Early Supported Discharge Services for People with Acute Stroke

Summary

A Cochrane review [Abstract] 1 included 17 studies with a total of 2422 subjects. Participants tended to be a selected elderly group of stroke survivors with moderate disability. The early supported discharge (ESD) group showed 6-day reductions in the length of hospital stay (MD -5.5; 95% CI -3 to -8 days; p<0.0001). Overall, the OR for the outcome of death or dependency at the end of scheduled follow-up (median 6 months; range 3 to 12) was 0.80 (95% CI 0.67 to 0.95, p = 0.01; 16 trials, n=2359) which equates to 5 fewer adverse outcomes per 100 patients receiving ESD. The results for death (16 trials, n=2116) and death or requiring institutional care (12 trials, n=1664) were OR 1.04 (95% CI 0.77 to 1.40) and OR 0.75 (95% CI 0.59 to 0.96, p = 0.02), respectively. Small improvements were also seen in participants' extended activities of daily living scores (SMD 0.14, 95% CI 0.03 to 0.25, p = 0.01) and satisfaction with services (OR 1.60, 95% CI 1.08 to 2.38, p = 0.02). There were no clear differences in participants' activities of daily living scores, patients subjective health status or mood, or the subjective health status, mood or satisfaction with services of carers. The risk of readmission to hospital was similar in the ESD and conventional care groups (OR 1.09, 95% CI 0.79 to 1.51). The evidence for the apparent benefits were weaker at 1- and 5-year follow-up. Estimated costs from 6 trials ranged from 23% lower to 15% greater for the ESD group vs. usual care.In a series of pre-planned analyses, the greatest reductions in death or dependency were seen in the trials evaluating a co-ordinated ESD team with a suggestion of poorer results in those services without it (p = 0.06). Stroke patients with mild to moderate disability at baseline showed greater reductions in death or dependency than those with more severe stroke (p = 0.04).