Evidence for Early Supported
Discharge.
Peter Langhorne
Professor of Stroke Care
University of Glasgow
Early Supported Discharge Trialists
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Craig Anderson (Auckland)
Erik Bautz-Holter (Oslo)
Paola Day (Manchester)
Martin Dennis (Secretariat)
Jean Douglas
Bent Indredavik (Coordinator)
Nancy Mayo (Montreal)
Gordon Murray (Statistician)
Michael Power (Belfast)
•Helen Rodgers (Newcastle)
•Ole Morten Ronning
(Akershus)
•Sally Rubenach (Adelaide)
•Anthony Rudd (London)
•Nijasri Suwanwela (Bangkok)
•Gillian Taylor (Statistician)
•Lotta Widen-Holmquist
(Stockholm)
•Charles Wolfe (London)
ESD trialists – submitted for publication
Early supported discharge
• Background and Definitions
• Systematic Review of ESD services
— Methodology
— Results (Effectiveness and Cost Effectiveness)
• Implementing ESD Services
• Conclusions
Background and Definitions
• ESD services aim to accelerate discharge home
from hospital and provide rehabilitation / support
in the home setting.
• Also termed “hospital at home” but……….
― Different from services which aim to prevent
admission to hospital (Admission avoidance).
Integrated Stroke Service - objectives
Primary Prevention?
Patient
Outpatient
Assessment
Prevention
Admission
avoidance
Inpatient
Assessment
Acute Care
Prevention
Rehabilitation
Continuing Support and Prevention
Long term support and re-assessment of needs
Avoidance of hospital admission
• Practical problems with domiciliary team
care in several trials
• No significant difference overall but…….
• Hospital Care based in a multidisciplinary
stroke unit appears to be superior
domiciliary care
Langhorne et al (1999)
Kalra et al (2000)
Integrated Stroke Service - objectives
Primary Prevention?
Patient
Outpatient
Assessment
Prevention
Early
Supported
Discharge
Service
Inpatient
Assessment
Acute Care
Prevention
Rehabilitation
Continuing Support and Prevention
Long term support and re-assessment of needs
Conventional Services
Admission
Hospital
Home
Acute
Review
Discharge
Rehabilitation
Support
Early Supported Discharge
Admission
Hospital
Acute
Review
Discharge
Rehab
Rehab
Home
Rehab
Support
Support
Early Supported Discharge
Potential Risks and Benefits
Potential Benefits
Potential Risks
• Home Better Setting
for Rehabilitation
• Favoured by Patients
and Carers
• Free Hospital Beds
• Reduce Costs
• Unable to manage
medical problems
• Strain on Patients and
Carers
• Expensive if done well
• Increase Costs
Why we need randomised trials
• In order to be confident about our estimates of
benefit and harm we need to look at studies
with:
•Adequate Randomisation
— Matched Patient Groups
•Blinded (masked) follow up
― Unbiased assessment of outcomes
•Complete follow up
― Unbiased assessment of outcomes
Why we need systematic reviews
(meta-analyses)
• Trials of small size
•Lack power and prone
to chance
• Single Centre
•Limited external validity
(applicability)
• Publication bias
•Need to examine all
similar trials
Randomised trials of early
supported discharge services
• 11 complete RCT’s
• Services aiming to accelerate discharge
home and provide some rehabilitation
and/or support at home
• Excluded trials of…
— Admission Avoidance Services (randomised before
admission)
— Post Discharge Services (randomised after
discharge)
Early Supported Discharge Trials
North America
United Kingdom
Scandinavia
S.E. Asia
Australia
Montreal
New York
Belfast
London
Manchester
Newcastle
Akerhus
Oslo
Stockholm
Trondheim
Bangkok
Adelaide
Description of Services
Multidisciplinary Team (MDT) Coordination/delivery
• MDT (nursing, physiotherapy, O.T, assistants) coordinate
discharge home and provide post -discharge rehabilitation
Multidisciplinary team (MDT) Coordination
• MDT (nursing, physiotherapy, O.T, assistants) coordinate
discharge home but then transfer much of care to other
services
No Multidisciplinary Team (MDT)
• No MDT coordination/delivery, services provided by a range
of other agencies (e.g. PT, volunteers)
Patient Selection
Patients Selected
Condition unstable
Severe dependency
Confusion
Live in PNH
Medically stable
Persisting disability
Able to comply
Live Locally
40 (12-70) %
of admissions
Good Recovery
Main Outcomes
• Primary
— Death or Dependency (Rankin 3-5) at end of
