Early Supported Discharge

Evidence Reviewed as of before: 21-12-2012
Author(s): Tatiana Ogourtsova, MSc OT; Annabel McDermott, OT; Dr Nicol Korner- Bitensky, PhD OT
Table of contents

Introduction

A stroke can impact on different person’s abilities and rehabilitation is frequently required in order to attempt to improve the affected functions. Currently, the rehabilitation services are mostly provided within the hospital or rehabilitation center settings. Early supported discharge is an innovative approach to rehabilitation where the services are provided at home by a mobile rehabilitation team. This module provides information on the effectiveness of early supported discharge in managing patients’ and carers’ outcomes after stroke.

Clinician Information

Note: When reviewing the findings, it is important to note that they are always made according to randomized clinical trial (RCT) criteria – specifically as compared to a control group. To clarify, if a treatment is “effective” it implies that it is more effective than the control treatment to which it was compared. Non-randomized studies are no longer included when there is sufficient research to indicate strong evidence (level 1a) for an outcome.

Note: It is important to note that while in most instances ESD was not more effective than conventional care it was as effective as conventional care. Thus, ESD can be considered as a cost-effective option that results in comparable outcomes to conventional care.

We have reviewed 15 studies (9 high quality RCTs, 3 fair quality RCTs, 1 poor quality RCT, 2 quasi experimental studies) that have investigated the effectiveness of early supported discharge for patient and carer outcomes following stroke. While early supported discharge was not more effective than conventional care for most outcomes, there are very few instances where it is less effective than conventional care. Early supported discharge was shown to be less effective than conventional care on outcomes including carers’ participation household maintenance activities, carers’ mental health and social functioning, and patients’ literal paraphrasia scores. Overall there were no significant differences between early supported discharge and conventional care for other patient outcomes including aphasia, cognition, functional independence, balance and mobility, upper extremity function, spasticity and stroke severity, nor patient/carer outcomes regarding emotional wellbeing, family dynamics, health-related quality of life, health status and service satisfaction. However, early supported discharge was more effective than conventional care for improving patients’ motor capacity and quality of care provided by carers. Interestingly, early supported discharge was also more effective for improving functional independence and stroke severity in subgroup analyses of patients with moderate to severe stroke. Most studies also reviewed the impact on process measures. Not surprisingly, early supported discharge resulted in significantly shorter length of hospital stay than conventional care. Overall there were no significant differences between early supported discharge and conventional care for other process measures including rate of readmission, institutionalisation, use of health services, death, dependency or adverse events.

Results Table

View results table

Outcomes

Early supported discharge vs. control or alternative treatments

Activity participation - carers
Not effective
1B

One high quality RCT (Anderson et al., 2000) investigated the effects of early supported discharge on activity participation among carers of patients with stroke. This high quality RCT randomized patients with acute stroke to receive early supported discharge or conventional care. The early discharge group received multidisciplinary rehabilitation at home for 5 weeks. There was a significant between-group difference in carers’ activity participation (Adelaide Activity Profile – household maintenance activities only) at 6 months post-stroke, in favour of conventional care compared to early supported discharge.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that early supported discharge is not more effective than conventional care for improving carers’ activity participation. In fact, early supported discharge was less effective than conventional care for improving carers’ participation in household maintenance activities.

Activity participation - patients
Not effective
1A

Four high quality RCTs (Widén Holmqvist et al., 1998, – von Koch et al., 2000 6-month follow-up study, von Koch et al., 2001 12-month follow-up study, Thorsén et al., 2005 5-year follow-up study – ; Anderson et al., 2000; Indredavik et al., 2000Fjærtoft et al, 2004 1-year follow-up study; Fjærtoft et al, 2011 5-year follow-up study –; and Mayo et al., 2000) investigated the effects of early supported discharge on activity participation among patients with stroke.

The first high quality RCT (Widén Holmqvist et al., 1998) randomized patients with acute stroke to receive early supported discharge and home rehabilitation or conventional care. The home rehabilitation group received multidisciplinary home rehabilitation for 3-4 months. There was no significant between-group difference in patients’ activity participation (Frenchay Activities Index) at 3 months post-stroke.

A 6-month follow-up to the study by Widén Holmqvist et al. (1998) (von Koch et al., 2000) revealed a significant between-group difference in only one activity (Frenchay Activities Index washing subscore), in favour of early supported discharge compared to conventional rehabilitation.

A 12-month follow-up to the study by Widén Holmqvist et al., (1998) (von Koch et al., 2001) found no significant between-group differences in patients’ activity participation (Frenchay Activities Index) at 12 months post-stroke.

A 5-year follow-up to the study by Widén Holmqvist et al., (1998) (Thorsén et al., 2005) found significant between-group differences in patients’ activity participation (Frenchay Activities Index washing dishes, washing clothes and reading books subscores) at 5 years post-stroke, favoring early supported discharge compared to conventional care.

The second high quality RCT (Anderson et al., 2000) randomized patients with acute stroke to receive early supported discharge or conventional care. The early discharge group received multidisciplinary rehabilitation at home for 5 weeks. There were no significant between-group differences in patients’ activity participation (Adelaide Activity Profile) at 6 months post-stroke.

The third high quality RCT (Indredavik et al., 2000) randomized patients with acute stroke to an extended stroke unit service (ESUS) or an ordinary stroke unit service (OSUS). The ESUS group received multidisciplinary home services that included a home assessment, discharge form the stroke unit, follow up rehabilitation program, out-patient clinic 4 weeks after discharge, and information meeting 3 months after discharge. Patients’ activity participation was reported in a one-year follow-up study (Fjæroft et al, 2004). There were no significant between-group differences in activity participation (Frenchay Activity Index) at 1 year post-stroke.

A five-year follow-up to the study by Indredavik et al. (2000) (Fjærtoft et al, 2011) also revealed no significant between-group difference in patients’ activity participation (Frenchay Activities Index) at 5 years post-stroke.

The fourth high quality RCT (Mayo et al., 2000) randomized patients with acute stroke to receive prompt discharge and home rehabilitation or usual care. The intervention group received home-based rehabilitation and nursing services for 4 weeks. There was a significant between-group difference in patients’ social participation (Reintegration to Normal Living Index) in favour of prompt discharge compared to usual care at post-treatment (4 weeks), but differences did not remain significant at follow-up (3 months).

Conclusion: There is strong evidence (level 1a) from three high quality RCTs that early supported discharge is not more effective than conventional care for improving patient’s activity participation.

Note: A fourth high quality RCT reported a significant difference in social participation in favour of prompt discharge and home rehabilitation compared to usual care, although results did not remain significant long-term. This study used a measure of social participation (Reintegration to Normal Living Index) different to the measures of activity participation used in other studies (Adelaide Activities Profile and Frenchay Activities Index), which may account for this discrepancy in results among studies.

Adverse events
Not effective
1b

One high quality RCT (Anderson et al., 2000) investigated the effects of early supported discharge on process measures (adverse events) following stroke. This high quality RCT randomized patients with acute stroke to receive early supported discharge or conventional care. The early discharge group received multidisciplinary rehabilitation at home for 5 weeks. Process measures included length of stay/total bed days, use of health services, institutionalization, frequency of readmissions and incidence of adverse events (death or falls). This study only reported results at 6-month follow-up. Significant between-group differences were found in length of stay/total bed days only, favoring early supported discharge compared to conventional care. There were no other significant between-group differences in patient outcomes at 6 months.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that there is no significant difference in incidence of adverse events between early supported discharge and conventional care.

Aphasia
Not effective
1B

One high quality RCT (Widén Holmqvist et al., 1998 and von Koch et al., 2000, von Koch et al., 2001 and Thorsén et al., 2005 follow-up studies) and one fair quality RCT (Rudd et al., 1997) investigated the effect of early supported discharge on aphasia in patients with acute stroke.

The high quality RCT (Widén Holmqvist et al., 1998) randomized patients with acute stroke to receive early supported discharge and home rehabilitation or conventional care. The home rehabilitation group received multidisciplinary home rehabilitation for 3-4 months. There was no significant between-group difference in patients’ aphasia (Aphasia Quotient) at 3 months post-stroke.

A 6-month follow-up to the study by Widén Holmqvist et al., (1998) (von Koch et al., 2000) revealed a significant between-group difference in aphasia (Reinvang Aphasia Test literal paraphrasia subscore only), favoring conventional therapy compared to early supported discharge.

A 12-month follow-up to the study by Widén Holmqvist et al., (1998) (von Koch et al., 2001) found no significant between-group differences in aphasia (Reinvang Aphasia Test) at 12 months post-stroke.

A 5-year follow-up to the study by Widén Holmqvist et al., (1998) (Thorsén et al., 2005) found no significant between-group differences in aphasia (Reinvang Aphasia Test ) at 5 years post-stroke.

The fair quality RCT (Rudd et al., 1997) randomized patients with acute stroke to receive specialist community rehabilitation or conventional hospital care. The specialist community rehabilitation group received an individual multidisciplinary daily care plan for 3 months. There were no significant between-group differences in aphasia (Frenchay Aphasia Screening Test) at 12 months post-stroke.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT and one fairquality RCTthat early supported discharge is not more effective than conventional care for improving patients’ aphasia. In fact, one study noted significantly better literal paraphrasia following conventional care compared to early supported discharge at 6 months post-stroke.

Balance
Not effective
1A

Two high quality RCTs (Widén Holmqvist et al., 1998 and von Koch et al., 2000, von Koch et al., 2001 and Thorsén et al., 2005 follow-up studies; Askim et al., 2006) investigated the effect of early supported discharge on balance in patients with stroke.

The first high quality RCT (Widén Holmqvist et al., 1998) randomized patients with acute stroke to receive early supported discharge and home rehabilitation or conventional care. The home rehabilitation group received multidisciplinary home rehabilitation for 3-4 months. There was no significant between-group difference in patients’ self-reported incidence of falls at 3 months post-stroke.

A 6-month follow-up to the study by Widén Holmqvist et al., (1998) (von Koch et al., 2000) revealed no significant between-group difference in patients’ self-reported incidence of falls at 6 months post-stroke.

A 12-month follow-up to the study by Widén Holmqvist et al., (1998) (von Koch et al., 2001) found no significant between-group differences in patients’ self-reported incidence of falls at 12 months post-stroke.

A 5-year follow-up to the study by Widén Holmqvist et al., (1998) (Thorsén et al., 2005) found no significant between-group differences in patients’ self-reported incidence of falls at 5 years post-stroke.

The second high quality RCT (Askim et al., 2006) randomized patients with acute stroke to an extended stroke unit service (ESUS) or an ordinary stroke unit service (OSUS). The ESUS group received early supported discharge and home-based rehabilitation for 4 weeks post-discharge whereas the OSUS group received regular inpatient rehabilitation. There were no significant between-group differences in balance (Berg Balance Scale) at 6, 26, or 52 weeks post-stroke.

Conclusion: There is strong evidence (level 1 a) from two high quality RCTs that early supported discharge is not more effective than conventional care for improving balance following stroke.

Cognition
Not effective
1A

Two high quality RCTs (Anderson et al., 2000; Indredavik et al., 2000 and Fjærtoft et al, 2004 and Fjærtoft et al, 2011 follow-up studies) and one fair quality RCT(Rudd et al., 1997) investigated the effect of early supported discharge on cognition following stroke.

