Implementing early supported discharge in stroke care

Abstract Background and purpose Early supported discharge (ESD) has been shown to be efficient and safe as part of the stroke care pathway. The best results have been seen with a multidisciplinary team and after mild to moderate stroke. However, how very early supported discharge (VESD) works has not been studied. The aim of this study was to investigate whether VESD for stroke patients in need of ongoing individualized rehabilitation affects the level of anxiety and overall disability for the patient compared with ordinary discharge routine. Methods A randomized controlled trial was performed with intention to treat analyses comparing VESD and ordinary discharge from hospital. All patients admitted at the stroke care unit at Sahlgrenska University Hospital of Gothenburg between August 2011 and April 2016 were screened. Inclusion occurred on day 4 using a block randomization of 20 and with a blinded assessor. Assessments were made 5 days post-stroke and 3 and 12 months post-stroke. Patients in the VESD group underwent continued rehabilitation in their homes with a multidisciplinary team from the stroke care unit for a maximum of 1 month. The patients in the control group had support as usual after discharge when needed such as home care service and outpatient rehabilitation. The primary outcome was anxiety as assessed by the Hospital Anxiety and Depression Scale-Anxiety subscale (HADS-A). The secondary outcome was the patients’ degree of overall disability, measured by the modified Rankin Scale (mRS). Results No significant differences were found between the groups regarding anxiety at three or 12 months post-stroke (p = 0.811). The overall disability was significantly lower in the VESD group 3 months post-stroke (p = 0.004), compared to the control group. However, there was no significant difference between the groups 1 year post-stroke. Conclusions The VESD does not affects the level of anxiety compared to ordinary rehabilitation. The VESD leads to a faster improvement of overall disability compared to ordinary rehabilitation. We suggest considering coordinated VESD for patients with mild to moderate stroke in addition to ordinary rehabilitation as part of the service from a stroke unit. Trial registration Clinical Trials.gov: NCT01622205. Registered 19 June 2012 (retrospectively registered).

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Large-scale implementation of stroke early supported discharge: the WISE realist mixed-methods study

Health Services and Delivery Research ◽

10.3310/hsdr09220 ◽

2021 ◽

Vol 9 (22) ◽

pp. 1-150

Author(s):

Rebecca J Fisher ◽

Niki Chouliara ◽

Adrian Byrne ◽

Trudi Cameron ◽

Sarah Lewis ◽

...

Keyword(s):

Patient Outcomes ◽

Care Pathway ◽

Stroke Care ◽

Realist Evaluation ◽

Mixed Methods Study ◽

Evidence Based ◽

Work Package ◽

Early Supported Discharge ◽

Consensus Score ◽

Core Components

Background In England, the provision of early supported discharge is recommended as part of an evidence-based stroke care pathway. Objectives To investigate the effectiveness of early supported discharge services when implemented at scale in practice and to understand how the context within which these services operate influences their implementation and effectiveness. Design A mixed-methods study using a realist evaluation approach and two interlinking work packages was undertaken. Three programme theories were tested to investigate the adoption of evidence-based core components, differences in urban and rural settings, and communication processes. Setting and interventions Early supported discharge services across a large geographical area of England, covering the West and East Midlands, the East of England and the North of England. Participants Work package 1: historical prospective patient data from the Sentinel Stroke National Audit Programme collected by early supported discharge and hospital teams. Work package 2: NHS staff (n = 117) and patients (n = 30) from six purposely selected early supported discharge services. Data and main outcome Work package 1: a 17-item early supported discharge consensus score measured the adherence to evidence-based core components defined in an international consensus document. The effectiveness of early supported discharge was measured with process and patient outcomes and costs. Work package 2: semistructured interviews and focus groups with NHS staff and patients were undertaken to investigate the contextual determinants of early supported discharge effectiveness. Results A variety of early supported discharge service models had been adopted, as reflected by the variability in the early supported discharge consensus score. A one-unit increase in early supported discharge consensus score was significantly associated with a more responsive early supported discharge service and increased treatment intensity. There was no association with stroke survivor outcome. Patients who received early supported discharge in their stroke care pathway spent, on average, 1 day longer in hospital than those who did not receive early supported discharge. The most rural services had the highest service costs per patient. NHS staff identified core evidence-based components (e.g. eligibility criteria, co-ordinated multidisciplinary team and regular weekly multidisciplinary team meetings) as central to the effectiveness of early supported discharge. Mechanisms thought to streamline discharge and help teams to meet their responsiveness targets included having access to a social worker and the quality of communications and transitions across services. The role of rehabilitation assistants and an interdisciplinary approach were facilitators of delivering an intensive service. The rurality of early supported discharge services, especially when coupled with capacity issues and increased travel times to visit patients, could influence the intensity of rehabilitation provision and teams’ flexibility to adjust to patients’ needs. This required organising multidisciplinary teams and meetings around the local geography. Findings also highlighted the importance of good leadership and communication. Early supported discharge staff highlighted the need for collaborative and trusting relationships with patients and carers and stroke unit staff, as well as across the wider stroke care pathway. Limitations Work package 1: possible influence of unobserved variables and we were unable to determine the effect of early supported discharge on patient outcomes. Work package 2: the pragmatic approach led to ‘theoretical nuggets’ rather than an overarching higher-level theory. Conclusions The realist evaluation methodology allowed us to address the complexity of early supported discharge delivery in real-world settings. The findings highlighted the importance of context and contextual features and mechanisms that need to be either addressed or capitalised on to improve effectiveness. Trial registration Current Controlled Trials ISRCTN15568163. Funding This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 22. See the NIHR Journals Library website for further project information.

