Abstract
BackgroundStroke causes lasting disability and the burden of stroke is expected to increase substantially during the next decades. Optimal rehabilitation is therefore mandatory. Early supported discharge (ESD) has previously shown beneficial, but all major studies were carried out more than ten years ago. We wanted to implement and study the results of ESD in our community today with comparisons between ESD and treatment as usual, as well as between two different ESD models.MethodsPatients with acute stroke were included during a three year period (2008–11) in a randomised controlled study comparing two different ESD models to treatment as usual. The two ESD models differed by the location of treatment: either in a day unit or in the patients’ homes. Patients in the ESD groups were followed by a multi-disciplinary ambulatory team in the stroke unit and discharged home as early as possible. The ESD models also comprised treatment by a multi-disciplinary community health team for up to five weeks and follow-up controls after 3 and 6 months. Primary outcome was modified Rankin Scale (mRS) at six months.ResultsThree-hundred-and-six patients were included. mRS scores and change scores were non-significantly better in the two ESD groups at 3 and 6 months. Within-group improvement from baseline to 3 months was significant in the ESD 1 (p = 0.042) and ESD 2 (p = 0.001) groups, but not in the controls. More patients in the pooled ESD groups were independent at 3 (p = 0.086) and 6 months (p = 0.122) compared to controls and there also was a significant difference in 3 month change score between them (p = 0.049). There were no differences between the two ESD groups. Length of stay in the stroke unit was 11 days in all groups.ConclusionsPatients in the ESD groups tended to be more independent than controls at 3 and 6 months, but no clear statistically significant differences were found. The added effect of supported discharge and improved follow-up seems to be rather modest. The improved stroke treatment of today may necessitate larger patient samples to demonstrate additional benefit of ESD.Clinical trial registrationUnique identifier: NCT00771771
Highlights
Stroke causes lasting disability and the burden of stroke is expected to increase substantially during the decades
Supported discharge (ESD) is a rehabilitation concept emphasising early discharge from institution to home for patients after stroke, followed by rehabilitation while home-dwelling, and often supervised by a specialised multi-disciplinary team [5]. This has been studied in several randomised controlled trials previously and the results have been analysed in an updated Cochrane report from 2012 [5]. This meta-analysis suggested a beneficial effect of Early supported discharge (ESD) for a selected group of stroke patients, but at the same time pointed towards the need for future studies in order to clarify which elements of ESD in the primary health care were important, and for more precise clarification of cost-benefit for different patient groups
In general, small differences in favour of the ESD groups for the outcomes modified Rankin Scale (mRS), National Institutes of Health Stroke Scale (NIHSS), Barthel ADL Index (BI), relevant change scores and patient satisfaction when examined by analysis of variance (ANOVA), but mostly not statistically significant
Summary
Stroke causes lasting disability and the burden of stroke is expected to increase substantially during the decades. Supported discharge (ESD) is a rehabilitation concept emphasising early discharge from institution to home for patients after stroke, followed by rehabilitation while home-dwelling, and often supervised by a specialised multi-disciplinary team [5]. This has been studied in several randomised controlled trials previously and the results have been analysed in an updated Cochrane report from 2012 [5]. An international consensus document was recently published with statements regarding team composition, model of team work, intervention, and success [7]
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