The first high quality RCT (Anderson et al., 2000) randomized patients with acute stroke to receive early supported discharge or conventional care. The early discharge group received multidisciplinary rehabilitation at home for 5 weeks. There were no significant between-group differences in patients’ cognitive function (Mini Mental State Examination) at 6 months post-stroke.

The second high quality RCT (Indredavik et al., 2000) randomized patients with acute stroke to an extended stroke unit service (ESUS) or an ordinary stroke unit service (OSUS). The ESUS group received multidisciplinary home services that included a home assessment, discharge form the stroke unit, follow up rehabilitation program, out-patient clinic 4 weeks after discharge, and information meeting 3 months after discharge. Patients’ cognition was reported in a one-year follow-up study (Fjærtoft et al, 2004). There were no significant between-group differences in cognition (Mini Mental State Examination) at 1 year post-stroke.

A five-year follow-up to the study by Indredavik et al. (2000) (Fjærtoft et al, 2011) also revealed no significant between-group difference in cognition (Mini Mental State Examination ) at 5 years post-stroke.

The fair quality RCT (Rudd et al., 1997) randomized patients with acute stroke to receive specialist community rehabilitation or conventional hospital care. The specialist community rehabilitation group received an individual multidisciplinary daily care plan for 3 months. There were no significant between-group differences in patients’ cognition (Mini-Mental State Examination) at 12 months post-stroke.

Conclusion: There is moderate evidence (level 1a) from two high quality RCTs and one fairquality RCTthat early supported discharge is not more effective than conventional care for improving cognition following stroke.

Dependency
Not effective
1a

Two high qualities RCTs (Ronning & Guldvog, 1998; Widén Holmqvist et al., 1998 and von Koch et al., 2000, von Koch et al., 2001 and Thorsén et al., 2005 follow-up studies) and one fair quality RCT(Suwanwela et al., 2002 investigated the effects of early supported discharge on process measures (dependency) following stroke.

Two high qualities RCTs (Ronning & Guldvog, 1998; Widén Holmqvist et al., 1998 and von Koch et al., 2000, von Koch et al., 2001 and Thorsén et al., 2005 follow-up studies) and one fair quality RCT (Suwanwela et al., 2002 investigated the effects of early supported discharge on process measures (dependency) following stroke.

The first high quality RCT (Ronning & Guldvog, 1998) randomized patients with acute stroke to receive municipality rehabilitation or hospital rehabilitation. Municipality rehabilitation comprised nursing home rehabilitation on inpatient or day-patient basis, and further ambulatory rehabilitation by a visiting physical therapist, speech therapist and/or nurse. Hospital rehabilitation was provided in a generalized hospital rehabilitation unit that provided coordinated multidisciplinary rehabilitation consisting of nursing care, physical, occupational and speech therapy, social work and neurologist services. Process measures included mortality, institutionalization and dependency (Barthel Index score of <75). While no significant between-group differences in individual process measures were found, there was a significant between-group difference in combined death/dependency rates, in favour of hospital rehabilitation compared to municipality rehabilitation. Further, there were significant between-group differences in dependency and death/dependency rates among patients with moderate to severe stroke, in favour of hospital rehabilitation vs. municipality rehabilitation. Among patients with mild stroke (BI score ≥50) there was a significant between-group difference in need of long-term care (p=0.02), in favour of municipality rehabilitation compared to hospital rehabilitation.

The second high quality RCT (Widén Holmqvist et al., 1998) randomized patients with acute stroke to receive early supported discharge with home rehabilitation or conventional care. The home rehabilitation group received multidisciplinary home rehabilitation for 3-4 months. Process measures taken at 3 months post-stroke included length of stay, mortality, service use and dependency. Significant between-group differences in length of stay only were found, favoring early supported discharge and home rehabilitation compared to conventional rehabilitation.

A 6-month follow-up to the Widén Holmqvist et al., (1998) study (von Koch et al., 2000) found no significant between-group differences in process measures (length of stay, mortality, service use) at 6 months post-stroke.

A 12-month follow-up to the Widén Holmqvist et al., (1998) study (von Koch et al., 2001) found significant between-group differences in use of primary care and home rehabilitation services, whereby patients in the conventional rehabilitation received more outpatient occupational therapy, private physiotherapy and day-hospital services, whereas patients in the early supported discharge and home rehabilitation group received more nursing and home rehabilitation services. There were no significant between-group differences in other process measures (mortality, dependency, cost of health care).

A 5-year follow up to the Widén Holmqvist et al. (1998) study (Thorsén et al., 2005) found no significant between-group differences in process measures (mortality, dependency) at 5 years post-stroke.

The fair quality RCT (Suwanwela et al., 2002) randomized patients with acute stroke to receive early discharge and home rehabilitation or conventional rehabilitation. The home rehabilitation intervention consisted of 3 days hospitalization followed by home interventions for 10 consecutive days and follow-up by visits in the 2nd week, at 1, 3, and 6 months. Process measures included mortality and dependency. There were no significant between-group differences in process measures.

Conclusion: There is strong evidence (level 1a) from two high quality RCTand one fairquality RCTthat there is no significant difference in dependency rates between early supported discharge and conventional care.

Emotional wellbeing - carers
Not effective
1A

Five high quality RCTs (Anderson et al., 2000; Bautz-Holter et al., 2002; Donnelly et al., 2004; Rodgers et al., 1997; Indredavik et al., 2000 and Fjærtoft et al., 2004 follow-up study), one fair quality RCT (Rudd et al., 1997) and one quasi-experimental study (Gräsel et al., 2005) investigated the effects of early supported discharge on mood and emotional wellbeing of carers of patients with stroke.

The first high quality RCT (Anderson et al., 2000) randomized patients with acute stroke to receive early supported discharge or conventional care. The early discharge group received multidisciplinary rehabilitation at home for 5 weeks. There were no significant between-group differences in carers’ emotional wellbeing (General Health Questionnaire-28, Caregiver Strain Index) at 6 months post-stroke.

The second high quality RCT (Bautz-Holter et al., 2002) randomized patients with acute stroke to receive early supported discharge or conventional hospital rehabilitation. Patients in the early supported discharge group received multidisciplinary home rehabilitation, followed by outpatient clinic services. There were no significant between-group differences in carers’ emotional wellbeing (General Health Questionnaire-20) at 3 or 6 months post-stroke.

The third high quality RCT (Donnelly et al., 2004) randomly assigned patients with acute stroke to receive early supported discharge or usual hospital rehabilitation. The early discharge group received multidisciplinary home services for 3 months (average of 2.5 visits a week/45 minutes per session). There were no significant between-group differences in carers’ emotional wellbeing (Caregiver Strain Index) at 12 months post-stroke.

The fourth high quality RCT (Rodgers et al., 1997) randomized patients with acute stroke to receive early supported discharge or conventional care. The early supported discharge group received home rehabilitation services from a community-based multidisciplinary stroke discharge team 5 days/week for a median of 9 weeks (range 1-44 weeks). There were no significant between-group differences in carers’ emotional wellbeing (General Health Questionnaire-30) at 7-10 days post discharge or at 3 months post-stroke.

The fifth high quality RCT (Indredavik et al., 2000) randomized patients with acute stroke to an extended stroke unit service (ESUS) or an ordinary stroke unit service (OSUS). The ESUS group received multidisciplinary home services that included a home assessment, discharge form the stroke unit, follow up rehabilitation program, out-patient clinic 4 weeks after discharge, and information meeting 3 months after discharge. Carers’ emotional wellbeing was reported in a 1-year follow-up fair quality RCT (Fjærtoft et al., 2004). There were no significant between-group differences in carers’ emotional wellbeing (Caregiver Strain Index) at 1 year post-stroke.

The fair quality RCT (Rudd et al., 1997) randomized patients with acute stroke to specialist community rehabilitation or conventional hospital care. The specialist community rehabilitation group received an individualised multidisciplinary daily care plan for up to 3 months. There were no significant between-group differences in carers’ emotional wellbeing (Caregiver Strain Index) at 12 months post-stroke.

The quasi-experimental study (Gräsel et al., 20055) allocated patients with acute stroke and their carers to an intervention group that received intensified transition consisting of education and support for patients and carers prior to and following discharge (ST+IT), or a control group that received standard transition (ST). There were no significant between-group differences in carers’ emotional wellbeing (Zerssen Depression Scale and the Burden Scale for Family Caregivers) at 4 weeks or 6 months post-discharge.

Conclusion: There is strong evidence (level 1a) from five high quality RCTs, one fair quality RCT and one quasi-experimental study that early supported discharge is not more effective than conventional care for improving carers’ emotional wellbeing.

Emotional wellbeing - patients
Not effective
1A

Five high quality RCTs (Rodgers et al., 1997; Anderson et al., 2000; Indredavik et al., 2000 and Fjærtoft et al., 2004 follow-up study; Bautz-Holter et al., 2002; Widén Holmqvist et al., 1998 and von Koch et al., 2000 and von Koch et al., 2001 follow-up studies) and two fair quality RCTs (Hui et al., 1995; Rudd et al., 1997) investigated the effects of early supported discharge on mood and emotional wellbeing of patients following stroke.

The first high quality RCT (Rodgers et al., 1997) randomized patients with acute stroke to receive early supported discharge or conventional care. The early supported discharge group received home rehabilitation services from a multidisciplinary community-based stroke discharge team for 5 days/week for a median of 9 weeks (range 1-44 weeks). There were no significant between-group differences in patients’ mood (Wakefield Depression Scale) at 7-10 days post discharge or at 3 months post-stroke.

The second high quality RCT (Anderson et al., 2000) randomized patients with acute stroke to receive early supported discharge or conventional care. The early discharge group received multidisciplinary rehabilitation at home for 5 weeks. There were no significant between-group differences in patients’ emotional wellbeing (General Health Questionnaire – 28) at 6 months post-stroke.

The third high quality RCT (Indredavik et al., 2000) randomized patients with acute stroke to an extended stroke unit service (ESUS) or an ordinary stroke unit service (OSUS). The ESUS group received multidisciplinary home services that included a home assessment, discharge form the stroke unit, follow up rehabilitation program, out-patient clinic 4 weeks after discharge, and information meeting 3 months after discharge. Patients’ mood was reported in a 1-year follow-up study (Fjærtoft et al., 2004). There were no significant between-group differences in patients’ mood (Montgomery Asberg Depression Scale) at 1 year post-stroke.

The fourth high quality RCT (Bautz-Holter et al., 2002) randomized patients with acute stroke to receive early supported discharge or conventional hospital rehabilitation. Patients in the early supported discharge group received multidisciplinary home rehabilitation, followed by outpatient clinic services. There was a significant between-group difference in patients’ emotional wellbeing (General Health Questionnaire-20) in favour of early supported discharge compared to conventional hospital rehabilitation at 3 months post-stroke, but this did not remain significant at 6 months post-stroke. There were no significant differences in other measures of mood (Montgomery Asberg Depression Rating Scale) at 3 or 6 months post-stroke.

The fifth high quality RCT (Widén Holmqvist et al., 1998) randomized patients with acute stroke to receive early supported discharge and home rehabilitation or conventional care. The home rehabilitation group received multidisciplinary home rehabilitation for 3-4 months. Patient’s emotional wellbeing was reported in a 6-month follow-up study (von Koch et al., 2000). There were no significant between-group differences in patients’ emotional wellbeing (Sense of Coherence Test) at 6 months post-stroke.

