Services for reducing duration of hospital care in people with acute stroke
We aimed to establish if Early Supported Discharge (ESD) services can result in a better patient recovery and if they are as acceptable and affordable as usual services.
Services that try to offer stroke patients an earlier discharge from hospital with rehabilitation provided in the community have been termed Early Supported Discharge (ESD) services. ESD services are usually provided by multidisciplinary teams of therapists, nurses, and doctors who work in a co-ordinated manner through regular meetings. They aim to allow patients to return home from hospital earlier than usual and also to receive more rehabilitation in the familiar environment of their own home.
We identified 17 clinical trials recruiting 2422 stroke patients (searching completed to January 2017). Patients who were recruited tended to have a moderate degree of disability (able to walk with assistance) and be sufficiently well to consider returning home. We categorised services as those based on a multidisciplinary ESD team (with different levels of co-ordination and delivery) and those with no multidisciplinary team co-ordination (no ESD team).
The length of initial stay in hospital was reduced by approximately five days for the ESD group. At an average of six months after their stroke ESD patients were more likely to be living at home (an extra five patients living at home for every 100 receiving ESD services; moderate-quality evidence). They were also more likely to be independent in daily activities (an extra six patients independent for every 100 receiving ESD services; moderate-quality evidence). We identified no apparent hazards in terms of patient mood or quality of life, carer mood or quality of life, or the risk of readmission to hospital. The greatest reductions in disability seemed to be present in trials based around a co-ordinated ESD team. When compared with usual care, costs of ESD services ranged from a reduction to a modest increase.
Quality of the evidence
The quality of the evidence was downgraded to 'moderate' for the main outcomes of death, discharge home or disability. This was because it was impossible to hide the treating service from participants or healthcare workers. These conclusions were not dependent on trials judged to be lower quality because of poor design or missing data. More information was missing for some of the other outcome measures, which we have downgraded to low-quality evidence.
Appropriately resourced ESD services with co-ordinated multidisciplinary team input can reduce disability and the length of time in hospital at least for a selected group of people with stroke. Results are unclear for services that are not based on a co-ordinated multidisciplinary team input. We did not identify any substantial harmful effects.