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      Early supported discharge after stroke in Bergen (ESD Stroke Bergen): three and six months results of a randomised controlled trial comparing two early supported discharge schemes with treatment as usual

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          Abstract

          Background

          Stroke causes lasting disability and the burden of stroke is expected to increase substantially during the next decades. Optimal rehabilitation is therefore mandatory. Early supported discharge (ESD) has previously shown beneficial, but all major studies were carried out more than ten years ago. We wanted to implement and study the results of ESD in our community today with comparisons between ESD and treatment as usual, as well as between two different ESD models.

          Methods

          Patients with acute stroke were included during a three year period (2008–11) in a randomised controlled study comparing two different ESD models to treatment as usual. The two ESD models differed by the location of treatment: either in a day unit or in the patients’ homes. Patients in the ESD groups were followed by a multi-disciplinary ambulatory team in the stroke unit and discharged home as early as possible. The ESD models also comprised treatment by a multi-disciplinary community health team for up to five weeks and follow-up controls after 3 and 6 months. Primary outcome was modified Rankin Scale (mRS) at six months.

          Results

          Three-hundred-and-six patients were included. mRS scores and change scores were non-significantly better in the two ESD groups at 3 and 6 months. Within-group improvement from baseline to 3 months was significant in the ESD 1 (p = 0.042) and ESD 2 (p = 0.001) groups, but not in the controls. More patients in the pooled ESD groups were independent at 3 (p = 0.086) and 6 months (p = 0.122) compared to controls and there also was a significant difference in 3 month change score between them (p = 0.049). There were no differences between the two ESD groups. Length of stay in the stroke unit was 11 days in all groups.

          Conclusions

          Patients in the ESD groups tended to be more independent than controls at 3 and 6 months, but no clear statistically significant differences were found. The added effect of supported discharge and improved follow-up seems to be rather modest. The improved stroke treatment of today may necessitate larger patient samples to demonstrate additional benefit of ESD.

          Clinical trial registration

          Unique identifier: NCT00771771

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          Most cited references12

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          Services for reducing duration of hospital care for acute stroke patients.

          Stroke patients conventionally receive a substantial part of their rehabilitation in hospital. Services have now been developed which offer patients in hospital an early discharge with rehabilitation at home (early supported discharge (ESD)). To establish the effects and costs of ESD services compared with conventional services. We searched the trials registers of the Cochrane Stroke Group (January 2012) and the Cochrane Effective Practice and Organisation of Care (EPOC) Group, MEDLINE (2008 to 7 February 2012), EMBASE (2008 to 7 February 2012) and CINAHL (1982 to 7 February 2012). In an effort to identify further published, unpublished and ongoing trials we searched 17 trial registers (February 2012), performed citation tracking of included studies, checked reference lists of relevant articles and contacted trialists. Randomised controlled trials recruiting stroke patients in hospital to receive either conventional care or any service intervention which has provided rehabilitation and support in a community setting with an aim of reducing the duration of hospital care. The primary patient outcome was the composite end-point of death or long-term dependency recorded at the end of scheduled follow-up. Two review authors scrutinised trials and categorised them on their eligibility. We then sought standardised individual patient data from the primary trialists. We analysed the results for all trials and for subgroups of patients and services, in particular whether the intervention was provided by a co-ordinated multidisciplinary team (co-ordinated ESD team) or not. Outcome data are currently available for 14 trials (1957 patients). Patients tended to be a selected elderly group with moderate disability. The ESD group showed significant reductions (P < 0.0001) in the length of hospital stay equivalent to approximately seven days. Overall, the odds ratios (OR) (95% confidence interval (CI)) for death, death or institutionalisation, death or dependency at the end of scheduled follow-up were OR 0.91 (95% CI 0.67 to 1.25, P = 0.58), OR 0.78 (95% CI 0.61 to 1.00, P = 0.05) and OR 0.80 (95% CI 0.67 to 0.97, P = 0.02) respectively. The greatest benefits were seen in the trials evaluating a co-ordinated ESD team and in stroke patients with mild to moderate disability. Improvements were also seen in patients' extended activities of daily living scores (standardised mean difference 0.12, 95% CI 0.00 to 0.25, P = 0.05) and satisfaction with services (OR 1.60, 95% CI 1.08 to 2.38, P = 0.02) but no statistically significant differences were seen in carers' subjective health status, mood or satisfaction with services. The apparent benefits were no longer statistically significant at five-year follow-up. Appropriately resourced ESD services provided for a selected group of stroke patients can reduce long-term dependency and admission to institutional care as well as reducing the length of hospital stay. We observed no adverse impact on the mood or subjective health status of patients or carers.
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            The impact of stroke.