A 12-month follow-up to the study by Widén Holmqvist et al., (1998) (von Koch et al., 2001) also found no significant between-group differences in patients’ emotional wellbeing (Sense of Coherence Test) at 12 months post-stroke.

The first fair quality RCT (Hui et al., 1995) randomized patients with acute stroke to an early supported discharge (ESD) geriatrician team or a conventional medical care team. Patients in the ESD team were discharged home with day hospital rehabilitation and management by a geriatrician. There were no significant between-group differences in patients’ mood (Geriatric Depression Scale) at 3 or 6 months post-stroke.

The second fair quality RCT (Rudd et al., 1997) randomized patients with acute stroke to receive specialist community rehabilitation or conventional hospital care. The specialist community rehabilitation group received an individual multidisciplinary daily care plan for 3 months. There were no significant between-group differences in patients’ emotional wellbeing (Hospital Anxiety and Depression Scale) at 12 months post-stroke.

Conclusion: There is strong evidence (level 1a) from five high quality RCTs and two fairquality RCTs that early supported discharge is not more effective than conventional care for improving patients’ mood and emotional wellbeing.
Note:
A high quality RCT did report significant between-group differences in emotional wellbeing at 3 months post-stroke in favour of early supported discharge, but results were not maintained at 6 months post-stroke. This study measured patients’ emotional wellbeing using the GHQ-20, whereas other studies used the GHQ-28 or other measures of mood and emotional wellbeing.

Family dynamics - carers
Not effective
1B

One high quality RCT (Anderson et al., 2000) investigated the effects of early supported discharge on carers’ perception of family dynamics following stroke. This high quality RCT randomized patients with acute stroke to receive early supported discharge or conventional care. The early discharge group received multidisciplinary rehabilitation at home for 5 weeks. There were no significant between-group differences in family dynamics (McMaster Family Assessment Device – general functioning subscale) reported by carers at 6 months post-stroke.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that early supported discharge is not more effective than conventional care for improving carers’ perception of family dynamics following stroke.

Family dynamics - patients
Not effective
1B

One high quality RCT (Anderson et al., 2000) investigated the effects of early supported discharge on patients’ perception of family dynamics following stroke. This high quality RCT randomized patients with acute stroke to receive early supported discharge or conventional care. The early discharge group received multidisciplinary rehabilitation at home for 5 weeks. There were no significant between-group differences in family dynamics (McMaster Family Assessment Device – general functioning subscale) reported by patients at 6 months post-stroke.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that early supported discharge is not more effective than conventional care for improving patients’ perception of family dynamics following stroke.

Functional independence
Not effective
1A

Eight high quality RCTs (Rodgers et al., 1997; Ronning & Guldvog, 1998; Widén Holmqvist et al., 1998von Koch et al., 2000, von Koch et al., 2001 and Thorsén et al., 2005 follow-up studies –; Anderson et al., 2000; Indredavik et al., 2000 – Fjærtoft et al., 2011 follow-up study–; Mayo et al., 2000; Bautz-Holter et al., 2002; Donnelly et al., 2004), three fair quality RCTs (Hui et al., 1995; Rudd et al., 1997; Suwanwela et al., 2002), one poor quality RCT (Shyu et al., 2010) and two quasi-experimental studies (Gräsel et al., 2005; Pessah-Rasmussen & Wendel, 2009) investigated the effect of early supported discharge on patients’ functional independence following stroke.

The first high quality RCT (Rodgers et al., 1997) randomized patients with acute stroke to receive early supported discharge or conventional care. The early supported discharge group received home rehabilitation services from a multidisciplinary community-based stroke discharge team for 5 days/week for a median of 9 weeks (range 1-44 weeks). There were no significant between-group differences in patients’ functional ability (Nottingham Extended ADL Scale, Oxford Handicap Scale) at 7-10 days post-discharge or at 3 months post-stroke.

The second high quality RCT (Ronning & Guldvog, 1998) randomized patients with acute stroke to receive municipality rehabilitation or standard hospital rehabilitation. Municipality rehabilitation comprised nursing home rehabilitation on inpatient or day-patient basis, and further ambulatory rehabilitation by a visiting physical therapist, speech therapist and/or nurse. There were no significant between-group differences in patients’ functional independence (Barthel Index) at 7 months post-stroke.

Note: Subgroup analysis showed a significant between-group difference among patients with moderate to severe stroke (BI score <50) in functional independence (Barthel Index) at 7 months, in favour of hospital rehabilitation compared to municipality rehabilitation. There were no significant between-group differences in the subgroup of patients with mild stroke (BI score ≥50).

The third high quality RCT (Widén Holmqvist et al., 1998) randomized patients with acute stroke to receive early supported discharge and home rehabilitation or conventional care. The home rehabilitation group received multidisciplinary home rehabilitation for 3-4 months. There were no significant between-group differences in patients’ functional independence (Barthel ADL Index, Katz ADL Index, Extended Katz ADL Index) at 3 months post-stroke.

A 6-month follow-up to the study by Widén Holmqvist et al., (1998) (von Koch et al., 2000) found no significant between-group differences in functional independence (Barthel Index, Katz ADL Index, Extended Katz ADL Index) at 6 months post-stroke.

Note: there was a significant between-group difference in functional mobility (Barthel ADL Index mobility subscore), in favour of early supported discharge compared to conventional rehabilitation.

A 12-month follow-up to the study by Widén Holmqvist et al., (1998) (von Koch et al., 2001) found no significant between-group differences in patients’ functional independence (Barthel ADL Index, Katz ADL Index, Extended Katz ADL index) at 12 months post-stroke.

A 5-year follow-up to the study by Widén Holmqvist et al., (1998) (Thorsén et al., 2005) found no significant between-group differences in patients’ functional independence (Barthel ADL Index, Katz ADL index) at 5 years post-stroke. However, there was a significant between-group difference in extended ADLs (Extended Katz ADL Index), in favour of early supported discharge compared to conventional care.

The fourth high quality RCT (Anderson et al., 2000) randomized patients with acute stroke to receive early supported discharge or conventional care. The early discharge group received multidisciplinary rehabilitation at home for 5 weeks. There were no significant between-group differences in patients’ functional independence (modified Barthel Index) at 6 months post-stroke.

The fifth high quality RCT (Indredavik et al., 2000) randomized patients with acute stroke to an extended stroke unit service (ESUS) or an ordinary stroke unit service (OSUS). The ESUS group received multidisciplinary home services that included a home assessment, discharge form the stroke unit, follow up rehabilitation program, out-patient clinic 4 weeks after discharge, and information meeting 3 months after discharge. There were no significant between-group differences in patients’ functional independence (Barthel Index, Modified Rankin Scale) at 6 weeks post-stroke. There was a significant between-group difference in Modified Rankin Scale scores at 26 weeks post-stroke, favoring the ESUS compared to the OSUS. There were no significant differences in Barthel Index scores at 26 weeks post-stroke.

Note: subgroup analysis at 26 weeks post-stroke revealed significant between-group differences in patients’ functional ability (Barthel Index and Modified Rankin Scale) among patients with moderate to severe stroke, in favour of the ESUS compared to the OSUS.

A five-year follow-up to the study by Indredavik et al. (2000) (Fjærtoft et al., 2011) found no significant between-group difference in patients’ functional independence (Barthel Index and Modified Rankin Scale) at 5 years post-stroke.

The sixth high quality RCT (Mayo et al., 2000) randomized patients with acute stroke to receive prompt discharge and home rehabilitation or usual care. The intervention group received home-based rehabilitation and nursing services for 4 weeks. There were no significant between-group differences in patients’ functional independence (Barthel Index, Older American Resource Scale for Instrumental ADLs) at post-treatment (4 weeks). There was a significant between-group difference in instrumental activities of daily living (Older American Resource Scale for Instrumental ADLs) at follow-up (3 months post-stroke), in favour of prompt discharge compared to usual care.

The seventh high quality RCT (Bautz-Holter et al., 2002) randomized patients with acute stroke to receive early supported discharge or conventional hospital rehabilitation. The early supported discharge group received multidisciplinary rehabilitation at home for as long as considered necessary followed by outpatient clinic intervention. There were no significant between-group differences in patients’ functional independence (Nottingham Extended ADL) at 3 or 6 months post-stroke.

The eighth high quality RCT (Donnelly et al., 2004) randomized patients with acute stroke to receive early hospital discharge or usual hospital rehabilitation. The early discharge group received multidisciplinary home services for 3 months (average of 2.5 visits a week, 45 minutes per session). There were no significant between-group differences in patients’ functional independence (Barthel Index, Nottingham ADL scale) at 12 months post-stroke.

The first fair quality RCT (Hui et al., 1995) randomized patients with acute stroke to an early supported discharge (ESD) geriatrician team or a conventional medical team. Patients in the ESD group were discharged home with day hospital rehabilitation and management by a geriatrician. There was no significant between-group difference in functional independence (Barthel Index) at 3 or 6 months post-stroke.

Note: There was a significant between-group difference in BI change scores from baseline to 3 months post-stroke in a subgroup of patients with BI scores ≤15, in favour of ESD compared to conventional medical care.

The second fair quality RCT (Rudd et al., 1997) randomized patients with acute stroke to receive specialist community rehabilitation or conventional hospital care. The specialist community rehabilitation group received an individual multidisciplinary daily care plan for 3 months. There were no significant between-group differences in patients’ functional independence (Barthel Index, Rivermead Activity of Daily Living Scale) at 12 months post-stroke.

The third fair quality RCT (Suwanwela et al., 2002) randomized patients with acute stroke to receive early discharge and home rehabilitation or conventional rehabilitation. Home rehabilitation intervention consisted of 3 days hospitalization followed by home interventions for 10 consecutive days and follow-up by visits. There were no significant between-group differences in patients’ functional independence (Barthel Index) at 6 months post-stroke.

The poor quality study (Shyu et al., 2009) randomised patients with acute stroke and their carers to receive a caregiver-oriented discharge preparation programme that comprised health education, referrals and problem-solving support, or routine discharge services. There were no significant between-group differences in patients’ functional independence (Chinese Barthel Index) at 1, 3, 6 or 12 months post-discharge.

The first quasi-experimental study (Gräsel et al., 2005) allocated patients with acute stroke and their carers to an intervention group that received intensified transition consisting of education and support for patients and carers prior to and following discharge (ST+IT), or a control group that received standard transition (ST). There were no significant between-group differences in patients’ functional independence (Barthel Index, Functional Independence Measure) at 4 weeks or 6 months post-discharge.

The second quasi-experimental study (Pessah-Rasmussen & Wendel, 2009) assigned patients with acute stroke to receive early supported discharge (ESD) that consisted of a pre-discharge home visit, coordinated planned discharge from the hospital and post-discharge multidisciplinary care. Patients demonstrated a significant improvement in functional independence (Katz ADL Index) at post-treatment (feeding, transfers, toileting, dressing, bathing grooming and communication) and at 6 months post-stroke (transfers, dressing), but no significant improvements were seen at 12 months post-stroke.

Conclusion: There is strong evidence (level 1a) from eight high quality RCTs, three fairquality RCTs, one poor quality RCT and one quasi-experimental study that early supported discharge is not more effective than conventional care for improving patients’ functional independence following stroke.

