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the Geriatric Department B (C.R.T., S.V., K.D.P., F.R.H.), Glostrup University Hospital, Denmark
the Research Centre for Prevention and Health (T.J., I.W.), Copenhagen County, Glostrup, Denmark
CAST - Centre for Applied Health Services Research and Technology Assessment (J.O.), University of Southern Denmark.
Abstract
Background and Purpose— Readmission rate within 6 months after a stroke is 40% to 50%. The purpose of the project was to evaluate whether an interdisciplinary stroke team could reduce length of hospital stay, readmission rate, increase patient satisfaction and reduce dependency of help.
Methods— One hundred and ninety-eight patients with acute stroke were randomized into 103 patients whose discharge was supported by an interdisciplinary stroke team and 95 control patients who received standard aftercare. Baseline characteristics were comparable in the 2 groups. The patients were evaluated after 6 and 12 months regarding functional status and need for help.
Results— Length of hospital admission was insignificantly shorter in the intervention compared with the control group (35.2 versus 39.8 days). There was no significant difference in readmission, GP-visits, and primary health care services. Furthermore, there was no significant difference in functional scores or patient satisfaction.
Conclusions— In this setting we could not show benefit of an interdisciplinary stroke team supporting patients at discharge perhaps because standard aftercare was very efficient already.
Key Words: randomized controlled trial rehabilitation
Introduction
In Denmark 12 000 patients are annually admitted to hospital with acute stroke. The 30 days mortality is about 20%, and the risk of recurrent stroke within the first year is 10% to 15%.1 In Europe there is consensus about the basic elements of the acute hospital treatment and inpatient rehabilitation.2,3 As a consequence most acute stroke patients are admitted to a stroke unit, which has led to a shortened length of stay and reduction in loss of function.4–8 In spite of this, many stroke patients still have functional reduction leading to increased need for home care facilities and readmission rate within 6 months of up to 40% to 50% mainly attributable to falls and comorbidity.3–11
Several studies on different models for discharge and follow-up for stroke patients have been performed with varying effect, and there is still no consensus concerning care of stroke patients after discharge.4,12–15
Studies of home visits carried out by a geriatric team after discharge of frail elderly patients have shown a significant reduction of readmission rates during the following year.16–18
Experiences from a multidisciplinary stroke unit8 and a geriatric team,16 focusing on personal continuous discharge planning, led to the development of an interdisciplinary stroke team. The team supported functionally limited stroke patients during hospital discharge at home visits and by personal coordination of the rehabilitation and home care in order to reduce functional loss after discharge. In Denmark the concept of such an interdisciplinary stroke team had not yet been evaluated in a controlled trial. Considering the high amount of resources spent on this patient group during hospital admission as well as during home care facilities, the aim of the present investigation was to evaluate whether an interdisciplinary stroke team could improve the existing discharge planning.
Materials and Methods
Patients
All patients in 6 municipalities (Glostrup, Hvidovre, Brndby, Hje Tstrup, Vallensbk and Albertslund) admitted to Glostrup University Hospital with stroke in the period February 1, 2001 to January 31, 2003 were evaluated for inclusion. Inclusion criteria were a diagnosis of acute stroke defined by the World Health Organization criteria19 and a stroke-related functional impairment that required hospital admission for >1 week after the acute stay. Exclusion criteria were severe comorbidity that prevented rehabilitation, severe aphasia, discharge to a nursing facility or rehabilitation home, or earlier inclusion in the project. Each municipality was a priori divided into 2 areas comparable as regarding age and sex of the population and social services based on discussion with the primary health care service. By computer-generated random numbers, the 2 parts of each municipality were randomized into either intervention area or control area (cluster randomization). This way all patients were prerandomized according to their address.
According to the hospital administration registration system, a total of 1956 patients were admitted to Glostrup University Hospital February 1, 2001 to January 31, 2003, with a diagnosis of acute stroke (Figure 1). The majority of patients were discharged within 7 days because of transient attacks. Of the patients who needed further hospital support, 410 patients were consecutively included in the study in the common geriatric/neurological rehabilitation ward. A total of 37 patients were not examined attributable to clerical errors, 13 patients died during their hospital stay, and 162 were excluded because of severe comorbidity, discharge to nursing home, or discharge to 24-hour training facility in the municipality. This left 198 patients (103 in the intervention group and 95 in the control group) for further study (Figure 1). Comparison of the excluded and included patients showed no significant differences regarding age and gender (data not shown). All patients signed an informed consent.
Rehabilitation
Patients in the control group received the standard treatment for stroke patients. This included transferral to the rehabilitation ward, where training and further rehabilitation planning was carried out. Discharge planning in the rehabilitation ward included meetings with close relatives and the coordinating public health nurses from the patients’ municipality. Furthermore, home visits were arranged before discharge. After discharge control patients received home care services, day care center and physiotherapy as did the intervention patients.
