Development and evaluation of rehabilitation at home after stroke in south-west Stockholm

Abstract

In Sweden (population 8.8 million) the great majority of patients with acute stroke are admitted to hospital. Each year 10 000-12 000 patients develop persistent disability. This thesis consists of a set of consecutive studies on: 1) the estimated need for late stroke rehabilitation and the basis for such an intervention among non-institutionalized individuals in south-west Stockholm (SWS); 2) the feasibility and health-economic implications of rehabilitation at home after acute stroke; 3) an experimental evaluation of rehabilitation at home for moderately disabled stroke patients.

On the basis of telephone interviews, we estimated the prevalent need for late stroke rehabilitation as being at least one per 1000 in SWS. The average duration of hospital stay for such patients was 95 days. Social and leisure activities were identified as the most promising goals for late rehabilitation programmes. We concluded that early rehabilitation in the community, linked to post-acute stroke care with reduction of hospital stay, would be functionally and socially advantageous and cost-effective for more than 25% of the incident stroke cases.

A pilot study of rehabilitation at home after stroke at the Department of Neurology at Huddinge Hospital in SWS showed that the target group embraced patients who were independent in feeding and continent, had mental function within normal limits, and residual motor and/or speech dysfunction one week after acute stroke. The most important components of the rehabilitation programme were: 1) training at home, consisting of task- specific activities, based on the patients' personal interests; 2) one therapist being selected as case-manager; 3) education and individual counselling being offered to all spouses; and 4) emphasis on adherence to structured training between therapy sessions.

Home rehabilitation patients had a mean duration of hospital stay of 14 days and on average received 11 home visits. During the first year after stroke, the average per capita cost of health care for these patients was 127 730 SEK, broken down as follows: hospital care, 50%; family caregivers, 18%; rehabilitation at home, 10%; out-patient visits to physicians and nurses, 9%; home-help service, 7%; auxiliary equipment, 2%; medication, 2%; home adaptation, 1%; and transportation service, under 1%.

Based on the results of the pilot study, we proposed and conducted a randomized controlled trial (on-going and currently at the 3-month follow-up stage) of rehabilitation at home for moderately disabled stroke patients. A total of 81 patients were followed-up at 3 months. Overall, there were no statistically significant differences in patient outcome. Multivariate logistic regression suggested a positive effect for the home rehabilitation group (HRG) in social activity, activities of daily living, motor capacity, manual dexterity and walking. A 52% reduction in bed-days was observed, from 29 days in the routine rehabilitation group to 14 days in the HRG, associated with a small increase (3 visits/patient) in total number of out-patient visits to physicians and nurses. After discharge, the mean number of home visits in the HRG was 10. No major differences in use of home help, impact on family caregivers in the form of time devoted to helping the patient or subjective well- being of spouses were found. Patient satisfaction favoured the HRG, with a significant difference in active participation in rehabilitation programme planning.

The above led us to conclude that early supported discharge with continuity of rehabilitation at home could be the rehabilitation service of choice for the majority of moderately disabled stroke patients, provided that follow-up at 6 and 12 months confirm the suggested enhanced effectiveness, the considerable reduction in use of health care and low impact on family caregivers. Rehabilitation at home after stroke could become an important component of stroke units. This research strategy may be useful for developing stroke rehabilitation in Scandinavian and other populations.