Note: However, 1 RCT reported better instrumental ADLs at 3 months, 1 RCT reported better functional independence at 6 month, and 1 RCT reported better functional mobility at 6 months and better extended ADLs at 5 years post-stroke, all in favour of early supported discharge compared to usual care. Furthermore, a second quasi-experimental study found a significant improvement in the short term for certain aspects of functional independence in patients who received early supported discharge.

Note: There is conflicting evidence regarding the effectiveness of early supported discharge for patients with moderate to severe impairment. One high quality RCT found that patients with moderate to severe stroke demonstrated better functional independence following hospital rehabilitation compared to early supported discharge with municipality rehabilitation; another high quality RCT and a fair quality RCT reported better functional independence or better gains in functional independence among patients with moderate to severe impairment who receive early supported discharge compared to those who received conventional care.

Health-related quality of life - carers
Not effective
1A

Two high quality RTCs (Widén Holmqvist et al., 1998; Anderson et al., 2000) and one poor quality RCT (Shyu et al., 2009) investigated the effects of early supported discharge on health-related quality of life of carers following stroke.

The first high quality RCT (Widén Holmqvist et al., 1998) randomized patients with acute stroke to receive early supported discharge and home rehabilitation or conventional care. The home rehabilitation group received multidisciplinary home rehabilitation for 3-4 months. There were no significant between-group differences in carers’ quality of life (measured according to time spent helping the patient with instrumental and self-care ADLs) at 3 months post-stroke.

The second high quality RCT (Anderson et al., 2000) randomized patients with acute stroke to receive early supported discharge or conventional care. The early supported discharge group received multidisciplinary rehabilitation at home for 5 weeks. There was a significant between-group difference in carers’ health related quality of life (Medical Outcomes Study Short Form – 36 mental health score only) at 6 months post-stroke, in favour of conventional care compared to early supported discharge.

The poor quality study (Shyu et al., 2009) randomised patients with acute stroke and their carers to receive a caregiver-oriented discharge preparation programme that comprised health education, referrals and problem-solving support, or routine discharge services. Carers’ quality of life was measured by the Medical Outcomes Study Short Form (SF-36) at 1, 3, 6 and 12 months post-discharge. At 3 months carers in the intervention group scored significantly worse on the SF-36 social functioning subtest than carers in the control group. No other between-group differences were seen at any time point.

Conclusion: There is strong evidence (level 1a) from two high quality RCTs and one poorquality RCTthat early supported discharge is not more effective than conventional care in improving carers’ health-related quality of life in the acute care period. In fact, one highquality RCT reported significantly better mental health and one poor quality RCT reported significant better social functioning among carers following conventional care compared to early supported discharge.

Note: The authors of the poor quality study commented that the discharge preparation programme is likely to have increased carers’ awareness of the demands of caregiving, thus contributing to a consequent reduction in social activities. The study also found lower rates of institutionalization at 6 to 12 months post-discharge in the intervention group than the control group, which may have increased burden among carers in the intervention group and contributed to poorer social functioning.

Health-related quality of life - patients
Not effective
1A

Four high qualities RTCs (Ronning & Guldvog, 1998; Anderson et al., 2000; Mayo et al., 2000; Donnelly et al., 2004), one poor quality RCT (Shyu et al., 2009) and one quasi-experimental study (Gräsel et al., 2005) investigated the effects of early supported discharge on patients’ health-related quality of life following stroke.

The first high quality RCT (Ronning & Guldvog, 1998) randomized patients with acute stroke to receive municipality rehabilitation or hospital rehabilitation. Municipality rehabilitation comprised nursing home rehabilitation on inpatient or day-patient basis, and further ambulatory rehabilitation by a visiting physical therapist, speech therapist and/or nurse. Hospital rehabilitation was provided in a generalized hospital rehabilitation unit that provided coordinated multidisciplinary rehabilitation consisting of nursing care, physical, occupational and speech therapy, social work and neurologist services. There were no significant between-group differences in patients’ health-related quality of life (Medical Outcomes Study Short Form – SF 36) at 7 months post-stroke.

The second high quality RCT (Anderson et al., 2000) randomized patients with acute stroke to receive early supported discharge or conventional care. The early supported discharge group received multidisciplinary rehabilitation at home for 5 weeks. There were no significant between-group differences in patients’ health related quality of life (SF-36) at 6 months post-stroke.

The third high quality RCT (Mayo et al., 2000) randomized patients with acute stroke to receive prompt discharge and home rehabilitation or usual care. The intervention group received a home rehabilitation program for 4 weeks consisting of tailor-made rehabilitation and nursing services. There were no significant between-group differences in patients’ health related quality of life (SF-36) at post-treatment (4 weeks). There was a significant between-group difference in quality of life related to physical health (SF-36 Physical Health and Physical Role subscales) at follow-up (3 months post-stroke), favoring prompt discharge and home rehabilitation compared to usual care.

The fourth high quality RCT (Donnelly et al., 2004) randomly assigned patients with acute stroke to an early discharge rehabilitation service or usual hospital rehabilitation. The early discharge group received multidisciplinary home services for 3 months (average of 2.5 visits a week, 45 minutes per session). There was no significant between-group difference in patients’ health related quality of life (SF-36, EuroQoL, non-standardized quality of life questionnaire) at 12 months post-stroke.

The poor quality study (Shyu et al., 2009) randomised patients with acute stroke and their carers to receive a caregiver-oriented discharge preparation programme that comprised health education, referrals and problem-solving support, or routine discharge services. There were no significant between-group differences in patients’ health related quality of life (SF-36) at 1, 3, 6 and 12 months post-discharge.

The quasi-experimental study (Gräsel et al., 2005) allocated patients with acute stroke and their carers to an intervention group that received intensified transition consisting of education and support for patients and carers prior to and following discharge (ST+IT), or a control group that received standard transition (ST). There were no significant between-group differences in patients’ health-related quality of life (SF-36) at 4 weeks or 6 months post-discharge.

Conclusion: There is strong evidence (level 1a) from four high quality RCTs, one poorquality RCT and one quasi-experimental study that early supported discharge is not more effective than conventional care for improving health-related quality of life among patients with stroke.

Note: One high quality RCT found a significant between-group difference in quality of life related to physical health at follow-up (3 months post-stroke), favoring prompt discharge and home rehabilitation compared to usual care.

Health status - carers
Not effective
1B

One high quality RCT (Widén Holmqvist et al., 1998 and von Koch et al., 2001 follow-up study) and one quasi-experimental study(Gräsel et al., 2005) investigated the effects of early supported discharge on health status of carers of patients with stroke.

The high quality RCT (Widén Holmqvist et al., 1998) randomised patients with acute stroke to receive early supported discharge and home rehabilitation or conventional rehabilitation. The home rehabilitation group received multidisciplinary home rehabilitation for 3-4 months after discharge. Carers’ health status was reported in a 12-month follow-up study (von Koch et al., 2001). There were no significant between-group differences in carers’ health status (Sickness Impact Profile) at 12 months post-stroke.

The quasi-experimental study (Gräsel et al., 2005) allocated patients with stroke and their carers to an intervention group that received intensified transition consisting of education and support for patients and carers prior to and following discharge (ST+IT), or a control group that received standard transition (ST). There were no significant between-group differences in carers’ health status (Giessen Symptom List) at 4 weeks or 6 months post-discharge.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT and one quasi-experimental studythat early supported discharge is not more effective than conventional care for improving carers’ health status.

Health status - patients
Not effective
1A

Four high qualities RCTs (Rodgers et al., 1997; Widén Holmqvist et al., 1998 and von Koch et al., 2000, von Koch et al., 2001 and Thorsén et al., 2005 follow-up studies; Anderson et al., 2000; Indredavik et al., 2000 and Fjærtoft et al., 2004 follow-up study) and two fair qualities RCTs (Hui et al., 1995; Rudd et al., 1997) investigated the effects of early supported discharge on patients’ health status following stroke.

The first high quality RCT (Rodgers et al., 1997) randomized patients with acute stroke to receive early supported discharge or conventional care. The early supported discharge group received home rehabilitation services from a community-based multidisciplinary stroke discharge team 5 days/week for a median of 9 weeks (range 1-44 weeks). There were no significant between-group differences in patients’ health status (Dartmouth Coop Function Charts) at 7-10 days post discharge or at 3 months post-stroke.

The second high quality RCT (Widén Holmqvist et al., 1998) randomized patients with acute stroke to receive early supported discharge and home rehabilitation or conventional care. Early supported discharge and home rehabilitation comprised multidisciplinary home rehabilitation for 3-4 months. Significant between group differences in health status (Sickness Impact Profile – SIP, Psychological dimension, and emotional behavioural and communication subtests) were found at 3 months post-stroke, favoring conventional rehabilitation compared to early supported discharge.

A 6-month follow-up to the Widén Holmqvist et al. (1998) study (von Koch et al., 2000), found significant between-group differences in patients’ health status (SIP Communication subtest only) at 6 months post-stroke, this time favoring early supported discharge and home rehabilitation compared to conventional rehabilitation.

A 12-month follow-up to the Widén Holmqvist et al., (1998) study (von Koch et al., 2001) found no significant between-group differences in patients’ health status (Sickness Impact Profile) at 12 months post-stroke.

A 5-year follow-up to the Widén Holmqvist et al., (1998) study (Thorsén et al., 2005) found no significant between-group differences in patients’ health status (Sickness Impact Profile) at 5 years post-stroke.

The third high quality RCT (Anderson et al., 2000) randomized patients with acute stroke to receive early supported discharge or conventional care. The early supported discharge group received multidisciplinary rehabilitation at home for 5 weeks. There were no significant between-group differences in patients’ health status (Nottingham Health Profile) at 6 months post-stroke.

The forth high quality RCT (Indredavik et al., 2000) randomized patients with acute stroke to an extended stroke unit service (ESUS) or an ordinary stroke unit service (OSUS). The ESUS group received multidisciplinary home services that included a home assessment, discharge form the stroke unit, follow up rehabilitation program, out-patient clinic 4 weeks after discharge, and information meeting 3 months after discharge. Patients’ health status was reported in a 1-year follow-up study (Fjærtoft et al., 2004). There were significant between-group differences in patients’ health status (Nottingham Health Profile) at 1 year post-stroke, favoring the ESUS group compared to the OSUS group.

The first fair quality RCT (Hui et al., 1995) randomized patients with acute stroke to an early supported discharge (ESD) geriatrician team or a conventional medical team. Patients in the ESD group were discharged home with day hospital rehabilitation and management by a geriatrician. Patients’ health status was measured using non standardized general wellbeing and sleep quality scale. There were no significant between-group differences in patients’ health status (measured using non-standardized general wellbeing and sleep quality scales) at 3 or 6 months post-stroke.

The second fair quality RCT (Rudd et al., 1997) randomized patients with acute stroke to receive specialist community rehabilitation or conventional hospital care. The specialist community rehabilitation group received an individual multidisciplinary daily care plan for 3 months. There were no significant between-group differences in patients’ health status (Nottingham Health Profile) at 12 months post-stroke.

Conclusion: There is strong evidence (level 1a) from three high quality RCTs and two fairquality RCTs that early supported discharge is not more effective than conventional care for patients’ health status.