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Combined Clinical and Home Rehabilitation: Case Report of an Integrated Knowledge-to-Action Study in a Dutch Rehabilitation Stroke Unit

Physical Therapy ◽

10.2522/ptj.20130495 ◽

2015 ◽

Vol 95 (4) ◽

pp. 558-567 ◽

Cited By ~ 8

Author(s):

Christa S. Nanninga ◽

Klaas Postema ◽

Marleen C. Schönherr ◽

Sacha van Twillert ◽

Ant T. Lettinga

Keyword(s):

Case Report ◽

Stroke Unit ◽

Practical Knowledge ◽

Transfer Problem ◽

Stroke Care ◽

Application Process ◽

Research Knowledge ◽

Knowledge To Action ◽

Straightforward Application ◽

Early Supported Discharge

Background and Purpose There is growing awareness that the poor uptake of evidence in health care is not a knowledge-transfer problem but rather one of knowledge production. This issue calls for re-examination of the evidence produced and assumptions that underpin existing knowledge-to-action (KTA) activities. Accordingly, it has been advocated that KTA studies should treat research knowledge and local practical knowledge with analytical impartiality. The purpose of this case report is to illustrate the complexities in an evidence-informed improvement process of organized stroke care in a local rehabilitation setting. Case Description A participatory action approach was used to co-create knowledge and engage local therapists in a 2-way knowledge translation and multidirectional learning process. Evidence regarding rehabilitation stroke units was applied in a straightforward manner, as the setting met the criteria articulated in stroke unit reviews. Evidence on early supported discharge (ESD) could not be directly applied because of differences in target group and implementation environment between the local and reviewed settings. Early supported discharge was tailored to the needs of patients severely affected by stroke admitted to the local rehabilitation stroke unit by combining clinical and home rehabilitation (CCHR). Outcomes Local therapists welcomed CCHR because it helped them make their task-specific training truly context specific. Key barriers to implementation were travel time, logistical problems, partitioning walls between financing streams, and legislative procedures. Discussion Improving local settings with available evidence is not a straightforward application process but rather a matter of searching, logical reasoning, and creatively working with heterogeneous knowledge sources in partnership with different stakeholders. Multiple organizational levels need to be addressed rather than focusing on therapists as sole site of change.

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Abstract 3030: Meta-analysis of Cost Effectiveness of Different Stroke Unit Subtypes

Stroke ◽

10.1161/str.43.suppl_1.a3030 ◽

2012 ◽

Vol 43 (suppl_1) ◽

Author(s):

Minal Jain ◽

Anunaya Jain ◽

Abhijit R Kanthala ◽

Babak S Jahromi

Keyword(s):

