Five-year follow-up of a randomized controlled trial of early supported discharge and continued rehabilitation at home after stroke

Abstract

Introduction: Stroke constitutes the second leading cause of death and the leading determinant of disability among the world population. Stroke is the single physiological condition that requires the most bed-days in Swedish hospitals. Today there is a consensus that the best care during the acute stage after stroke is provided by a dedicated stroke unit. However, the optimal organization of rehabilitation services after discharge from a stroke unit has not been determined. In southwest Stockholm, a service model of early supported discharge and continued rehabilitation at home (ESD) has been evaluated in a randomized controlled trial (RCT) 3, 6 and 12 months after stroke for patients with mild to moderate disability after stroke. The core components of the ESD service were: initial treatment in a stroke unit and the involvement of an outreach team with a casemanager, who coordinated the home-based rehabilitation in partnership with the patient. Twelve months after stroke, the ESD service was found to be more effective with regard to extended activities of daily living (ADL) while also reducing the length of the hospital stay and reducing costs by 20% compared with conventional rehabilitation.

Long-term follow-up for measuring the effects of rehabilitation is warranted, particularly if one aim of the intervention is to influence behavior. Results of follow-ups of ESD longer than 12 months after stroke have not been published. In order to accumulate more evidence about the effects of ESD, a 5year follow-up study was conducted.

Objective: The aim of the present study was to assess the effect of the ESD service on survival, functioning and utilization of health care and social services 5 years after stroke, in comparison with conventional rehabilitation in southwest Stockholm.

Methods: Eighty-three patients with mild to moderate disability 5 to 7 days after acute stroke, were enrolled in the RCT from September 1993 to April 1996. Patients who had participated in the 12months follow-up and who were alive and residing in Stockholm County 5 years after stroke were eligible for the 5-year follow-up. Measures used to assess patient outcome at the 5-year follow-up included survival, motor capacity, dysphasia, ADL, social activities, health-related quality of life and selfreported falls. Information on resource use included hospital and day hospital care, outpatient care and rehabilitation, use of community-based social services and informal care. Information was collected 1) by interviewing and testing the patient and interviewing his/her spouse during a home visit, and 2) from the computerized register of the Stockholm County Council.

Results Fifty-four patients-30 in the ESD group and 24 in the conventional rehabilitation groupwere evaluated 5 years after stroke, at which time a significantly larger proportion of patients in the ESD group were independent in extended ADL (p=0.04) and active in household activities (washing dishes p=0.006, washing clothes p= 0.04). A difference in the mean total length of hospitalization was observed (51 days in conventional rehabilitation group vs. 32 days in ESD group; p=0.02). Patients in the conventional rehabilitation group were more frequent consumers of outpatient rehabilitation (p=0.04), including physiotherapy in primary care (p=0.05).

Conclusion: This ESD service has a beneficial effect on extended ADL and resource utilization 5 years after stroke for patients with mild to moderate disability.