rehabilitation group had significantly lower mental health SF-36 scores (mean difference, 7 points).
                A policy of early hospital discharge and home-based rehabilitation for patients with stroke can reduce the use of hospital rehabilitation beds without compromising clinical patient outcomes. However, there is a potential risk of poorer mental health on the part of caregivers. The choice of this management strategy may therefore depend on convenience and costs but also on further evaluations of the impact of stroke on caregivers. To assess the clinical effectiveness of an early discharge policy for patients with stroke by using a community based rehabilitation team.
                Randomised controlled trial to compare conventional care with an early discharge policy.
                Two teaching hospitals in inner London.
                331 medically stable patients with stroke (mean age 71) who lived alone and were able to transfer independently or who lived with a resident carer and were able to transfer with help.
                167 patients received specialist community rehabilitation for up to 3 months after randomisation. 164 patients continued with conventional hospital and community care.
                Barthel score at 12 months. Secondary outcomes measured impairment with motoricity index, minimental state examination, and Frenchay aphasia screening test; disability with the Rivermead activity of daily living scales, hospital anxiety and depression scale, and 5 m walk; handicap with the Nottingham health profile; carer stress with caregiver strain index and patient and carer satisfaction. The main process measure was length of stay after randomisation.
                One year after randomisation no significant differences in clinical outcomes were found apart from increased satisfaction with hospital care in the community therapy group. Length of stay after randomisation in the community therapy group was significantly reduced (12 v 18 days; P < 0.0001). Patients with impairments were more likely to receive treatment in the community therapy group.
                Early discharge with specialist community rehabilitation after stroke is feasible, as clinically effective as conventional care, and acceptable to patients. Considerable reductions in use of hospital beds are achievable. To evaluate the feasibility and effectiveness of early supported discharge (ESD) following acute stroke.
                An ESD scheme was compared to conventional rehabilitation in a randomized controlled trial. All patients admitted with acute stroke were considered for inclusion. Eighty-eight (20.2%) were found to be eligible and 82 were randomized either to early supported discharge (n = 42) or conventional rehabilitation (n = 40). The primary outcome measure was the Nottingham Extended Activities of Daily Living Scale. The General Health Questionnaire, the Montgomery Aasberg Depression Rating Scale, mortality, placement and patient and career satisfaction served as secondary outcome measures.
                Median length of stay was reduced from 31 days in the conventional hospital rehabilitation group to 22 days in the early supported discharge group (p = 0.09). No differences were found regarding primary outcome. The General Health Questionnaire score showed a significant difference in favour of the early supported discharge group at three months (19.5/24, p = 0.02), but not at six. At six months, the proportion of patients being dead or in institution showed a trend of being higher in the conventional rehabilitation group (OR 3.8, 95% CI 0.8-23).
                Early supported discharge after stroke is feasible and it is possible that it has benefits compared with conventional rehabilitation. To compare a community-based multidisciplinary stroke team (CST) approach with hospital-based rehabilitation in terms of hospital stay, functioning, quality of life, and service use and costs.
                Stroke patients who met pre-agreed criteria were allocated randomly to the CST service (n=59) or to usual inpatient rehabilitation and follow-up care (n=54). Assessments were completed at randomization and 12 months later. Caregiver strain and satisfaction (n=55) were also assessed. Cost data were collected for a subsample of 38 patients.
                Almost 80% of surviving patients (n=691) were discharged home and a small number (n=55) were readmitted. Approximately 17% (113/649) were randomized. There were no statistically significant differences in hospital duration, costs, or outcome measures at baseline and 12 months except for higher satisfaction reported by CST patients. Overall, both groups recorded improvement in most domains over time. Carers reported a high level of satisfaction although the level of strain among carers is cause for concern. The community group (n=18) cost less than the hospital group (n=20).
                A mixed model of hospital-based and community-based rehabilitation services is likely to lead to increased patient choice and satisfaction and a potential reduction in bed pressures for less severe stroke patients. Readmission rate within 6 months after a stroke is 40% to 50%. The purpose of the project was to evaluate whether an interdisciplinary stroke team could reduce length of hospital stay, readmission rate, increase patient satisfaction and reduce dependency of help.
                One hundred and ninety-eight patients with acute stroke were randomized into 103 patients whose discharge was supported by an interdisciplinary stroke team and 95 control patients who received standard aftercare. Baseline characteristics were comparable in the 2 groups. The patients were evaluated after 6 and 12 months regarding functional status and need for help.
                Length of hospital admission was insignificantly shorter in the intervention compared with the control group (35.2 versus 39.8 days). There was no significant difference in readmission, GP-visits, and primary health care services. Furthermore, there was no significant difference in functional scores or patient satisfaction.
                In this setting we could not show benefit of an interdisciplinary stroke team supporting patients at discharge perhaps because standard aftercare was very efficient already. To establish the feasibility and method of evaluation of an early supported hospital discharge policy for patients with acute stroke.
                A randomized controlled trial comparing an early supported discharge service to conventional care.
                Three acute hospitals in Newcastle upon Tyne.
                Ninety-two eligible patients with acute stroke admitted between 1 February 1995 and 31 January 1996.
                Placement, length of stay, readmission rates, mortality, functional ability (Nottingham Extended Activities of Daily Living (ADL) Scale), handicap (Oxford Handicap Scale), global health status (Dartmouth Coop Function Charts) and carer stress (General Health Questionnaire 30 item).
                The median length of stay for patients randomized to early supported discharge was 13 days compared to 22 days in the conventional care group (p = 0.02). The median Barthel ADL index at seven days post stroke of patients randomized to early supported discharge was 15, and 13 for those randomized to conventional care (NS). At three months post stroke the median Nottingham EADL score of patients randomized to early supported discharge was 10 compared to 7 for those who received conventional care (NS). There were no statistically significant differences in the global health status of patients or carer stress.
                An early supported discharge service following acute stroke with individualized rehabilitation in the community is feasible and can be evaluated by a randomized controlled trial but a larger multicentre trial is needed before such a service is widely adopted. To evaluate the effect of an extended stroke unit service (extended service), with early supported discharge and co-ordination of further rehabilitation in co-operation with the primary health care system in three rural municipalities.
                A randomized controlled trial comparing extended service with ordinary stroke unit service (ordinary service).
                Sixty-two eligible patients with acute stroke living in the rural municipalities of Malvik, Melhus and Klaebu.
                The primary outcome was the proportion of patients who were independent according to Modified Rankin Scale (mRS) (independence = mRS < or = 2) 52 weeks after onset of stroke. Secondary outcomes were mRS at 6 and 26 weeks and Barthel Index (BI), Nottingham Health Profile (NHP) and Caregiver Strain Index (CSI) at 6, 26 and 52 weeks. Mortality and length of stay were registered during the 52 weeks.
                Twelve patients (39%) in the extended service group versus 16 patients (52%) in the ordinary service group were independent according to mRS at 52 weeks (p = 0.444). The odds ratio for independence (extended service versus ordinary service) was 0.33 (95% confidence interval (CI) 0.088-1.234). According to outcome by secondary measures there were no significant differences except less social isolation on NHP in the extended service group at 26 weeks (p = 0.046). There were no significant differences in length of stay.
                An extended stroke unit service with early supported discharge seems to have no positive effect on functional outcome for patients living in rural communities, but might give a trend toward better quality of life. There were no significant differences in length of stay.
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.