Patients in the intervention group were allocated to the care of an interdisciplinary stroke team. This team consisted of an occupational therapist, a physiotherapist and a physician from the rehabilitation unit who followed the intervention patients during their hospital stay through conferences and personal communication with staff members. The stroke team worked as an independent team inside the stroke rehabilitation ward. The therapists took over the training and carried out home-visits during the last 7 days of the hospital stay to ensure a personal contact with the patient before discharge. The physician was used as a medical consultant in cases of doubt about medical treatment and doubt concerning health questions. After discharge the therapists carried out a comprehensive rehabilitation program for the patients for up to 30 days with a maximum of 10 home visits. They supervised patient, relatives, and home care professionals and handed over the care of the patient to local home care services through personal contact to the relevant health staff (Figure 1).
Assessments
Assessments of the patients were made at inclusion, at discharge, and after 26 weeks and 52 weeks. Assessment was performed through questionnaires, structural interviews, and central registers (Figure 2). Assessments included demographics, health status, occupational status, education, comorbidity, lifestyle, and community care services. The patients functional scores were assessed by Barthel Index (BI)20,21 and Frenchay Activity Index.22–24 Cognitive evaluation was performed with Mini Mental State Examination4 and CT-50,25 and depression was assessed by Geriatric Depression Scale.26,27 Quality of life was assessed by SF-36.28
The stroke team made assessments during admission, whereas independent therapists not aware of the randomization of the patients performed assessment after 26 weeks. The stroke team contacted the municipal home care services 1 year after discharge for information about use of public health care services such as home care, home-nurse, day care facilities, and nursing home.
Data on hospital admissions, outpatient visits and use of services in primary health care were collected from the Copenhagen County Social Register for the period 1 year before the acute hospitalization and 1 year after discharge. These data included diagnosis, length of hospital stay, outpatient services, primary health care services, and costs related to these services.29–31 Information about mortality was collected from the Danish Civil Registration system.
Statistics
Wilcoxon 2-sample test was used for continuous variables and 2 test and Fisher exact test for categorical variables. To compare length of hospital stay (LOHS) linear regression was used to control for potential confounders (gender, age, network, education and BI). Changes over time in continuous variables were tested through Wilcoxon 2-sample test, whereas changes in categorical variables were tested through either logistic or proportional odds regression models. All estimates were adjusted for values at baseline. No correction for cluster randomization was performed.
Difference in costs between the intervention and control group (incremental costs) was valued as difference in length of stay during the acute hospitalization (LOHS), extra time spent by the interdisciplinary stroke team, readmissions and differences in home care by the public health nurse, day care facilities, nursing home, meals on wheels, and private help. The costs were valued by using predefined charges and salaries.29,30,31 A reduction in the hospitalization period attributable to hospital-supported discharge would as a minimum save hotel costs. Hotel costs include costs related to food, care, linen, cleaning, buildings and the like. The daily hotel cost was approximated by the bed day charge used in the Danish DRG system for reimbursement of hospital days in excess of the normal hospital admission period.29 It is estimated that this charge (201 EUR/d) reasonably precisely reflects the costs of hospital days at the end of a period of hospitalization (supplemental Figure I, available online at http://stroke.ahajournals.org).
All analyses were performed according to intention-to-treat on discharge patients. Level of significance was set to 5%. Statistical procedures were made using the SAS program version 8e.
Results
Compared with the control group, patients in the intervention group had a significantly better social network at baseline (Table 1), and the number of hospital admissions were significantly fewer (Table 2). Otherwise there were no significant differences at baseline between the 2 groups on a number of parameters (Table 1 and 2).
The average length of stay (LOHS) was 35.2 days for the intervention group and 39.8 days for the control group, which was not significantly different (–4.6 days, 95% CI: –12.4 days; 3.1 days). In a subgroup analysis including only moderately functionally limited patients (discharge BI Score 26 to 79), we found no significant difference regarding LOHS either (+1.0 day; P=0.61).
The total number of admissions, outpatient visits, and contact to primary health care increased in both groups in a 1-year period after the acute admission with stroke. The trend was toward more health care contacts in the intervention group compared with the control group, but the difference was not significant (Table 2). The increase in number of contacts in primary health care was primarily related to GP-visits and laboratory analyses. Looking only at stroke or stroke related readmission the same trend was seen (data not shown). In a subgroup analysis of patients with a discharge BI Score of 26 to 79, there was no significant difference as regarding readmissions (data not shown).
The frequency of home care service, public nurse visits at home, and use of day care centers was not significantly different between the groups (Table 3). No significant differences were found as regards BI, Mini Mental State Examination, SF-36, coping, self-evaluated function or social network between the groups 26 weeks after discharge (Table 3).