schedule follow up (6; 3-12 months)
• Secondary
— Death by end of scheduled follow up
— Death or institutional care at end of follow up
— Length of hospital stay
— ADL score, extended ADL score
— Patient and carer subjective health
— Patient and carer satisfaction
Early supported discharge service vs. conventional care – Outcome Death or
dependency
Study
Treatment
n/H
Control
n/H
OR
(95% CI Fixed)
OR
(95% CI Fixed)
MDT coordination and delivery
Adelaide
Belfast
London
Montreal
Newcastle
Stockholm
Subtotal (95% CI)
13/42
29/59
105/167
17/58
22/46
9/42
195/414
16/44
32/54
109/164
24/56
28/46
12/41
221/405
0.72 (0.54,0.96)
MDT Coordinators
Oslo
Trondheim
Subtotal (95%CI)
16/42
64/160
80/202
17/40
81/160
98/200
0.68(0.46,1.01)
No MDT Coordination
Akershus
Bangkok
Subtotal (95%CI)
70/124
9/52
79/176
61/127
11/50
72/177
1.23(0.79,1.91)
391/782
0.80(0.65,0.98)
Total (95%CI)
354/792
Test for heterogeneity chi-square =7.63 df=9 p=0.57
Test for Overall effect z=2.17 p=0.03
-2
-5
Favours Treatment
1
2
5
Favours Control
Absolute Outcomes
(additional events per 100 patients treated)
• Alive at end of follow up (6-12 months)
— 1 (-2,4) Not Significant
• Living at home (6-12 months)
— 5 (1,9) P=0.02
• Independent (6-12 months)
— 6 (1,10) P=0.02
Secondary Outcomes
• Resource Outcomes
— Length of stay reduced 8 days (5-11; P<0.0001)
— No Difference in readmissions
• Patient Outcomes
— No significant difference ADL, subjective health
— Improved EADL, patient satisfaction
• Carer Outcomes
— No significant difference in subjective health
Subgroup analysis – Patient Characteristics
Treatment
n/H
Patient age
Less than 65 years
65-75 Years
More than 75 years
Patient gender
Male
Female
Presence of Carer
No
Yes
Initial Stroke Severity (week1)
Barthel 0-9
Barthel 10-15
Barthel 16-20
Control
n/H
53/124
93/224
134/231
48/123
101/203
150/246
140/259
141/321
140/257
140/315
36/133
195/381
106/204
193/358
111/127
161/345
57/251
109/145
195/336
72/246
OR
(95% CI Fixed)
-2
-5
Favours Treatment
1
2
5
Favours Control
Subgroup analysis – Service Characteristics
Treatment
n/H
Presence of Carer
No
Yes
ESD Characteristics
MDT Coordination
No MDT coordination
Hospital Outreach
Community in reach
Control Service
Stroke Unit
Other Wards
Control
n/H
96/199
185/381
106/204
193/368
275/616
79/176
102/286
252/506
319/605
72/177
126/285
265/497
203/476
151/316
225/476
166/305
OR
(95% CI Fixed)
-2
-5
Favours Treatment
1
2
5
Favours Control
Economics of ESD Services
• Individual Trial analyses (London,
Newcastle, Adelaide) indicate;
— Reduction in hospital bed use
— Increase in community costs
• Overall there were modest savings
with ESD services
• Savings particularly evident with
more severe stroke patients?
Implementation - structure
• Multidisciplinary Team
– Physiotherapy, occupational therapy, nursing (SALT
and medical input)
– Based in Hospital or community
• Access to services and equipment
• Access to stroke unit / inpatient services
Implementation - example
Admission to hospital
Contact with patient/Carer
Identify Key worker
Home Assessment
Plan discharge
Agree rehabilitation Goals
Discharge from hospital
Implement Rehabilitation plan
Access relevant services
MDT review of progress
Negotiate withdrawal
Discharge from ESD
Implementation - examples
• Hospital outreach team
– Stockholm (Stroke 1998; 29: 591-597)
– Trondheim (Stroke 2000; 31: 2989-2994)
• Community in reach team
– Newcastle (Clin Rehab 1997; 11: 280-287)
– London (BMJ 1997; 315: 1039-1044)
– Adelaide (Stroke 2000; 31: 1032-1037)
Integrated Stroke Service - Components
Patient
(1)
(2,3,4)
Comprehensive
Stroke Unit
Rapid access
neurovascular
clinic
(2,3)
(2)
Key
1) TIA
2) Mild
3) Moderate
4) Severe
Early Supported
Discharge
(1)
Continuing Rehabilitation
Long term support and reassessment of needs
(3,4)
Inpatient
Rehabilitation
Early Supported Discharge Services
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Promising role for the future
Not applicable to all stroke patients (50%)
Can accelerate discharge home
Appear t improve longer term recovery
Best results with ESD services
– Coordinated and provided by a multidisciplinary
rehabilitation team and
– Targeted at mild-moderate stroke patients
• Not an alternative to stroke unit care!