Dataset Information

Effect of stroke early supported discharge on length of hospital stay: analysis from a national stroke registry.

ABSTRACT:

Objective

The first observational study to investigate the impact of early supported discharge (ESD) on length of hospital stay in real-world conditions.

Design

Using historical prospective Sentinel Stroke National Audit Programme (SSNAP) data (1 January 2013-31 December 2016) and multilevel modelling, cross-sectional (2015-2016; 30 791 patients nested within 55 hospitals) and repeated cross-sectional (2013-2014 vs 2015-2016; 49 266 patients nested within 41 hospitals) analyses were undertaken.

Setting

Hospitals were sampled across a large geographical area of England covering the West and East Midlands, the East of England and the North of England.

Participants

Stroke patients whose data were entered into the SSNAP database by hospital teams.

Interventions

Receiving ESD along the patient care pathway.

Primary and secondary outcome measures

Length of hospital stay.

Results

When adjusted for important case-mix variables, patients who received ESD on their stroke care pathway spent longer in hospital, compared with those who did not receive ESD. The percentage increase was 15.8% (95% CI 12.3% to 19.4%) for the 2015-2016 cross-sectional analysis and 18.8% (95% CI 13.9% to 24.0%) for the 2013-2014 versus 2015-2016 repeated cross-sectional analysis. On average, the increased length of hospital stay was approximately 1 day.

Conclusions

This study has shown that by comparing ESD and non-ESD patient groups matched for important patient characteristics, receiving ESD resulted in a 1-day increase in length of hospital stay. The large reduction in length of hospital stay overall, since original trials were conducted, may explain why a reduction was not observed. The longer term benefits of accessing ESD need to be investigated further.

Trial registration number

http://www.isrctn.com/ISRCTN15568163.

SUBMITTER: Fisher RJ

PROVIDER: S-EPMC7818805 | biostudies-literature |

REPOSITORIES: biostudies-literature

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Project description:BackgroundImplementation of stroke early supported discharge (ESD) services has been recommended in many countries' clinical guidelines, based on clinical trial evidence. This is the first observational study to investigate the effectiveness of ESD service models operating in real-world conditions, at scale.Methods and resultsUsing historical prospective data from the United Kingdom Sentinel Stroke National Audit Programme (January 1, 2016-December 31, 2016), measures of ESD effectiveness were "days to ESD" (number of days from hospital discharge to first ESD contact; n=6222), "rehabilitation intensity" (total number of treatment days/total days with ESD; n=5891), and stroke survivor outcome (modified Rankin scale at ESD discharge; n=6222). ESD service models (derived from Sentinel Stroke National Audit Programme postacute organizational audit data) were categorized with a 17-item score, reflecting adoption of ESD consensus core components (evidence-based criteria). Multilevel modeling analysis was undertaken as patients were clustered within ESD teams across the Midlands, East, and North of England (n=31). A variety of ESD service models had been adopted, as reflected by variability in the ESD consensus score. Controlling for patient characteristics and Sentinel Stroke National Audit Programme hospital score, a 1-unit increase in ESD consensus score was significantly associated with a more responsive ESD service (reduced odds of patient being seen after ≥1 day of 29% [95% CI, 1%-49%] and increased treatment intensity by 2% [95% CI, 0.3%-4%]). There was no association with stroke survivor outcome measured by the modified Rankin Scale.ConclusionsThis study has shown that adopting defined core components of ESD is associated with providing a more responsive and intensive ESD service. This shows that adherence to evidence-based criteria is likely to result in a more effective ESD service as defined by process measures. Registration: URL: http://www.isrctn.com/; Unique identifier: ISRCTN15568163.

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Project description: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.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.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.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.Unique identifier: NCT00771771.

Project description:Objective'More is better' is a recognised mantra within stroke therapy, however, this has been developed in patients receiving long term rehabilitation. We investigated the relationship between amount of therapy received (from therapists and psychologists) and key patient outcomes during inpatient care.DesignA secondary analysis of data from a prospective cohort study was performed. Multilevel mixed models adjusting for measured confounders (eg, severity), explored the relationship between therapy dose (average minutes per day of stay) and outcomes (disability, length of stay, home at discharge and mortality). Therapy was explored using simple linear terms and flexible natural cubic splines to allow for more complex relationships.SettingData from the Sentinel Stroke National Audit Programme, covering England, Wales and Northern Ireland between July 2013 and July 2015 contained 94 905 adults with a stroke and still an inpatient after 72 hours. These patients received 92% (physiotherapy), 88% (occupational therapy), 57% (speech and language therapy) and 5% (clinical psychology), respectively.ResultsThe average amount of therapy, for individual and 'any' therapy combined per day of stay was low. Overall, 41% were discharged with an 'independent' modified Rankin Scale (≤2), 14% died, 44% were discharged home, and the median length of stay was 16 days. We observed complex relationships between amount of therapy received and outcomes. An additional minute of 'any' therapy, occupational therapy, speech and language therapy and clinical psychology was associated with improved outcomes. Conversely, more physiotherapy was also associated with lower mortality and shorter length of stay, but also lower independence and discharge home.ConclusionsOur findings suggest for stroke inpatients requiring therapy, 'More is better' may be overly simplistic. Strong limitations associated with analysis of routine data restrict further robust investigation of the therapy-response relationship. Robust prospective work is urgently needed to further investigate the relationships observed here.