On average the therapists spent 6.5 hours on home visits and 3.3 hours on transportation per patient in the intervention group. Furthermore, the team physician spent 0.1 hours per patient. This corresponds to a total of 235 EUR/patient.30 Analyses of other relevant (incremental) costs showed insignificant differences between the intervention and control group (Table 2). The total costs per patient in the intervention and the control group from admission to 1 year after discharge were 7674 and 6660 EUR/patient, respectively. The difference was not significant. This implies that the extra time spent by the stroke team equals the incremental costs (235 EUR) between the intervention group and the control group.
Discussion
Only insignificant differences were observed between the intervention and control group with a trend toward shorter hospital stay and less use of home care service, public health nurse visits and use of day care center, but more readmissions and GP-visits in the intervention group compared with the control group. No differences in functional scores or patient satisfaction were seen. The incremental costs were 235 EUR in the intervention group.
Stroke units and succeeding rehabilitation programs are very differently organized in different countries,34 and not much consensus exists about the appropriate rehabilitation services for stroke patients once they have left hospital. Comparing this study with other early discharge studies is very difficult. This is partly attributable to a wide variety in domiciliary services and already established cooperation between primary and secondary health care systems,4,8,14,33–36 and partly attributable to a very varied patient selection, eg, depending on patients’ functional capacity12 or a requirement of caregivers at home.28 Furthermore, the term "standard aftercare" conceals many different treatment and rehabilitation programs. The effects of some standard aftercare are clearly underestimated and not comparable.4,8,12–15,28,33–34,37–41 Even within Denmark there are marked differences in standard aftercare. In a study comparable to the present study where BI scores at discharge were comparable to the scores in the present study, the mean length of hospital stay was between 83 and 98 days,4 compared with 35 to 39 days in the present study. This could be attributable to stroke severity or the policy of cooperation between the hospital and primary health care services. Hospital stays of 35 to 39 days are quite long, but included in the study were only patients with the need for at least 7 days of inpatient treatment. Moreover, the patients in this geographical area were from a primary low social class indicating a potential longer hospital stay.
Patients were prerandomized according to place of dwelling to make the study as comparable to real life as possible. A concealed randomization was impossible in such a set up, as intervention contained close contact to the patients. Randomization procedure made sure that a primary health care unit in a municipality should treat all their patients in the same way. Comparison of baseline data showed that the randomization was successful.
One thousand nine hundred and fifty-nine stroke patients were discharged but only 410 patients were discharged from the rehabilitation unit for several reasons: (a) stroke rehabilitation in the geriatric/neurological acute stroke unit is very efficient; (b) all minor strokes-TCI (not quantified) is included in the 1956 patients; (c) because of structural problems the patient registration was not sufficient on Glostrup County Hospital in the study period.
All patients moved to the rehabilitation unit were, however, evaluated for inclusion. The study group was, therefore, representative for the stroke patient group. If the 3 inclusion patients who had moved to nursing home were included it would not have changed the results in favor of the intervention.
The lack of effect of the intervention could be explained by the existing very effective standard aftercare already established in the collaborating domiciliary region of Glostrup University Hospital. The standard aftercare includes a daily contact with coordinating domiciliary nurses in the stroke unit who coordinates the discharge of stroke patients and further domiciliary rehabilitation services. Maybe the discharge policy in the intervention group should have been more aggressive to show an effect as regards shorter hospital stays. If a significant reduction in total costs should have been obtained, a decrease of at least 2 weeks admission in the intervention group should have been obtained, which would have been unrealistic. Although the groups were rather comparable at baseline, it of course cannot be ruled out that the lack of effect could be attributable to unknown confounding.
The groups were only followed-up for 1 year, and it could be of interest to expand the follow-up period to study more long-term effects of the intervention. Further studies might focus on patients with severe comorbidity or discharge to further rehabilitation or nursing home (67 intervention and 80 control patients). With a different organization of aftercare this weak patient group could have been obvious for the stroke team to follow. In conclusion the study cannot confirm a positive effect of an interdisciplinary stroke team as a discharge team for potentially fragile stroke patients compared with the standard rehabilitation program. Neither was it possible to define a subgroup among stroke survivors who could benefit from the stroke team. In further investigation there should be more focus on the description of the organization of standard aftercare in order to make comparable studies describing the effect of this standard aftercare.
Acknowledgments
This study was supported by grants from Danish Centre for Evaluation and HTA (DACEHTA), National Board of Health; The Danish Pharmaceutical Association; The Health Insurance Foundation; Danish Research Agency, Ministry of Science and Innovation; Augustinus Foundation; Dir. Jacob Madsen’s Foundation; The Danish Stroke and Aphasia Association; Ingrid Maiboell’s Foundation; Boehringer Ingelheim A/S. The authors wish to thank statistician Steen Ladelund, Research Centre for Prevention and Health, Copenhagen County, Glostrup, for a substantial contribution to the statistical calculations.
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