Early Supported Discharge for Stroke Patients Improves Clinical Outcome. Does It Also Reduce Use of Health Services and Costs?
Department of Public Health, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway. Cerebrovascular Diseases
(Impact Factor: 3.75).
02/2005; 19(6):376-83. DOI: 10.1159/000085543
An early supported discharge service (ESD) appears to be a promising alternative to conventional care. The aim of this trial was to compare the use of health services and costs with traditional stroke care during a one-year follow-up.
Three hundred and twenty patients were randomly allocated either to ordinary stroke unit care or stroke unit care combined with ESD which was coordinated by a mobile team. The use of all health services was recorded prospectively; its costs were measured as service costs and represent a combination of calculated average costs and tariffs. Hospital expenses were measured as costs per inpatient day and adjusted for the DRG.
There was a reduction in average number of inpatient days at 52 weeks in favour of the ESD group (p = 0.012), and a non-significant reduction in total mean service costs in the ESD group (EUR 18,937/EUR 21,824). ESD service seems to be most cost-effective for patients with a moderate stroke.
Acute stroke unit care combined with an ESD programme may reduce the length of institutional stay without increasing the costs of outpatient rehabilitation compared with traditional stroke care.
Available from: Inger Johansen
- "Others have shown that the one year costs of medical care after intensive rehabilitation of patients with hip-fractures did not differ significantly from medical care after standard hospital rehabilitation
. An acute stroke-unit care combined with an Early Supported Discharge programme may reduce the length of hospital stay and improve independence without increasing the costs of outpatient rehabilitation compared with traditional stroke care
. Intermediate level services like community hospitals, Early Supported Discharge services and home based rehabilitation also report on gain in the level of independence of older patients with different conditions
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ABSTRACT: The optimal setting and content of primary health care rehabilitation of older people is not known. Our aim was to study independence, institutionalization, death and treatment costs 18 months after primary care rehabilitation of older people in two different settings.
Eighteen months follow-up of an open, prospective study comparing the outcome of multi-disciplinary rehabilitation of older people, in a structured and intensive Primary care dedicated inpatient rehabilitation (PCDIR, n=202) versus a less structured and less intensive Primary care nursing home rehabilitation (PCNHR, n=100). Participants: 302 patients, disabled from stroke, hip-fracture, osteoarthritis and other chronic diseases, aged ≥65years, assessed to have a rehabilitation potential and being referred from general hospital or own residence. Outcome measures: Primary: Independence, assessed by Sunnaas ADL Index(SI). Secondary: Hospital and short-term nursing home length of stay (LOS); institutionalization, measured by institutional residence rate; death; and costs of rehabilitation and care. Statistical tests: T-tests, Correlation tests, Pearson’s χ2, ANCOVA, Regression and Kaplan-Meier analyses.
Overall SI scores were 26.1 (SD 7.2) compared to 27.0 (SD 5.7) at the end of rehabilitation, a statistically, but not clinically significant reduction (p=0.003 95%CI(0.3-1.5)). The PCDIR patients scored 2.2points higher in SI than the PCNHR patients, adjusted for age, gender, baseline MMSE and SI scores (p=0.003, 95%CI(0.8-3.7)). Out of 49 patients staying >28 days in short-term nursing homes, PCNHR-patients stayed significantly longer than PCDIR-patients (mean difference 104.9 days, 95%CI(0.28-209.6), p=0.05). The institutionalization increased in PCNHR (from 12%-28%, p=0.001), but not in PCDIR (from 16.9%-19.3%, p= 0.45). The overall one year mortality rate was 9.6%. Average costs were substantially higher for PCNHR versus PCDIR. The difference per patient was 3528€ for rehabilitation (p<0.001, 95%CI(2455–4756)), and 10134€ for the at-home care (p=0.002, 95%CI(4066–16202)). The total costs of rehabilitation and care were 18702€ (=1.6 times) higher for PCNHR than for PCDIR.
At 18 months follow-up the PCDIR-patients maintained higher levels of independence, spent fewer days in short-term nursing homes, and did not increase the institutionalization compared to PCNHR. The costs of rehabilitation and care were substantially lower for PCDIR. More communities should consider adopting the PCDIR model.
Clinicaltrials.gov ID NCT01457300
Available from: J.M.A. Visser-Meily
- "Fjaertoft et al.  observed a similar cost reduction of 13%. The patients who received care via the integrated stroke service also had a significantly higher Rankin scale (65 vs. 52% independence; p=0.02), "
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ABSTRACT: Given the high incidence of stroke worldwide and the large costs associated with the use of health care resources, it is important to define cost-effective and evidence-based services for stroke rehabilitation. The objective of this review was to assess the evidence on the relative cost or cost-effectiveness of all integrated care arrangements for stroke patients compared to usual care. Integrated care was defined as a multidisciplinary tool to improve the quality and efficiency of evidence-based care and is used as a communication tool between professionals to manage and standardize the outcome-orientated care.
A systematic literature review of cost analyses and economic evaluations was performed. Study characteristics, study quality and results were summarized.
Fifteen studies met the inclusion criteria; six on early-supported discharge services, four on home-based rehabilitation, two on stroke units and three on stroke services. The follow-up per patient was generally short; one year or less. The comparators and the scope of included costs varied between studies.
Six out of six studies provided evidence that the costs of early-supported discharge are less than for conventional care, at similar health outcomes. Home-based rehabilitation is unlikely to lead to cost-savings, but achieves better health outcomes. Care in stroke units is more expensive than conventional care, but leads to improved health outcomes. The cost-effectiveness studies on integrated stroke services suggest that they can reduce costs. For future research we recommend to focus on the moderate and severely affected patients, include stroke severity as variable, adopt a societal costing perspective and include long-term costs and effects.
Available from: Marc Rousseaux
- "The first is that this kind of study does not take account of the differences between the conventional health systems which are being compared with ESD. In this respect, one can note that the Norwegian and Swedish systems involve both relatively intense community rehabilitation care (including physiotherapy , occupational therapy and speech therapy) and social care    . This could help explain why some studies did not show any (or only minor) differences between ESD and standard care. "
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ABSTRACT: The goal of early supported discharge (ESD) is to reduce the duration of in-patient care in stroke units (SUs) and to optimize the management of pre- and post-discharge rehabilitation. Here, we report on and discuss ESD's effects on various outcome parameters in stroke patients.
Analysis of randomized, controlled studies and meta-analyses identified in the Medline and Cochrane databases.
ESD interventions have been evaluated in more than 10 studies. Most of the included patients had suffered from mild or moderate strokes. Meta-analyses have shown that when compared with standard care, ESD has a positive effect on the risk of death or institutionalisation, death or dependence and participation in instrumental activities of daily living (iADL). In-patient hospitalization in the SU and the overall cost of care were significantly lower. Individual studies showed variability in the inclusion criteria, type of care, comparisons performed and conclusions drawn. ESD's superiority in terms of the risk of death or dependency was mainly reported in a Norwegian study and that in terms of iADL was reported in a Swedish study. There was no specific effect on functional impairment and personal ADL (pADL).
This technique reduces the length of the in-patient stay and the overall cost of care while lowering the risk of death or institutionalisation and promoting participation in iADL. However, studies on this topic are heterogeneous.
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