Cost Effectiveness ◽

Stroke Unit ◽

Systems Of Care ◽

Surrogate Marker ◽

Cost Effective ◽

Stroke Care ◽

Developed Countries ◽

Direct Care ◽

Early Supported Discharge ◽

Acute Rehabilitation

Aim: To perform a systematic review and metanalysis, comparing outcome and cost of stroke care in a stroke unit (SU) versus conventional care (CC). Secondary aim was to compare cost effectiveness of different SU subtypes. Methods: Pubmed search was performed for “Stroke Unit” among all English language articles from 01/01/1996 to 01/01/2011. Only articles from developed countries, reporting the length of stay (LOS) and/or cost and outcomes for ischemic stroke were included. Studies wherein data was collected before 01/01/1996, articles only on rehabilitation units, and all systematic reviews were excluded. LOS was taken as a surrogate marker of stroke care cost in studies wherein direct care costs were not reported. Non-QALY outcomes were converted to QALYs using reported logistic regressions. Ratios less than $50,000/QALY were considered cost effective while greater than $100,000 /QALY were considered non-cost effective. All cost were reported in 2010 US$. Result: A total of 5,537 articles in Pubmed were studied, of which 19 studies met the inclusion criteria. LOS for patients managed at SU ranged from 9.2-32.3 days versus 8-35.3 days for CC units and average incremental QALYs between them were 0.09. The average incremental cost/QALY was $41,204.37. The average cost/QALY for different types of SU were $19,428.64 for Acute only SU (A SU), $44,228.81 for Acute+Rehabilitation SU (A+R SU), $29,145.93 for Acute+Rehabilitation+Early Supported Discharge (A+R+ESD) SU and $20,460.56 for SU with Continuous monitoring (SU CM). In comparison to an A SU, SU CM and A+R+ESD SU were cost effective alternatives (ICER SU CM estimated at $25,120.89, ICER A+R+ESD SU estimated at $24,574.59). Conclusion: Stroke Units are cost effective when compared to the conventional systems of care. Acute + rehab SU with early supported discharge appears to be the most cost effective model amongst different subtypes of SU.

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A review of early supported discharge after stroke

Reviews in Clinical Gerontology ◽

10.1017/s0959259810000249 ◽

2010 ◽

Vol 20 (4) ◽

pp. 327-337 ◽

Cited By ~ 3

Author(s):

Linda Brewer ◽

David Williams

Keyword(s):

Cost Effectiveness ◽

Discharge Planning ◽

Stroke Care ◽

International Studies ◽

Acute Stroke Care ◽

Rehabilitation Team ◽

Early Supported Discharge ◽

Essential Components ◽

Bed Days ◽

The Cost

SummaryStroke is a leading cause of disability worldwide and patients with stroke frequently require prolonged periods of in-patient rehabilitation prior to discharge. This poses a large economic strain on health services, and the cost-effectiveness of this system has been questioned. However, in implementing changes in the delivery of post-acute stroke care it is important that patient outcome is not compromised. Early supported discharge (ESD) was introduced approximately 15 years ago and allows suitable patients to be discharged home early with increased support from a well co-ordinated, multi-disciplinary rehabilitation team in the patient's own home. This paper focuses upon the evidence available from multiple international studies of ESD over the last decade, including both clinical benefit and cost-effectiveness. Findings from these trials are largely positive resulting from a reduction in bed days, therefore overall cost, and an improvement in function and independence reported in many studies. Suitable patient selection, careful discharge planning and continuity of care by the ESD linked to a stroke unit are essential components of the success of this service.

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The economic burden of stroke care in England, Wales and Northern Ireland: Using a national stroke register to estimate and report patient-level health economic outcomes in stroke

European Stroke Journal ◽

10.1177/2396987317746516 ◽

2017 ◽

Vol 3 (1) ◽

pp. 82-91 ◽

Cited By ~ 36

Author(s):

Xiang-Ming Xu ◽

Emma Vestesson ◽

Lizz Paley ◽

Anita Desikan ◽

David Wonderling ◽

...

Keyword(s):

Northern Ireland ◽

Social Care ◽

Stroke Care ◽

Stroke Severity ◽

National Audit ◽

Patient Level ◽

Early Supported Discharge ◽

Health And Social Care ◽

The Cost ◽

Care Costs

Introduction Stroke registries are used in many settings to measure stroke treatment and outcomes, but rarely include data on health economic outcomes. We aimed to extend the Sentinel Stroke National Audit Programme registry of England, Wales and Northern Ireland to derive and report patient-level estimates of the cost of stroke care. Methods An individual patient simulation model was built to estimate health and social care costs at one and five years after stroke, and the cost-benefits of thrombolysis and early supported discharge. Costs were stratified according to age, sex, stroke type (ischaemic or primary intracerebral haemorrhage) and stroke severity. The results were illustrated using data on all patients with stroke included in Sentinel Stroke National Audit Programme from April 2015 to March 2016 (n = 84,184). Results The total cost of health and social care for patients with acute stroke each year in England, Wales and Northern Ireland was £3.60 billion in the first five years after admission (mean per patient cost: £46,039). There was fivefold variation in the magnitude of costs between patients, ranging from £19,101 to £107,336. Costs increased with older age, increasing stroke severity and intracerebral hemorrhage stroke. Increasing the proportion of eligible patients receiving thrombolysis or early supported discharge was estimated to save health and social care costs by five years after stroke. Discussion The cost of stroke care is large and varies widely between patients. Increasing the proportion of eligible patients receiving thrombolysis or early supported discharge could contribute to reducing the financial burden of stroke. Conclusion Extending stroke registers to report individualised data on costs may enhance their potential to support quality improvement and research.

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