Note: While a high quality RCT found significant differences in health status (SIP psychological dimension, emotional behaviours and communication subtests) in favour of conventional rehabilitation at 3 months post-stroke, the study subsequently found significant differences in SIP communication scores in favour of early supported discharge at 6 months post-stroke. A second study found significant differences in health status in favour of early supported discharge compared to conventional care at 12 months post-stroke.

Institutionalization
Not effective
1A

Five high qualities RCTs (Rodgers et al., 1997; Ronning & Guldvog, 1998; Anderson et al., 2000; Indredavik et al., 2000 and Fjærtoft et al., 2011 follow up study; Bautz-Holter et al., 2002;), one fair quality RCT (Rudd et al., 1997), one poor quality RCT (Shyu et al., 2009) and two quasi-experimental studies (Gräsel et al., 2005 and Gräsel et al., 2006 follow-up study; Pessah-Rasmussen & Wendel, 2009) investigated the effects of early supported discharge on process measures (institutionalisation) following stroke.

The first high quality RCT (Rodgers et al., 1997) randomized patients with acute stroke to receive early supported discharge or conventional care. The early supported discharge group received multidisciplinary rehabilitation home services 5 days per week. Process measures included length of stay, readmission rates, institutionalization and mortality. Significant between-group differences were found in length of stay only, favoring early supported discharge compared to conventional care.

The second high quality RCT (Ronning & Guldvog, 1998) randomized patients with acute stroke to receive municipality rehabilitation or hospital rehabilitation. Municipality rehabilitation comprised nursing home rehabilitation on inpatient or day-patient basis, and further ambulatory rehabilitation by a visiting physical therapist, speech therapist and/or nurse. Hospital rehabilitation was provided in a generalized hospital rehabilitation unit that provided coordinated multidisciplinary rehabilitation consisting of nursing care, physical, occupational and speech therapy, social work and neurologist services. Process measures included mortality, institutionalization and dependency (Barthel Index score of <75). While no significant between-group differences in individual process measures were found, there was a significant between-group difference in combined death/dependency rates, in favour of hospital rehabilitation compared to municipality rehabilitation. Further, there were significant between-group differences in dependency and death/dependency rates among patients with moderate to severe stroke, in favour of hospital rehabilitation vs. municipality rehabilitation. Among patients with mild stroke (BI score ≥50) there was a significant between-group difference in need of long-term care (p=0.02), in favour of municipality rehabilitation compared to hospital rehabilitation.

The third high quality RCT (Anderson et al., 2000) randomized patients with acute stroke to receive early supported discharge or conventional care. The early discharge group received multidisciplinary rehabilitation at home for 5 weeks. Process measures included length of stay/total bed days, use of health services, institutionalization, frequency of readmissions and incidence of adverse events (death or falls). Significant between-group differences were found in length of stay/total bed days only, favoring early supported discharge compared to conventional care.

The fourth high quality RCT (Indredavik et al., 2000) randomized patients with acute stroke to an extended stroke unit service (ESUS) or an ordinary stroke unit service (OSUS). The ESUS group received multidisciplinary home services that included a home assessment, discharge form the stroke unit, follow up rehabilitation program, out-patient clinic 4 weeks after discharge, and information meeting 3 months after discharge. Process measures included mortality, institutionalization and length of stay. Significant between-group differences were found in average length of stay in hospital (stroke unit and rehabilitation clinic) recorded at discharge, and number of patients discharged home vs. institutions recorded at discharge and 6 weeks post-stroke, favoring the ESUS compared to the OSUS. Differences in residential status were no longer significant at long-term follow-up (26 weeks post-stroke). There were no significant between-group differences in mortality rates.

A 5-year follow-up to the Indredavik et al., (2000) study (Fjærtoft et al., 2011) found significant between-group differences in mortality and institutionalization rates at 5 years post-stroke, favoring the ESUS compared to the OSUS.

The fifth high quality RCT (Bautz-Holter et al., 2002) randomized patients with acute stroke to receive early supported discharge or conventional hospital rehabilitation. The early supported discharge group received multidisciplinary rehabilitation at home for as long as considered necessary followed by outpatient clinic intervention. Process measures included use of health services, mortality and institutionalization. No significant between-group differences were found.

The fair quality RCT (Rudd et al., 1997) randomized patients with acute stroke to receive specialist community rehabilitation or conventional hospital and community care. The specialist community rehabilitation group received an individual multidisciplinary daily care plan for 3 months. Process measures included length of stay, readmission rates, institutionalization, mortality and health service use. Significant between-group differences were found in length of stay only, favoring specialist community rehabilitation compared to conventional hospital and community care.

The poor quality study (Shyu et al., 2009) randomised patients with acute stroke and their carers to receive a caregiver-oriented discharge preparation programme that comprised health education, referrals and problem-solving support, or routine discharge services. Patient service use was measured at 1, 3, 6 and 12 months post-discharge according to length of hospital stay, hospital readmissions and institutionalisations. Patients in the intervention group demonstrated significantly less institutionalisation than patients in the control group 6 to 12 months post-discharge. There were no significant between-group differences in length of hospital stay or hospital readmissions at any time point.

The first quasi-experimental study (Gräsel et al., 2005) allocated patients with acute stroke and their carers to receive intensified transition consisting of education and support for patients and carers prior to and following discharge (ST+IT), or a control group that received standard transition (ST). Number of physician visits and newly appearing illnesses were measured at 4 weeks and 6 months post-discharge. Patients in the control group showed significantly more new illnesses than those in the intervention group at 4 weeks post-discharge, but this difference did not remain significant at 6 months. There was a significant between-group difference in the number of physician visits in favour of the intervention group compared to the control group at 6 months post-discharge (these differences were not present at four weeks post-discharge).

In a follow-up study (Gräsel et al., 2006), patients were contacted by telephone on average 31 months after discharge from hospital to determine whether the patient was (a) alive; and (b) living at home or in a nursing home. There was a significant difference between groups in the number of patients who were alive and living at home, in favour of the intervention group compared to the control group.

The second quasi-experimental study (Pessah-Rasmussen & Wendel, 2009) assigned patients with acute stroke to receive early supported discharge (ESD) and compared results with a control stroke population. Early supported discharge services consisted of a pre-discharge home visit, coordinated planned discharge from the hospital and post-discharge multidisciplinary care. Process measures included length of stay and institutionalization. A significant between-group difference was found in number of patients living alone, favoring ESD compared to the control cohort.

Conclusion: There is strong evidence (level 1a) from five high quality RCTs, one fair quality RCT, one poor quality RCT and two quasi-experimental studies that there is no significant difference in institutionalisation rates between early supported discharge and conventional care.

Length of stay
Effective
1A

Six high qualities RCTs (Rodgers et al., 1997; Widén Holmqvist et al., 1998 and von Koch et al., 2000, follow-up study; Anderson et al., 2000; Indredavik et al., 2000; Mayo et al., 2000; Donnelly et al., 2004), two fair qualities RCTs (Hui et al., 1995;Rudd et al., 1997), one poor quality RCT (Shyu et al., 2009) and one quasi-experimental study (Pessah-Rasmussen & Wendel, 2009) investigated the effects of early supported discharge on process measures (length of stay) following stroke.

The first high quality RCT (Rodgers et al., 1997) randomized patients with acute stroke to receive early supported discharge or conventional care. The early supported discharge group received multidisciplinary rehabilitation home services 5 days per week. Process measures included length of stay, readmission rates, institutionalization and mortality. Significant between-group differences were found in length of stay only, favoring early supported discharge compared to conventional care.

The second high quality RCT (Widén Holmqvist et al., 1998) randomized patients with acute stroke to receive early supported discharge with home rehabilitation or conventional care. The home rehabilitation group received multidisciplinary home rehabilitation for 3-4 months. Process measures taken at 3 months post-stroke included length of stay, mortality, service use and dependency. Significant between-group differences in length of stay only were found, favoring early supported discharge and home rehabilitation compared to conventional rehabilitation.

A 6-month follow-up to the Widén Holmqvist et al., (1998) study (von Koch et al., 2000) found no significant between-group differences in process measures (length of stay, mortality, service use) at 6 months post-stroke.

The third high quality RCT (Anderson et al., 2000) randomized patients with acute stroke to receive early supported discharge or conventional care. The early discharge group received multidisciplinary rehabilitation at home for 5 weeks. Process measures included length of stay/total bed days, use of health services, institutionalization, frequency of readmissions and incidence of adverse events (death or falls). Significant between-group differences were found in length of stay/total bed days only, favoring early supported discharge compared to conventional care.

The fourth high quality RCT (Indredavik et al., 2000) randomized patients with acute stroke to an extended stroke unit service (ESUS) or an ordinary stroke unit service (OSUS). The ESUS group received multidisciplinary home services that included a home assessment, discharge form thestroke unit, follow up rehabilitation program, out-patient clinic 4 weeks after discharge, and information meeting 3 months after discharge. Process measures included mortality, institutionalization and length of stay. Significant between-group differences were found in average length of stay in hospital (stroke unit and rehabilitation clinic) recorded at discharge, and number of patients discharged home vs. institutions recorded at discharge and 6 weeks post-stroke, favoring the ESUS compared to the OSUS. Differences in residential status were no longer significant at long-term follow-up (26 weeks post-stroke). There were no significant between-group differences in mortality rates.

The fifth high quality RCT (Mayo et al., 2000) randomized patients with acute stroke to receive prompt discharge and home rehabilitation or usual care. The intervention group received a home rehabilitation program for 4 weeks consisting of tailor-made rehabilitation and nursing services. Process measures included length of stay and health services use. Significant between-group differences were found in length of stay, favoring the intervention group.

The sixth high quality RCT (Donnelly et al., 2004) randomly assigned patients with acute stroke to early hospital discharge or usual hospital rehabilitation. The early discharge group received multidisciplinary home services for 3 months (average of 2.5 visits a week, 45 minutes per session). Process measures included length of stay, service use and cost. Significant between-group differences were found in use of occupational therapy, social work and rehabilitation assistant services (but not physiotherapy or Meals on Wheels services), favoring early discharge rehabilitation compared to conventional rehabilitation. There were no significant between-group differences in length of stay or cost.

The first fair quality RCT (Hui et al., 1995) randomized patients with acute stroke to an early supported discharge (ESD) team managed by a geriatrician or a conventional medical team managed by a neurologist. Patients in the ESD team were managed by a geriatrician and received rehabilitation at a day hospital. Process measures included length of stay, mortality, health service use (readmissions, outpatient services and community services) and cost. Significant between-group differences were found in number of outpatient visits only, favoring ESD compared to conventional care.

The second fair quality RCT (Rudd et al., 1997) randomized patients with acute stroke to receive specialist community rehabilitation or conventional hospital and community care. The specialist community rehabilitation group received an individual multidisciplinary daily care plan for 3 months. Process measures included length of stay, readmission rates, institutionalization, mortality and health service use. Significant between-group differences were found in length of stay only, favoring specialist community rehabilitation compared to conventional hospital and community care.

The poor quality study (Shyu et al., 2009) randomised patients with acute stroke and their carers to receive a caregiver-oriented discharge preparation programme that comprised health education, referrals and problem-solving support, or routine discharge services. Patient service use was measured at 1, 3, 6 and 12 months post-discharge according to length of hospital stay, hospital readmissions and institutionalisations. Patients in the intervention group demonstrated significantly less institutionalisation than patients in the control group 6 to 12 months post-discharge. There were no significant between-group differences in length of hospital stay or hospital readmissions at any time point.