            The socio-economic impact of stroke is considerable world-wide. Stroke is assuming an increasing impact in terms of media attention, patient and career knowledge, service developments and research. It is estimated that there are 4.5 million deaths a year from stroke in the world and over 9 million stroke survivors. Almost one in four men and nearly one in five women aged 45 years can expect to have a stroke if they live to their 85th year. The overall incidence rate of stroke is around 2-2.5 per thousand population. The risk of recurrence over 5 years is 15-40%. It is estimated that by 2023 there will be an absolute increase in the number of patients experiencing a first ever stroke of about 30% compared with 1983. There is a total prevalence rate of around 5 per thousand population. One year after a stroke, 65% of survivors are functionally independent, stroke comprising the major cause of adult disability.
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              Rehabilitation for community-dwelling people with stroke: home or centre based? A systematic review.

              Stroke rehabilitation for people living in the community is commonly delivered either in a centre, outpatient or day hospital setting. More recently, services may be offered in the actual home of the person as home-based or domiciliary rehabilitation. There are differing reports of the benefits and barriers of home-based vs. centre-based community rehabilitation. This systematic review sought to pool data from all retrieved studies that compared the functional benefits of home-based vs. centre for community-dwelling people with stroke. A comprehensive search strategy was implemented in all major databases (Cochrane library, Medline, AMED, Embase, Ageline, Cinahl, PEDro) for randomised controlled trials investigating this question in relation to functional benefits as a primary outcome and carer, cost or other benefits as secondary outcomes. There were no language or date limits. Eleven trials were found and results pooled for the Barthel Index, the measure of functional independence used consistently across the majority of retrieved studies. There was a significant effect in favour of home-based rehabilitation at 6 weeks (P=0.03) and 3-6 months (P=0.01). The effects were less clear at 6 months, although this was using the less sensitive version of the Barthel Index (P=0.27 or adjusted P=0.04). Individual studies reported cost benefits and increased carer satisfaction in favour of home-based rehabilitation. The provision of rehabilitation for people living in the community should trend towards home-based. Further research is required into adverse events and the experiences of all stakeholders.
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                Author and article information

                Contributors
                hhof@helse-bergen.no
                bente.elisabeth.bassoe.gjelsvik@helse-bergen.no
                haln@helse-bergen.no
                geir.egil.eide@helse-bergen.no
                jan.skouen@helse-bergen.no
                Journal
                BMC Neurol
                BMC Neurol
                BMC Neurology
                BioMed Central (London )
                1471-2377
                21 December 2014
                21 December 2014
                2014
                : 14
                : 1
                : 239
                Affiliations
                [ ]Department of Physical Medicine and Rehabilitation, Haukeland University Hospital, PO Box 1400, Bergen, N-5021 Norway
                [ ]Department of Global Public Health and Primary Care, Physiotherapy Research Group, University of Bergen, Bergen, Norway
                [ ]Department of Physiotherapy, Haukeland University Hospital, Bergen, Norway
                [ ]Department of Neurology, Haukeland University Hospital, Bergen, Norway
                [ ]Centre for Age-related Medicine, Stavanger University Hospital, Stavanger, Norway
                [ ]Institute of Clinical Medicine, University of Bergen, Bergen, Norway
                [ ]Centre for Clinical Research, Haukeland University Hospital, Bergen, Norway
                [ ]Department of Global Public Health and Primary Care, Lifestyle Epidemiology Research Group, University of Bergen, Bergen, Norway
                Article
                239
                10.1186/s12883-014-0239-3
                4301654
                25528166
                711c9a25-f032-4e6d-8537-b561c4fd9881
                © Hofstad et al.; licensee BioMed Central. 2014

                This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                History
                : 5 August 2014
                : 1 December 2014
                Categories
                Research Article
                Custom metadata
                © The Author(s) 2014

                Neurology
                stroke,randomised controlled trial,rehabilitation,early supported discharge,esd,community rehabilitation

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