Background: Limited information exists on the best way to organise stroke rehabilitation after hospital discharge and the relative costs of such services.
Objective: To review the evidence of the cost effectiveness of services that accelerate hospital discharge and provide home-based rehabilitation for patients with acute stroke.
Methods: A systematic review with economic analysis of published randomised clinical trials (available to March 2001) comparing early hospital discharge and domiciliary rehabilitation with usual care in patients with stroke was conducted. From included studies, data were extracted on study quality; major clinical outcomes including hospital stay, death, institutionalisation, disability, and readmission rates; and resource use associated with hospital stay, rehabilitation, and community services. The resources were priced using Australian dollars ($A) healthcare costs. The outcomes and costs of the new intervention were compared with standard care.
Results: Seven published trials involving 1277 patients (54% men; mean age 73 years) were identified. The pooled data showed that overall, a policy of early hospital discharge and domiciliary rehabilitation reduced total length of stay by 13 days [95% confidence interval (CI): -19 to -7 days]. There was no significant effect on mortality (odds ratio = 0.95; 95% CI: 0.65 to 1.38) or other clinical outcomes making a cost minimisation analysis for the economic analysis appropriate. The overall mean costs were approximately 15% lower for the early discharge intervention [$A16 016 ($US9941) versus $A18 350 ($US11 390)] compared with standard care.
Conclusions: A policy of early hospital discharge and home-based rehabilitation for patients with stroke may reduce the use of hospital beds without compromising clinical outcomes. Our analysis shows this service to be a cost saving alternative to conventional in-hospital stroke rehabilitation for an important subgroup of patients with stroke-related disability.
Standard Care Institutional Care Early Discharge Stroke Rehabilitation Australian Hospital
This is a preview of subscription content, log in to check access
We are grateful to Derrick Bennett of the Clinical Trials Research Unit for his advice with the statistical analyses; to Sally Rubenach for providing us with Australian cost data; to Valery Feigin for his comments on the manuscript; and to the Cochrane Stroke Review Group for their assistance. Cliona Ni Mhurchu undertook this work while holding a Fellowship from the National Heart Foundation of New Zealand. Craig Anderson holds the New Zealand Freemasons Chair of Geriatric Medicine and is a member of the Cochrane Collaboration Stroke Group Editorial Board. There was no direct financial support for this work; there are no conflicts of interest.
Warlow CP, Dennis MS, van Gijn J, et al. Stroke: a practical guide to management. Edinburgh: Blackwell Science, 1996Google Scholar
Jamrozik K, Broadhurst RJ, Lai N, et al. Trends in the incidence, severity and short-term outcome of stroke in Perth, Western Australia. Stroke 1999; 30: 2105–11PubMedCrossRefGoogle Scholar
Anderson CS, Jamrozik KD, Stewart-Wynne EG. Patterns of acute hospital care, rehabilitation, and discharge disposition after acute stroke: the Perth Community Stroke Study 1989–1990. Cerebrovasc Dis 1994; 4: 344–53CrossRefGoogle Scholar
Isard PA, Forbes JF. The cost of stroke to the National Health Service in Scotland. Cerebrovasc Dis 1992; 2: 47–50CrossRefGoogle Scholar
Aho K, Harmsen P, Hatano S, et al. Cerebrovascular disease in the community: results of a WHO Collaborative Study. Bull World Health Organ 1980; 58: 113–30PubMedGoogle Scholar
Stroke Unit Trialists’ Collaboration. Collaborative systematic review of the randomised trials of organised in-patient (stroke unit) care after stroke. BMJ 1997; 314: 1151–9CrossRefGoogle Scholar
Early Supported Discharge Trialists. Services for reducing duration of hospital care for acute stroke patients (Cochrane Review). Available in The Cochrane Library [database on disk and CD ROM]. Updated quarterly. The Cochrane Collaboration; issue 3. Oxford: Update Software, 2000Google Scholar
Beech R, Rudd AG, Tilling K, et al. Economic consequences of early inpatient discharge to community-based rehabilitation for stroke in an inner-London teaching hospital. Stroke 1999; 30: 729–35PubMedCrossRefGoogle Scholar
Anderson C, Ni Mhurchu C, Rubenach S, et al. Home or hospital for stroke rehabilitation? Results of a randomised controlled trial. II: costminimisation analysis at 6 months. Stroke 2000; 31: 1032–7PubMedCrossRefGoogle Scholar
McNamee P, Christensen J, Soutter J, et al. Cost analysis of early supported hospital discharge for stroke. Age Ageing 1998; 27: 345–51CrossRefGoogle Scholar
Widen Holmqvist L, de Pedro Cuesta J, Moller G, et al. A pilot study of rehabilitation at home after stroke: a health-economic appraisal. Scand J Rehabil Med 1996; 28: 9–18PubMedGoogle Scholar
Anderson C, Rubenach S, Ni Mhurchu C, et al. Home or hospital for stroke rehabilitation? Results of a randomised controlled trial. I: health outcomes at 6 months. Stroke 2000; 31: 1024–31PubMedCrossRefGoogle Scholar
Australian Hospital Cost Data Collection, 1998/99. Final report of the development of AR-DRG, version 4.1, August 2000. Available from URL: http://www.health.gov.au [Accessed 2002 Jun 19]Google Scholar
Normand ST. Tutorial in biostatistics: meta-analysis: formulating, evaluation, combining, and reporting. Stat Med 1999; 18: 321–59PubMedCrossRefGoogle Scholar
Mantel W, Haenszel W. Statistical aspects of the analysis of data from retrospective studies of disease. J Natl Cancer Inst 1959; 22: 710–48Google Scholar
Hedges LV, Olkin I. Statistical methods for meta-analysis. New York (NY): Academic Press, 1985Google Scholar
Lafferty G. Community-based alternatives to hospital rehabilitation services: a review of the evidence and suggestions for approaching future evaluations. Rev Clin Gerontol 1996; 6: 183–94CrossRefGoogle Scholar
Gladman JRF, Lincoln NB, for the DOMINO Study Group. Follow-up of a controlled trial of domiciliary stroke rehabilitation (DOMINO Study). Age Ageing 1994; 23: 9–13PubMedCrossRefGoogle Scholar