The quasi-experimental study (Pessah-Rasmussen & Wendel, 2009) assigned patients with acute stroke to receive early supported discharge (ESD) and compared results with a control stroke population. Early supported discharge services consisted of a pre-discharge home visit, coordinated planned discharge from the hospital and post-discharge multidisciplinary care. Process measures included length of stay and institutionalization. A significant between-group difference was found in number of patients living alone, favoring ESD compared to the control cohort.

Conclusion: There is strong evidence (level 1a) from five high quality RCTs and one fair quality RCT that there is a significant difference in length of stay following early supported discharge compared to usual care.

Note: However, one high quality RCT, one fair quality RCT, one poor quality RCT and one quasi experimental study found no significant between-group differences following early supported discharge.

Mobility
Not effective
1A

Four high quality RCTs (Widén Holmqvist et al., 1998 and von Koch et al., 2000 and von Koch et al., 2001 and Thorsén et al., 2005 follow-up studies; Mayo et al., 2000; Donnelly et al., 2004; Askim et al., 2006), one fair quality RCT (Rudd et al., 1997) and one quasi-experimental study (Gräsel et al., 2005) investigated the effect of early supported discharge on patients’ mobility following stroke.

The first high quality RCT (Widén Holmqvist et al., 1998) randomized patients with acute stroke to receive early supported discharge and home rehabilitation or conventional care. The home rehabilitation group received multidisciplinary home rehabilitation for 3-4 months. There was no significant between-group difference in mobility (10m walking test) at 3 months post-stroke.

A 6-month follow-up to the study by Widén Holmqvist et al., (1998) (von Koch et al., 2000) revealed no significant between-group difference in mobility (10m walking test) at 6 months post-stroke.

A 12-month follow-up to the study by Widén Holmqvist et al., (1998) (von Koch et al., 2001) found no significant between-group differences in mobility (10m walking test) at 12 months post-stroke.

A 5-year follow-up to the study by Widén Holmqvist et al., (1998) (Thorsén et al., 2005) found no significant between-group differences in mobility (10m walking test) at 5 years post-stroke.

The second high quality RCT (Mayo et al., 2000) randomized patients with acute stroke to receive prompt discharge and home rehabilitation or usual care. The intervention group received home-based rehabilitation and nursing services for 4 weeks. There were no significant between-group differences in patients’ movement and mobility (Stroke Rehabilitation Assessment of Movement, Timed Up and Go Test) at post-treatment (4 weeks) or follow-up (3 months post-stroke).

The third high quality RCT (Donnelly et al., 2004) randomized patients with acute stroke to receive early hospital discharge or usual hospital rehabilitation. The early discharge group received multidisciplinary home services for 3 months (average of 2.5 visits a week, 45 minutes per session). There were no significant between-group differences in patients’ mobility (10 meter timed walk test) at 12 months post-stroke.

The fourth high quality RCT (Askim et al., 2006) randomized patients with acute stroke to an extended stroke unit service (ESUS) or an ordinary stroke unit service (OSUS). The ESUS group received early supported discharge and home-based rehabilitation for 4 weeks post-discharge whereas the OSUS group received regular inpatient rehabilitation. There were no significant between-group differences in walking speed (5 Meter Walking Test) at 6, 26, or 52 weeks post-stroke.
Note: There was a significant between-group difference in walking speed at 1 week post-stroke (while both groups were receiving the same treatment), in favour of the OSUS group compared to the ESUS group.

The fair quality RCT (Rudd et al., 1997) randomized patients with acute stroke to receive specialist community rehabilitation or conventional hospital care. The specialist community rehabilitation group received an individual multidisciplinary daily care plan for 3 months. There were no significant between-group differences in mobility (5 Meter Walking Test) at 12 months post-stroke.

The quasi-experimental study (Gräsel et al., 2005) allocated patients with acute stroke and their carers to an intervention group that received intensified transition consisting of education and support for patients and carers prior to and following discharge (ST+IT), or a control group that received standard transition (ST). There were no significant between-group differences in mobility (Timed Up and Go Test) at 4 weeks or 6 months post-discharge.

Conclusion: There is strong evidence (level 1a) from four high quality RCTs, one fair quality RCT and one quasi-experimental study that early supported discharge is not more effective than conventional care in improving patients’ mobility following stroke.

Mortality
Not effective
1A

Five high qualities RCTs (Rodgers et al., 1997; Ronning & Guldvog, 1998; Widén Holmqvist et al., 1998 and von Koch et al., 2000, von Koch et al., 2001 and Thorsén et al., 2005 follow-up studies; Indredavik et al., 2000 and Fjærtoft et al., 2011 follow up study; Bautz-Holter et al., 2002) and three fair qualities RCTs (Hui et al., 1995;Rudd et al., 1997; Suwanwela et al., 2002) investigated the effects of early supported discharge on process measures (mortality) following stroke.

The first high quality RCT (Rodgers et al., 1997) randomized patients with acute stroke to receive early supported discharge or conventional care. The early supported discharge group received multidisciplinary rehabilitation home services 5 days per week. Process measures included length of stay, readmission rates, institutionalization and mortality. Significant between-group differences were found in length of stay only, favoring early supported discharge compared to conventional care.

The second high quality RCT (Ronning & Guldvog, 1998) randomized patients with acute stroke to receive municipality rehabilitation or hospital rehabilitation. Municipality rehabilitation comprised nursing home rehabilitation on inpatient or day-patient basis, and further ambulatory rehabilitation by a visiting physical therapist, speech therapist and/or nurse. Hospital rehabilitation was provided in a generalized hospital rehabilitation unit that provided coordinated multidisciplinary rehabilitation consisting of nursing care, physical, occupational and speech therapy, social work and neurologist services. Process measures included mortality, institutionalization and dependency (Barthel Index score of <75). While no significant between-group differences in individual process measures were found, there was a significant between-group difference in combined death/dependency rates, in favour of hospital rehabilitation compared to municipality rehabilitation. Further, there were significant between-group differences in dependency and death/dependency rates among patients with moderate to severe stroke, in favour of hospital rehabilitation vs. municipality rehabilitation. Among patients with mild stroke (BI score ≥50) there was a significant between-group difference in need of long-term care (p=0.02), in favour of municipality rehabilitation compared to hospital rehabilitation.

The third high quality RCT (Widén Holmqvist et al., 1998) randomized patients with acute stroke to receive early supported discharge with home rehabilitation or conventional care. The home rehabilitation group received multidisciplinary home rehabilitation for 3-4 months. Process measures taken at 3 months post-stroke included length of stay, mortality, service use and dependency. Significant between-group differences in length of stay only were found, favoring early supported discharge and home rehabilitation compared to conventional rehabilitation.

A 6-month follow-up to the Widén Holmqvist et al., (1998) study (von Koch et al., 2000) found no significant between-group differences in process measures (length of stay, mortality, service use) at 6 months post-stroke.

A 12-month follow-up to the Widén Holmqvist et al., (1998) study (von Koch et al., 2001) found significant between-group differences in use of primary care and home rehabilitation services, whereby patients in the conventional rehabilitation received more outpatient occupational therapy, private physiotherapy and day-hospital services, whereas patients in the early supported discharge and home rehabilitation group received more nursing and home rehabilitation services. There were no significant between-group differences in other process measures (mortality, dependency, cost of health care).

A 5-year follow up to the Widén Holmqvist et al. (1998) study (Thorsén et al., 2005) found no significant between-group differences in process measures (mortality, dependency) at 5 years post-stroke.

The fourh high quality RCT (Indredavik et al., 2000) randomized patients with acute stroke to an extended stroke unit service (ESUS) or an ordinary stroke unit service (OSUS). The ESUS group received multidisciplinary home services that included a home assessment, discharge form thestroke unit, follow up rehabilitation program, out-patient clinic 4 weeks after discharge, and information meeting 3 months after discharge. Process measures included mortality, institutionalization and length of stay. Significant between-group differences were found in average length of stay in hospital (stroke unit and rehabilitation clinic) recorded at discharge, and number of patients discharged home vs. institutions recorded at discharge and 6 weeks post-stroke, favoring the ESUS compared to the OSUS. Differences in residential status were no longer significant at long-term follow-up (26 weeks post-stroke). There were no significant between-group differences in mortality rates.

A 5-year follow-up to the Indredavik et al., (2000) study (Fjæroft et al., 2011) found significant between-group differences in mortality and institutionalization rates at 5 years post-stroke, favoring the ESUS compared to the OSUS.

The fifth high quality RCT (Bautz-Holter et al., 2002) randomized patients with acute stroke to receive early supported discharge or conventional hospital rehabilitation. The early supported discharge group received multidisciplinary rehabilitation at home for as long as considered necessary followed by outpatient clinic intervention. Process measures included use of health services, mortality and institutionalization. No significant between-group differences were found.

The first fair quality RCT (Hui et al., 1995) randomized patients with acute stroke to an early supported discharge (ESD) team managed by a geriatrician or a conventional medical team managed by a neurologist. Patients in the ESD team were managed by a geriatrician and received rehabilitation at a day hospital. Process measures included length of stay, mortality, health service use (readmissions, outpatient services and community services) and cost. Significant between-group differences were found in number of outpatient visits only, favoring ESD compared to conventional care.

The second fair quality RCT (Rudd et al., 1997) randomized patients with acute stroke to receive specialist community rehabilitation or conventional hospital and community care. The specialist community rehabilitation group received an individual multidisciplinary daily care plan for 3 months. Process measures included length of stay, readmission rates, institutionalization, mortality and health service use. Significant between-group differences were found in length of stay only, favoring specialist community rehabilitation compared to conventional hospital and community care.

The third fair quality RCT (Suwanwela et al., 2002) randomized patients with acute stroke to receive early discharge and home rehabilitation or conventional rehabilitation. The home rehabilitation intervention consisted of 3 days hospitalization followed by home interventions for 10 consecutive days and follow-up by visits in the 2nd week, at 1, 3, and 6 months. Process measures included mortality and dependency. There were no significant between-group differences in process measures.

Conclusion: There is strong evidence (level 1a) from five high quality RCTs and three fairquality RCTs that there is no significant difference in mortality rates following early supported discharge compared to conventional care.

Motor skills
Effective
1B

One high quality RCT (Widén Holmqvist et al., 1998 and von Koch et al., 2000 and von Koch et al., 2001 and Thorsén et al., 2005 follow-up studies) and one fair quality RCT (Rudd et al., 1997) investigated the effect of early supported discharge on patients’ motor skills following stroke.

The high quality RCT (Widén Holmqvist et al., 1998) randomized patients with acute stroke to receive early supported discharge and home rehabilitation or conventional care. The home rehabilitation group received multidisciplinary home rehabilitation for 3-4 months. At 3 months post-stroke, there was a significant between-group difference in motor capacity (Lindmark Motor Capacity Assessment coordination subtest), favoring early supported discharge compared to conventional rehabilitation.

A 6-month follow-up to the study by Widén Holmqvist et al., (1998) (von Koch et al., 2000) also revealed significant between-group differences in motor capacity (Lindmark Motor Capacity Assessment total maximal motor score) at 6 months post-stroke, in favour of early supported discharge compared to conventional rehabilitation.

