1. Evidence for Early Supported Discharge. Peter Langhorne Professor of Stroke Care University of Glasgow

2. Early Supported Discharge Trialists 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

3. Early supported discharge Background and Definitions Systematic Review of ESD services — Methodology — Results (Effectiveness and Cost Effectiveness) Implementing ESD Services Conclusions

4. 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).

5. Integrated Stroke Service - objectives Primary Prevention? Admission avoidance Inpatient Assessment Acute Care Prevention Rehabilitation Continuing Support and Prevention Long term support and re-assessment of needs Outpatient Assessment Prevention Patient

6. 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)

7. Integrated Stroke Service - objectives Primary Prevention? Inpatient Assessment Acute Care Prevention Rehabilitation Continuing Support and Prevention Long term support and re-assessment of needs Outpatient Assessment Prevention Patient Early Supported Discharge Service

8. Conventional Services Acute Rehabilitation Support Admission Discharge Review Hospital Home

9. Early Supported Discharge Acute Rehab Admission Discharge Review Hospital Home Rehab Support

10. Early Supported Discharge Potential Risks and Benefits Potential Benefits Home Better Setting for Rehabilitation Favoured by Patients and Carers Free Hospital Beds Reduce Costs Potential Risks Unable to manage medical problems Strain on Patients and Carers Expensive if done well Increase Costs

11. 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

12. Why we need systematic reviews (meta-analyses) Trials of small size Single Centre Publication bias Lack power and prone to chance Limited external validity (applicability) Need to examine all similar trials

13. 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)

14. Early Supported Discharge Trials North America Montreal New York United Kingdom Belfast London Manchester Newcastle Scandinavia Akerhus Oslo Stockholm Trondheim S.E. Asia Bangkok Australia Adelaide

15. 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)

16. Patient Selection Patients Selected Condition unstable Severe dependency Confusion Live in PNH Medically stable Persisting disability Able to comply Live Locally Good Recovery 40 (12-70) % of admissions

17. 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

18. Early supported discharge service vs. conventional care – Outcome Death or dependency Treatment n/H Control n/H OR (95% CI Fixed) 125-5-2 Favours ControlFavours Treatment MDT coordination and delivery Adelaide Belfast London Montreal Newcastle Stockholm Subtotal (95% CI) MDT Coordinators Oslo Trondheim Subtotal (95%CI) No MDT Coordination Akershus Bangkok Subtotal (95%CI) Total (95%CI) Test for heterogeneity chi-square =7.63 df=9 p=0.57 Test for Overall effect z=2.17 p=0.03 Study 13/42 29/59 105/167 17/58 22/46 9/42 195/414 16/42 64/160 80/202 70/124 9/52 79/176 354/792 16/44 32/54 109/164 24/56 28/46 12/41 221/405 17/40 81/160 98/200 61/127 11/50 72/177 391/782 0.72 (0.54,0.96) 0.68(0.46,1.01) 1.23(0.79,1.91) 0.80(0.65,0.98) OR (95% CI Fixed)

19. 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 — 6 (1,10) P=0.02 Independent (6-12 months)

20. 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

21. Subgroup analysis – Patient Characteristics Treatment n/H Control n/H OR (95% CI Fixed) 125-5-2 Favours ControlFavours Treatment 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 53/124 93/224 134/231 140/259 141/321 36/133 195/381 111/127 161/345 57/251 48/123 101/203 150/246 140/257 140/315 106/204 193/358 109/145 195/336 72/246

22. Subgroup analysis – Service Characteristics Treatment n/H Control n/H OR (95% CI Fixed) 125-5-2 Favours ControlFavours Treatment Presence of Carer No Yes ESD Characteristics MDT Coordination No MDT coordination Hospital Outreach Community in reach Control Service Stroke Unit Other Wards 96/199 185/381 275/616 79/176 102/286 252/506 203/476 151/316 106/204 193/368 319/605 72/177 126/285 265/497 225/476 166/305

23. 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?

24. 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

25. Implementation - example Admission to hospital Discharge from hospital Discharge from ESD Contact with patient/Carer Identify Key worker Home Assessment Plan discharge Agree rehabilitation Goals Implement Rehabilitation plan Access relevant services MDT review of progress Negotiate withdrawal

26. 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)

27. Integrated Stroke Service - Components Patient Rapid access neurovascular clinic Comprehensive Stroke Unit Early Supported Discharge Inpatient Rehabilitation Continuing Rehabilitation Long term support and reassessment of needs Key 1)TIA 2)Mild 3)Moderate 4)Severe (1)(2,3,4) (3,4)(2,3) (1) (2)

28. Early Supported Discharge Services 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!