Peter Langhorne and colleagues (Glasgow Royal Infirmary, Scotland) combined data from 11 trials, involving 1597 patients altogether that recruited stroke patients to receive conventional care or early supported discharge (ESD). Trials were selected if ESD provided rehabilitation and support in a community setting with the aim of shortening hospital care. ESD services were mostly provided by a specialist multi-disciplinary team (comprising physiotherapy, occupational therapy, and speech and language therapy, staff with medical, nursing, and social work support) to a selected group (41%) of stroke patients admitted to hospital.
Patients in the analysis had similar characteristics. The investigators found that those who received the ESD service had statistically fewer deaths and reduced dependency. The reduction equates to an extra six patients regaining independence for every 100 patients receiving ESD services. The hospital stays were 8 days shorter for patients assigned to ESD services than those assigned to conventional services. The greatest benefits were seen in the trials evaluating a coordinated multidisciplinary team and stroke patients with mild to moderate disability. Five of the 11 trials reported an economic analysis. All concluded that savings from fewer hospital-bed days were greater than the cost of the ESD service.
Professor Langhorne concludes: "An appropriately resourced and coordinated ESD team can offer a further effective service option for a selected group of stroke patients and should be considered, in addition to organised inpatient (stroke unit) care, as part of a comprehensive stroke service."
In an accompanying commentary Ronald Meijer and Jacques van Limbeek (Rehabilitation Centre Groot Klimmendaal, Netherlands) write that it will be important to identify which patients are eligible for ESD and that the reduction in length of hospital stay seen in the ESD group could have different causes.
Dr Meijer concludes: "To clinically interpret Langhorne and colleagues' latest results, admission to ESD services will be the optimum choice for patients who no longer need medical and nursing treatment that only a hospital can provide; have moderate stroke severity; can return home because they can care for themselves or they have the help of professional care, family care, or both; need rehabilitation treatment that can be provided at home; do not need rehabilitation treatment that cannot be provided at home; live at a considerable distance from the hospital or rehabilitation services and for whom the combination of travelling to an outdoor service with exercise could be too tiring; or patients who would benefit most from situational learning instead of trying to generalise learned skills."
Professor Peter Langhorne, Academic Section of Geriatric Medicine, 3rd Floor, Centre Block, Royal Infirmary, GLASGOW, G4 0SF, UK. T) 0141-211-4976 p.langhorne@clinmed.gla.ac.uk
(comment) Dr Ronald Meijer, Department of Neurological Rehabilitation, Rehabilitation Centre Groot Klimmendaal, PO Box 9044, 6800 GG Arnhem, Netherlands T) 31-263-526-100 ronald.meijer11@freeler.nl
Journal
The Lancet