Current issues of ACP Journal Club are published in Annals of Internal Medicine


Therapeutics

Early discharge to community care was as effective as conventional care for stroke

ACP J Club. 1998 May-June;128:58. doi:10.7326/ACPJC-1998-128-3-058


Source Citation

Rudd AG, Wolfe CD, Tilling K, Beech R. Randomised controlled trial to evaluate early discharge scheme for patients with stroke. BMJ. 1997 Oct 25;315:1039-44.


Abstract

Objective

To compare the effectiveness of early discharge to a community-based rehabilitation team with the effectiveness of conventional treatment in terms of impairment and disability for patients with stroke.

Design

Randomized controlled trial with 1-year follow-up.

Setting

2 teaching hospitals in London, United Kingdom.

Patients

331 patients with stroke (mean age 71 y, 56% men) who were able to transfer independently if they lived alone or transfer with assistance if they lived with a willing caregiver. Patients were excluded if they lived too far away for visits by the team. 262 patients (79%) completed the 1-year follow-up, 9 were lost to follow-up, and 60 died.

Intervention

Patients allocated to the community-based rehabilitation team (n = 167) remained hospitalized until their rehabilitation needs were assessed, initial objectives were set, social services were organized, and home adaptations were completed. After discharge, patients received an individualized, planned course of physiotherapy, occupational therapy, and speech therapy (maximum 1 visit/d per therapist) for a maximum of 3 months from a team that included a senior physiotherapist, a senior occupational therapist, a speech and language therapist, and a therapy aide. Patients allocated to conventional care (n = 164) received usual treatment; discharge planning; and outpatient services, which included a hospital-based stroke clinic, a geriatric day hospital, generic physiotherapy, speech and language therapy, hospital outpatient physiotherapy, and usual community resources.

Main outcome measures

Barthel Index of Activities of Daily Living. Secondary measures were patient impairment (Motoricity Index, Mini-Mental State Examination, and Frenchay Aphasia Screening Test), disability (Rivermead Activities of Daily Living Score, Hospital Anxiety and Depression Scale, 5-Meter Timed Walk, and Nottingham Health Profile), patient and care-giver satisfaction, and resource use.

Main results

The groups did not differ for any of the standardized measures. More patients in the community-care group were satisfied with their hospital care than were patients in the conventional-care group (79% vs 65%, P = 0.03). Mean length of stay after randomization was shorter in the community-care group than in the conventional-care group (12 vs 18 d, P < 0.001).

Conclusion

Patients with stroke who were discharged early to a community-based rehabilitation team did not differ in impairment and disability compared with patients who received conventional care.

Sources of funding: Stroke Association; Lambeth, Southwark and Lewisham Health Authority; Special Trustees of St. Thomas's Hospital; Nuffield Provincial Hospitals Trust; Wandsworth Health Gain Fund.

For article reprint: Dr. A.G. Rudd, Elderly Care Unit, United Medical and Dental Schools of Guy's and St. Thomas's Hospital, London SE1 7EH, England, UK. FAX 44-171-928-2339.


Commentary

The decision to discharge a stroke patient requires balancing the patient's medical stability and need for intensive rehabilitation, the patient's or caregiver's ability to manage at home, and the need to control costs. Rudd and colleagues have attempted to address the issue by studying whether early discharge with intensive community-based therapy is as effective as continued inpatient rehabilitation care. The authors controlled for the medical stability of patients and for therapeutic intensity, thereby testing whether patients and caregivers could competently function at home after a shorter period of inpatient care. Details were not provided about qualitative differences between the community-based and inpatient interdisciplinary therapy programs. Unlike inpatients, patients receiving therapy at home usually do not have access to equipment, such as therapeutic mats and parallel bars, or group therapy.

Patients who could transfer safely by themselves if they lived alone or with assistance if they lived with an able caregiver were chosen. These patients typically have a shorter hospital stay than the general stroke rehabilitation population because they have a higher functional level at admission (1). After randomization, patients assigned to community-based therapy were discharged only after the rehabilitation team had completed discharge planning. Discharge planning involved obtaining equipment for the patient's home and training the patient and caregiver in transfers and other activities of daily living.

Forces in the health care market have successfully led to reductions in the total mean hospital stays of all stroke rehabilitation patients in the United States; these reductions are similar to those reported for the community-based therapy group in this study (38 vs 34 d, respectively) (2). Rudd and colleagues provide objective research that supports the safety and efficacy of early discharge from the hospital with proper patient and caregiver preparation.

Richard L. Harvey, MD
The Rehabilitation Institute of ChicagoChicago, Illinois, USA


References

1. Stineman MG, Williams SV. Predicting inpatient rehabilitation length of stay. Arch Phys Med Rehabil. 1990;71:881-7.

2. Fiedler RC, Granger CV. Uniform data system for medical rehabilitation: report of first admissions for 1995. Am J Phys Med Rehabil. 1997;76:76-81.