A 12-month follow-up to the study by Widén Holmqvist et al., (1998) (von Koch et al., 2001) found no significant between-group differences in patients’ motor capacity (Lindmark Motor Capacity Assessment) at 12 months post-stroke.

A 5-year follow-up to the study by Widén Holmqvist et al., (1998) (Thorsén et al., 2005) found no significant between-group differences in patients’ motor capacity (Lindmark Motor Capacity Assessment) at 5 years post-stroke.

The fair quality RCT (Rudd et al., 1997) randomized patients with acute stroke to receive specialist community rehabilitation or conventional hospital care. The specialist community rehabilitation group received an individual multidisciplinary daily care plan for 3 months. There were no significant between-group differences in patients’ motor abilities (Motricity Index) at 12 months post-stroke.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that early supported discharge is more effective than conventional care for improving patients’ motor capacity following stroke.

Note: Significant between-group differences were not maintained long term. A fair quality RCT found no significant between-group differences in patients’ motor abilities.

Quality of care
Effective
2b

One poor quality RCT (Shyu et al., 2009) investigated the effects of early supported discharge on quality of care provided by carers of patients with stroke. This poor quality study randomised patients with acute stroke and their carers to receive a caregiver-oriented discharge preparation programme that comprised health education, referrals and problem-solving support, or routine discharge services. There was a significant between-group difference in quality of care (Family Caregiving Consequence Inventory – frail elder outcome subscale) at 6 months, in favour of the intervention group compared to the control group, and caregivers in the intervention group provided significantly better overall quality of care in the first 12 months than those in the control group.

Conclusion: There is limited evidence (level 2b) from one poor quality RCT that early supported discharge is more effective than conventional care for improving carers’ quality of care.

Readmission
Not effective
1a

Two high qualities RCTs (Rodgers et al., 1997; Anderson et al., 2000), two fair qualities RCTs (Hui et al., 1995; Rudd et al., 1997) and one poor quality RCT (Shyu et al., 2009) investigated the effects of early supported discharge on process measures (readmission rates) following stroke.

The first high quality RCT (Rodgers et al., 1997) randomized patients with acute stroke to receive early supported discharge or conventional care. The early supported discharge group received multidisciplinary rehabilitation home services 5 days per week. Process measures included length of stay, readmission rates, institutionalization and mortality. Significant between-group differences were found in length of stay only, favoring early supported discharge compared to conventional care.

The second high quality RCT (Anderson et al., 2000) randomized patients with acute stroke to receive early supported discharge or conventional care. The early discharge group received multidisciplinary rehabilitation at home for 5 weeks. Process measures included length of stay/total bed days, use of health services, institutionalization, frequency of readmissions and incidence of adverse events (death or falls). Significant between-group differences were found in length of stay/total bed days only, favoring early supported discharge compared to conventional care.

The first fair quality RCT (Hui et al., 1995) randomized patients with acute stroke to an early supported discharge (ESD) team managed by a geriatrician or a conventional medical team managed by a neurologist. Patients in the ESD team were managed by a geriatrician and received rehabilitation at a day hospital. Process measures included length of stay, mortality, health service use (readmissions, outpatient services and community services) and cost. Significant between-group differences were found in number of outpatient visits only, favoring ESD compared to conventional care.

The second fair quality RCT (Rudd et al., 1997) randomized patients with acute stroke to receive specialist community rehabilitation or conventional hospital and community care. The specialist community rehabilitation group received an individual multidisciplinary daily care plan for 3 months. Process measures included length of stay, readmission rates, institutionalization, mortality and health service use. Significant between-group differences were found in length of stay only, favoring specialist community rehabilitation compared to conventional hospital and community care.

The poor quality study (Shyu et al., 2009) randomised patients with acute stroke and their carers to receive a caregiver-oriented discharge preparation programme that comprised health education, referrals and problem-solving support, or routine discharge services. Patient service use was measured at 1, 3, 6 and 12 months post-discharge according to length of hospital stay, hospital readmissions and institutionalisations. Patients in the intervention group demonstrated significantly less institutionalisation than patients in the control group 6 to 12 months post-discharge. There were no significant between-group differences in length of hospital stay or hospital readmissions at any time point.

Conclusion: There is strong evidence (level 1a) from two high quality RCTs and two fair quality RCTs and one poor quality RCT that there is no significant difference in rate of readmission following early supported discharge compared to conventional care.

Satisfaction - carers
Not effective
1A

Four high quality RTCs (Widén Holmqvist et al., 1998 and von Koch et al., 2000, von Koch et al., 2001 and Thorsén et al., 2005 follow-up studies; Anderson et al., 2000; Bautz-Holter et al., 2002; Donnelly et al., 2004) and two fair quality RCTs (Hui et al., 1995; Rudd et al, 1997) investigated the effects of early supported discharge on satisfaction among carers’ of patients with stroke.

The first high quality RCT (Widén Holmqvist et al., 1998) randomized patients with acute stroke to receive early supported discharge and home rehabilitation or conventional care. The home rehabilitation group received multidisciplinary home rehabilitation for 3-4 months. No significant between-group differences in carers’ satisfaction (measured by non-standardized questionnaire) were found at 3 months post-stroke.

A 6-month follow-up to the study by Widén Holmqvist et al., (1998) (von Koch et al., 2000) also found no significant between-group differences in carers’ satisfaction (measured by non-standardized questionnaire) at 6 months post-stroke.

A 12-month follow-up to the study by Widén Holmqvist et al., (1998) (von Koch et al., 2001) also found no significant between-group differences in carers’ satisfaction (measured by non-standardized questionnaire) at 12 months post-stroke.

A 5-year follow-up to the study by Widén Holmqvist et al., (1998) (Thorsén et al., 2005) found no significant between-group differences in carers’ satisfaction (measured by non-standardized questionnaire) at 5 years post-stroke.

The second high quality RCT (Anderson et al., 2000) randomized patients with acute stroke to the early supported discharge or the conventional care group. In the early discharge group, patients received multidisciplinary rehabilitation at home for 5 weeks. No significant between-group differences in carers’ satisfaction (measured by a non-standardized questionnaire) were found at 6 months post-stroke.

The third high quality RCT (Bautz-Holter et al., 2002) randomized patients with acute stroke to receive early supported discharge or conventional hospital rehabilitation. The early supported discharge group received multidisciplinary rehabilitation at home for as long as considered necessary followed by outpatient clinic intervention. No significant between-group differences in carers’ satisfaction (measured by a 5-point Likert scale) were found at 3 or 6 months post-stroke.

The fourth high quality RCT (Donnelly et al., 2004) randomly assigned patients with acute stroke to an early hospital discharge service or usual hospital rehabilitation. The early discharge group received multidisciplinary home services for 3 months (average of 2.5 visits a week, 45 minutes per session). No significant between-group difference in carers’ satisfaction (measured by non-standardized questionnaire) were found 12 months post-stroke.

The first fair quality RCT (Hui et al., 1995) randomized patients with acute stroke to an early supported discharge (ESD) geriatrician team or a conventional medical team. Patients in the ESD group were discharged home with day hospital rehabilitation and management by a geriatrician. No significant between-group differences were found for carers’ satisfaction (measured by non-standardized questionnaire) at 3 or 6 months post-stroke.

The second fair quality RCT (Rudd et al, 1997) randomized patients with acute stroke to the specialist community rehabilitation or the conventional hospital care group. The specialist community rehabilitation group received an individual multidisciplinary daily care plan for 3 months. No significant between group difference in carers’ satisfaction with hospital care, therapy provision, community support and general satisfaction (measured with stroke-specific questionnaires) were found at 12 months post-stroke.

Conclusion: There is strong evidence (level 1a) from four high quality RCTs and two fairquality RCTs that early supported discharge is not more effective than conventional care for improving satisfaction among carers of patients with stroke.

Satisfaction - patients
Not effective
1A

Four high qualities RTCs (Widén Holmqvist et al., 1998 and von Koch et al., 2000, von Koch et al., 2001 and Thorsén et al., 2005 follow-up studies; Anderson et al., 2000; Bautz-Holter et al., 2002; Donnelly et al., 2004), and three fair quality RCTs (Hui et al., 1995; Rudd et al,, 1997; Suwanwela et al., 2002) investigated the effects of early supported discharge on satisfaction among patients with stroke.

The first high quality RCT (Widén Holmqvist et al., 1998) randomized patients with acute stroke to receive early supported discharge and home rehabilitation or conventional care. The home rehabilitation group received multidisciplinary home rehabilitation for 3-4 months. No significant between-group differences in patients’ satisfaction (measured by non-standardized questionnaire) were found at 3 months post-stroke.

A 6-month follow-up to the study by Widén Holmqvist et al., (1998) (von Koch et al., 2000) also found no significant between-group differences in patients’ satisfaction (measured by non-standardized questionnaire) at 6 months post-stroke.

A 12-month follow-up to the study by Widén Holmqvist et al., (1998) (von Koch et al., 2001) also found no significant between-group differences in patients’ satisfaction (measured by non-standardized questionnaire) at 12 months post-stroke.

A 5-year follow-up to the study by Widén Holmqvist et al., (1998) (Thorsén et al., 2005) found no significant between-group differences in patients’ satisfaction (measured by non-standardized questionnaire) at 5 years post-stroke.

The second high quality RCT (Anderson et al., 2000) randomized patients with acute stroke to the early supported discharge or the conventional care group. In the early discharge group, patients received multidisciplinary rehabilitation at home for 5 weeks. No significant between-group differences in patients’ satisfaction with medical care, rehabiliation or recovery (measured by non-standardized questionnaire) were found at 6 months post-stroke.

The third high quality RCT (Bautz-Holter et al., 2002) randomized patients with acute stroke to receive early supported discharge or conventional hospital rehabilitation. The early supported discharge group received multidisciplinary rehabilitation at home for as long as considered necessary followed by outpatient clinic intervention. No significant between-group differences in patients’ satisfaction (measured by a 5-point Likert scale) were found at 3 or 6 months post-stroke.

The fourth high quality RCT (Donnelly et al., 2004) randomly assigned patients with acute stroke to the earlier hospital discharge or the usual hospital rehabilitation group. The earlier discharge group received multidisciplinary home services for 3 months (average of 2.5 visits a week, 45 minutes per session). A significant between-group difference in patient satisfaction (measured using a non-standardized questionnaire) was found at 12 months post-stroke, favoring early discharge compared to usual hospital rehabilitation.

The first fair quality RCT (Hui et al., 1995) randomized patients with acute stroke to an early supported discharge (ESD) geriatrician team or a conventional medical team. Patients in the ESD group were discharged home with day hospital rehabilitation and management by a geriatrician. Patients’ satisfaction was measured using a questionnaire developed at the day hospital. No significant between-group differences in patients’ satisfaction (measured using a non-standardized questionnaire) were found at 3 or 6 months post-stroke.

The second fair quality RCT (Rudd et al,, 1997) randomized patients with acute stroke to the specialist community rehabilitation or the conventional hospital care group. The specialist community rehabilitation group received an individual multidisciplinary daily care plan for 3 months. Significant between-group differences were found in patient’s satisfaction with hospital care (measured by questionnaire), favoring specialist community rehabilitation compared to conventional care. There were no significant between-group differences in patients’ satisfaction with therapy provision, community support or general satisfaction (measured by stroke-specific questionnaires) at 12 months post-stroke.

