Role of Early Supported Discharge in Acute Stroke Patients

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    bya ccococarregnocomplementary medicine. The Stroke Trials Register nowcontains more than 7,000 reports in all languages, relating tomo


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    inpearlesdeintbewhThdischarge also appears to increase the patient, but interestinglynot caregiver, satisfaction, perhaps because the burden of care

    Vore than 3,300 individual trials.

    UDY SELECTIONStudies were included if they were RCTs of stroke patients,ntervention such as rehabilitation or physical support werevided in a community setting, and if the aim of the trial waselerated discharge home from the hospital (ie, randomizationes place during hospital admission). Trials were evaluated byndependent reviewers who decided on eligibility. Primarytient outcome was death or long-term dependency. Secondary

    would start earlier for the caregiver. The benefits of these resultsare masked by the fact that patients with less initial disabilitywere recruited and conclusions were based on a relatively smallnumber of trials.

    Cochrane Systematic Review Author ContactPeter Langhorne, MBChB, BSc, FRCP, PhDAcademic Section of Geriatric MedicineGlasgow, United KingdomE-mail:

    lume , . : May Annals of Emergency Medicine 693Role of Early Supported Disch

    EM Commentator Contacttha G. Stead, MDkshmi Vaidyanathan, MBBS

    From the Department of Emerg

    96-0644/$-see front matterpyright 2007 by the American College of Emergency Physicians.:10.1016/j.annemergmed.2006.12.001

    [Ann Emerg Med. 2007;49:693-695.]


    This is a systematic review abstract, a regular feature of thenals Evidence-Based Emergency Medicine (EBEM) features an abstract of a systematic review from thechrane Database of Systematic Reviews and a commentaryan emergency physician knowledgeable in the subject area.The source for this systematic review abstract is: LanghorneServices for reducing duration of hospital care for acuteoke patients (Cochrane review). Chichester, UK: Cochranerary; 2006; issue 2.The Annals EBEM editors helped prepare the abstract of thischrane systematic review, as well as the Evidence-Based

    edicine Teaching Points.

    JECTIVETo establish the effects and costs of early supported dischargevices compared with conventional services.

    TA SOURCESThe Cochrane Stroke Groups trials register was last searchedthe review group coordinator in August 2004. This register isompilation of randomized controlled trials (RCTs) andntrolled clinical trials. The register is the result of amprehensive and up-to-date trials identification programried out at the groups editorial base in Edinburgh. Theister includes studies of a wide range of pharmacologic andndrug interventions, including rehabilitation, surgery, andge in Acute Stroke Patients

    Medicine, Mayo Clinic, Rochester, MN.

    tcomes included the activities of daily living score, subjectivealth status, mood, caregiver mood and subjective healthtus, and patient and caregiver satisfaction. The primaryource outcomes were the length of the index hospital stay,e of readmissions, and cost.

    TA EXTRACTION AND ANALYSISIndividual patient data were obtained from the trialists, andetailed description of their intervention and control servicess sought. Where data were obtained from published sources,y were extracted by 2 independent reviewers using a standard

    ta extraction form. Data were sought on initial stroke severityctivities of Daily Living score during the first week poststroke).

    AIN RESULTSThe search strategy initially identified 28 potentially eligible

    als, of which the assessors agreed on the inclusion of 11 trials.pending on the available data, a summary of the relative risks for primary and secondary outcomes is provided in the Table.

    NCLUSIONSSelected stroke patients in a hospital setting who receivedut from an early supported discharge service returned homelier than those receiving conventional care. They were alsos likely to be in institutional care; they had decreased risk ofath or dependency, at approximately 5 to 6 per 100 in whomervention was undertaken. Not surprisingly, the greatestnefit was noted in patients with mild to moderate disabilityo had the most tightly coordinated early supported discharge.e multidisciplinary and structured nature of early supported

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    Table. Summary of results.

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    De 9 (0.6

    SeExt 2 (0.0

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    EBEM/Systematic Review Abstract

    69MMENTARY: CLINICAL IMPLICATIONStroke is the third leading cause of death in the United States

    d a major cause of serious, long-term disability.1 Successfulte stroke intervention depends on early recognition ofptoms, prompt emergency transport, and rapid in-hospital

    atment.2 Considering this increase in incidence, extensiveearch has been performed to improve patient care andctional outcome. RCTs have shown that care of stroke

    tients in dedicated stroke units improves outcome comparedth alternative forms of care and that beneficial effects are stilltectable 5 years after stroke.3,4

    This Cochrane review of early discharge after the initialoke unit care demonstrates that home-based rehabilitationd care is beneficial for patients, especially for those with mild

    ptoms. Physical and psychosocial elements of thevironment influence patients ability to perform desiredivities and attain targeted levels of participation duringabilitation.5,6 It has also been suggested that increased

    tient involvement in control of rehabilitation has a bettertcome and that diminished control can have an adverse effect emotional and physical health.7 Home-based rehabilitation is

    tcome Data Available in OR (95%

    maryathath or institutional care 9 Trials (1,398 patients) 0.7

    ath or dependency 11 Trials (1,597 patients) 0.7

    condary: patientended ADL 9 Trials (1,051 patients) SMD: 0.1

    alth status 10 Trials (1,154 patients)

    od Status 8 Trials (851 patients)

    tisfaction 5 Trials (513 patients) 1.6

    condary: resourcesgth of hospital stay 9 Trials (1015 patients) P

    admissions 5 Trials (663 patients)

    st 4 Trials (592 patients)

    , Activities of daily living; ESD, early supported discharge; NS, not significant; SMess commented on, no significant heterogeneity was noted among trials for given4 Annals of Emergency Medicinewn to increase motor and functional gain, with communityntegration and a better perception of physical health.8