The third fair quality RCT (Suwanwela et al., 2002) randomized patients with acute stroke to receive early discharge and home rehabilitation or conventional rehabilitation. The home rehabilitation intervention consisted of 3 days hospitalization followed by home interventions for 10 consecutive days and follow-up by visits in the 2nd week, at 1, 3, and 6 months. No significant between-group differences in patients’ satisfaction (measured by non-standardized questionnaire) were found at 6 months post-stroke.

Conclusion: There is strong evidence (level 1a) from three high quality RCTs and three fairquality RCTs that early supported discharge is not more effective than conventional care for improving satisfaction among patients with stroke.

Note: However, 1 high quality RCT reported higher satisfaction among patients following early supported discharge compared to conventional rehabilitation, and 1 fair quality RCT found a significant between-group difference in patients’ satisfaction with hospital care in favour of early supported discharge compared to conventional rehabilitation.

Spasticity
Not effective
2b

One quasi-experimental study (Gräsel et al., 2005) investigated the effect of early supported discharge on spasticity in patients with stroke. This quasi-experimental study allocated patients with acute stroke and their carers to an intervention group that received intensified transition consisting of education and support for patients and carers prior to and following discharge (ST+IT), or a control group that received standard transition (ST). There were no significant between-group differences in patients’ spasticity (Ashworth Spasticity Scale) at 4 weeks or 6 months post-discharge.

Conclusion: There is limited evidence (level 2b) from one quasi-experimental studythat early supported discharge is not more effective than conventional care in improving patients’ spasticity.

Stroke severity
Not effective
1A

Four high quality RCTs (Ronning & Guldvog, 1998; Indredavik et al., 2000 – Fjærtoft et al., 2011 follow-up study–; Mayo et al., 2000; Askim et al., 2006) and one fair quality RCT (Suwanwela et al., 2002) investigated the effect of early supported discharge on stroke severity.

The first high quality RCT (Ronning & Guldvog, 1998) randomized patients with acute stroke to receive municipality rehabilitation or standard hospital rehabilitation. Municipality rehabilitation comprised nursing home rehabilitation on inpatient or day-patient basis, and further ambulatory rehabilitation by a visiting physical therapist, speech therapist and/or nurse. There were no significant between-group differences in patients’ stroke severity (Scandinavian Stroke Scale – SSS) at 7 months post-stroke.
Note: Subgroup analysis showed a significant between-group difference in stroke severity (SSS) among patients with moderate to severe stroke (Barthel Index score <50), in favour of hospital rehabilitation compared to municipality rehabilitation. There were no significant between-group differences in the subgroup of patients with mild stroke.

The second high quality RCT (Indredavik et al., 2000) randomized patients with acute stroke to an extended stroke unit service (ESUS) or an ordinary stroke unit service (OSUS). The ESUS group received multidisciplinary home services that included a home assessment, discharge form thestroke unit, follow up rehabilitation program, out-patient clinic 4 weeks after discharge, and information meeting 3 months after discharge. Stroke severity was reported in a five-year follow-up study (Fjæroft et al, 2011). There was no significant between-group difference in stroke severity (Scandinavian Stroke Scale) at 5 years post-stroke.

The third high quality RCT (Mayo et al., 2000) randomized patients with acute stroke to receive prompt discharge and home rehabilitation or usual care. The intervention group received home-based rehabilitation and nursing services for 4 weeks. There were no significant between-group differences in stroke severity (Canadian Neurological Scale) at post-treatment (4 weeks) or follow-up (3 months post-stroke).

The fourth high quality RCT (Askim et al., 2006) randomized patients with acute stroke to an extended stroke unit service (ESUS) or an ordinary stroke unit service (OSUS). The ESUS group received early supported discharge and home-based rehabilitation for 4 weeks post-discharge whereas the OSUS group received regular inpatient rehabilitation. There were no significant between-group differences in stroke severity (Scandinavian Stroke Scale) at 6, 26, or 52 weeks post-stroke.

The fair quality RCT (Suwanwela et al., 2002) randomized patients with acute stroke to receive early discharge and home rehabilitation or conventional rehabilitation. Home rehabilitation intervention consisted of 3 days hospitalization followed by home interventions for 10 consecutive days and follow-up by visits. There were no significant between-group differences in stroke severity (National Institute of Health Stroke Scale) at 6 months post-stroke.

Conclusion: There is strong evidence (level 1a) from four high quality RCTs and one fairquality RCTthat early supported discharge is not more effective than conventional care for improving severity of stroke.

Note: A high quality RCT reported a significant between-group difference in stroke severity among patients with moderate to severe stroke, in favour of conventional care compared to early supported discharge.

Upper extremity function and dexterity
Not effective
1B

One high quality RCT (Widén Holmqvist et al., 1998 and von Koch et al., 2000 and von Koch et al., 2001 and Thorsén et al., 2005 follow-up studies) and one quasi-experimental study (Gräsel et al., 2005) investigated the effect of early supported discharge on upper extremity function and dexterity following stroke.

The high quality RCT (Widén Holmqvist et al., 1998) randomized patients with acute stroke to receive early supported discharge and home rehabilitation or conventional care. The home rehabilitation group received multidisciplinary home rehabilitation for 3-4 months. There were no significant between-group differences in dexterity (Nine Hole Peg Test) at 3 months follow-up.

A 6-month follow-up to the study by Widén Holmqvist et al., (1998) (von Koch et al., 2000) revealed no significant between-group difference in patients’ dexterity (Nine Hole Peg Test) at 6 months post-stroke.

A 12-month follow-up to the study by Widén Holmqvist et al., (1998) (von Koch et al., 2001) found no significant between-group differences in patients’ dexterity (Nine Hole Peg Test) at 12 months post-stroke.

A 5-year follow-up to the study by Widén Holmqvist et al., (1998) (Thorsén et al., 2005) found no significant between-group differences in patients’ dexterity (Nine Hole Peg Test) at 5 years post-stroke.

The quasi-experimental study (Gräsel et al., 2005) allocated patients with acute stroke and their carers to an intervention group that received intensified transition consisting of education and support for patients and carers prior to and following discharge (ST+IT), or a control group that received standard transition (ST). There were no significant between-group differences in upper extremity function (Frenchay Arm Test) at 4 weeks or 6 months post-discharge.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT and one quasi-experimental study that early supported discharge is not more effective than conventional care for improving upper extremity function and dexterity following stroke.

Use of health services
Not effective
1A

Five high qualities RCTs (Widén Holmqvist et al., 1998 and von Koch et al., 2000 follow-up study; Anderson et al., 2000; Mayo et al., 2000; Bautz-Holter et al., 2002; Donnelly et al., 2004), two fair qualities RCTs (Hui et al., 1995; Rudd et al., 1997), and one quasi-experimental study (Gräsel et al., 2005 and Gräsel et al., 2006 follow-up study) investigated the effects of early supported discharge on process measures (use of health services) following stroke.

The first high quality RCT (Widén Holmqvist et al., 1998) randomized patients with acute stroke to receive early supported discharge with home rehabilitation or conventional care. The home rehabilitation group received multidisciplinary home rehabilitation for 3-4 months. Process measures taken at 3 months post-stroke included length of stay, mortality, service use and dependency. Significant between-group differences in length of stay only were found, favoring early supported discharge and home rehabilitation compared to conventional rehabilitation.

A 6-month follow-up to the Widén Holmqvist et al., (1998) study (von Koch et al., 2000) found no significant between-group differences in process measures (length of stay, mortality, service use) at 6 months post-stroke.

The second high quality RCT (Anderson et al., 2000) randomized patients with acute stroke to receive early supported discharge or conventional care. The early discharge group received multidisciplinary rehabilitation at home for 5 weeks. Process measures included length of stay/total bed days, use of health services, institutionalization, frequency of readmissions and incidence of adverse events (death or falls). Significant between-group differences were found in length of stay/total bed days only, favoring early supported discharge compared to conventional care.

The third high quality RCT (Mayo et al., 2000) randomized patients with acute stroke to receive prompt discharge and home rehabilitation or usual care. The intervention group received a home rehabilitation program for 4 weeks consisting of tailor-made rehabilitation and nursing services. Process measures included length of stay and health services use. Significant between-group differences were found in length of stay, favoring the intervention group.

The fourth high quality RCT (Bautz-Holter et al., 2002) randomized patients with acute stroke to receive early supported discharge or conventional hospital rehabilitation. The early supported discharge group received multidisciplinary rehabilitation at home for as long as considered necessary followed by outpatient clinic intervention. Process measures included use of health services, mortality and institutionalization. No significant between-group differences were found.

The fifth high quality RCT (Donnelly et al., 2004) randomly assigned patients with acute stroke to early hospital discharge or usual hospital rehabilitation. The early discharge group received multidisciplinary home services for 3 months (average of 2.5 visits a week, 45 minutes per session). Process measures included length of stay, service use and cost. Significant between-group differences were found in use of occupational therapy, social work and rehabilitation assistant services (but not physiotherapy or Meals on Wheels services), favoring early discharge rehabilitation compared to conventional rehabilitation. There were no significant between-group differences in length of stay or cost.

The first fair quality RCT (Hui et al., 1995) randomized patients with acute stroke to an early supported discharge (ESD) team managed by a geriatrician or a conventional medical team managed by a neurologist. Patients in the ESD team were managed by a geriatrician and received rehabilitation at a day hospital. Process measures included length of stay, mortality, health service use (readmissions, outpatient services and community services) and cost. Significant between-group differences were found in number of outpatient visits only, favoring ESD compared to conventional care.

The second fair quality RCT (Rudd et al., 1997) randomized patients with acute stroke to receive specialist community rehabilitation or conventional hospital and community care. The specialist community rehabilitation group received an individual multidisciplinary daily care plan for 3 months. Process measures included length of stay, readmission rates, institutionalization, mortality and health service use. Significant between-group differences were found in length of stay only, favoring specialist community rehabilitation compared to conventional hospital and community care.

The quasi-experimental study (Gräsel et al., 2005) allocated patients with acute stroke and their carers to receive intensified transition consisting of education and support for patients and carers prior to and following discharge (ST+IT), or a control group that received standard transition (ST). Number of physician visits and newly appearing illnesses were measured at 4 weeks and 6 months post-discharge. Patients in the control group showed significantly more new illnesses than those in the intervention group at 4 weeks post-discharge, but this difference did not remain significant at 6 months. There was a significant between-group difference in the number of physician visits in favour of the intervention group compared to the control group at 6 months post-discharge (these differences were not present at four weeks post-discharge).

In a follow-up study (Gräsel et al., 2006), patients were contacted by telephone on average 31 months after discharge from hospital to determine whether the patient was (a) alive; and (b) living at home or in a nursing home. There was a significant difference between groups in the number of patients who were alive and living at home, in favour of the intervention group compared to the control group.

Conclusion: There is strong evidence (level 1a) from four high quality RCTs and two fair quality RCTs that there is no significant difference in use of health services between early supported discharge and conventional care.

Note: However, a fifth high quality RCT found a significant between-group differences in use of occupational therapy, social work and rehabilitation assistant services, favoring early discharge rehabilitation compared to conventional rehabilitation. Furthermore, one quasi-experimental study found a significant between-group difference in the number of physician visits in favour of the intervention group of intensified transition compared to the control group, at 6 months post-discharge.

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