    This systematic review is important to emergency physicianscause it highlights the need for stroke care to begin as earlypossible, with the emergency physicians identifying andtiating goal-directed management in the emergencypartment (ED) itself. According to the initial presentationd disability, potential candidates for early supported discharge

    be identified. Physical support and rehabilitation unitsuld also be contacted early to enable early supportedcharge. Communication can be sent to the stroke unit andabilitation department on presentation to the ED. Resultsthis review lend themselves to the creation of a streamlinedtocol whereby the appropriate services such as neurology,

    ysical medicine and rehabilitation, social services, speech andcupational therapy, and psychology could be automaticallyployed as early as ED presentation.The most important limitations in the application of theseults stem from the fact that they are based on a limitedmber of studies and their estimates are influenced by themission disability. For example, an overall decrease in hospital

    r P Value Comment

    No significant difference for single endpoint of death60.96) Patients with missing data (17 intervention patients,

    18 controls) assumed to be alive andindependent. Significant reduction in odds ofdeath or institutional care, equivalent to an extra5 patients regaining independence for every 100treated.

    40.97) Patients with missing data (17 intervention patients,18 controls) assumed to be alive andindependent. Significant reduction in combinedadverse outcome, equivalent to an extra 6patients regaining independence for every 100receiving ESD.

    00.25) Apparent increase in extended ADL scores amongsurvivors receiving ESD.

    No significant difference in the subjective healthstatus scores of both groups.

    Overall, there was no significant difference in moodscores.

    82.38) Significantly more likely to report satisfaction withinpatient services.

    1 Reduction in the length of hospital stay, which isapproximately equivalent to 8 days.

    Readmission rates during scheduled follow-up weresimilar between the ESD service and conventionalcare groups.

    Estimated costs were 9% to 20% less in the ESDgroup than controls.

    andardized mean difference.ble.shorei



    D, stvariaVolume , . : May

  • length of stay is noted. Some of this is influenced by the localpractices of individual countries; in countries in which thehospital length of stay is already shorter than average, thesame benefit may not be possible. Furthermore, the decrease inshorter hospitalization lengths is primarily driven by the moresevere strokes, and one questions whether shorter stays forthe sickest patients are truly possible or beneficial. Anotherlimitation is that patients with missing data for death outcomeswere assumed to be alive and independent, which would biasthe benefit of early supported discharge measures. Theseconcerns notwithstanding, the concept of early supporteddischarge, which requires the formal cooperation of all thoseinvolved in the care of a stroke victim, is a proactive approachthat deserves further study.






    Problems in the interpretation of these trials arise whencomposite endpoints include component outcomes to whichpatients attribute very different importance.10 Compositeendpoints are acceptable, provided the endpoints are ofequivalent importance to the patient. For example, thecomposite endpoints of stroke or myocardial infarctionwould be appropriate, whereas combining stroke, need foranticoagulation, or repeated hospitalization would not be,because stroke is a far more severe outcome than the other 2.Especially when including softer endpoints such asrehospitalization or need for chronic medication, the frequencyof these softer endpoints should not outweigh the moreclinically meaningful endpoint. The best composite endpointsare those that are clinically meaningful, standardized, andpreferably unaffected by bias.











    EBEM/Systematic Review Abstract

    VoWith an increase in the incidence of strokes, emergencyysicians can expect to encounter more cases in the ED.cording to this review, early initiation of supported dischargeasures in the ED, in addition to conventional care, mayuce the total duration of hospital stay and thus reduceoverall cost of hospitalization, depending on the initialsentation and disability. Some might argue that large RCTsthis patient population are urgently needed to answer thisestion definitively; however, in the meantime, this is yetother example of the need for emergency physicians to linkth their specialist colleagues to improve the care providedpatients from the time they present to the ED.

    EM Commentator Contacttha G. Stead, MDpartment of Emergency Medicineyo Clinic College of Medicinechester, MNmail:

    EM TEACHING POINTComposite endpoints. Composite endpoints refer to groupedtcomes. Investigators often use composite endpoints tohance the statistical precision and efficiency of clinical trials.9lume , . : May American Heart Association. Heart and Stroke Statistics. Availableat: Accessed December 29, 2006.Place of death after stroke: United States, 1999-2002. MMWRMorb Mortal Wkly Rep. 2006;55:529-532.Jorgensen HS, Kammersgaard LP, Nakayama H, et al. Treatmentand rehabilitation on a stroke unit improves 5-year survival:a community-based study. Stroke. 1999;30:930-933.Thorsen AM, Holmqvist LW, de Pedro-Cuesta J, et al. Arandomized controlled trial of early supported discharge andcontinued rehabilitation at home after stroke: five-year follow-upof patient outcome. Stroke. 2005;36:297-303.Disler PB, Wade DT. Should all stroke rehabilitation be homebased? Am J Phys Med Rehabil. 2003;82:733-735.von Koch L, Wottrich AW, Holmqvist LW. Rehabilitation in thehome versus the hospital: the importance of context. DisabilRehabil. 1998;20:367-372.Partridge C, Johnston M. Perceived control of recovery fromphysical disability: measurement and prediction. Br J Clin Psychol.1989;28:53-59.Mayo NE, Wood-Dauphinee S, Cote R, et al. Theres no place likehome: an evaluation of early supported discharge for stroke.Stroke. 2000;31:1016-1023.Kleist P. Composite endpoints: proceed with caution. Appl ClinTrials. 2006; May:3.

    . Montori VM, Permanyer-Miralda G, Ferreira-Gonzlez I, et al.Validity of composite end points in clinical trials. BMJ. 2005;330:594-596.Annals of Emergency Medicine 695


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