Abstract

This study examined the cost-effectiveness of accelerating the discharge of stroke patients from hospital and replacing hospital based rehabilitation services with home-based programs. Evidence from 7 international randomized controlled trials comparing homebased programs to standard care is summarized. Accelerated discharge from hospital followed by intensive home-based rehabilitation appears to reduce costs to the health care system without jeopardizing patient outcomes. Background: Randomized clinical trials have demonstrated that a well-organized, multidisciplinary approach to acute and rehabilitative stroke care in the hospital leads to improvement in survival and patient independence after stroke. There is now a strong interest in accelerating hospital discharge so that rehabilitation programs may be implemented in the patient's home rather than hospital. This study conducted a systematic review of the literature and synthesized the evidence of the cost-effectiveness of shifting the focus of care from the hospital to the community.

Method: This project identified 7 international randomized controlled trials that compared conventional hospital treatment to early discharge followed by a home-based stroke rehabilitation program. In 6 of the 7 trials, a new multi-disciplinary stroke team was organized to coordinate community care. Length of the home-based intervention ranged from 4 to 44 weeks. 2 of the trials were conducted in the United Kingdom, 2 in Norway, and one each in Australia, Canada and Sweden. Approximately one-third to one-half of all stroke patients were eligible to participate in these trials.

Findings: Pooled data from all of the trials showed that there were no statistically significant differences in patient mortality, requirement for long-term institutional care or readmission to hospital. There were non-significant trends of a lower probability of death, lower probability of admission to long-term institutional care and a higher probability of readmission to hospital in the accelerated hospital discharge group. Data on patient quality of life could not be pooled due to differences in measurement methods, but overall, quality of life of patients in the standard care and accelerated discharge groups were similar. Resource use data from the trials and unit costs from the Australian healthcare system were use to calculate all direct costs including hospital care, community services, and institutional care for a period of 12 months. (Costs are presented in 1998 to 1999 Australian dollars $A and American dollars $US.) The average patient cost for accelerated hospital discharge was about 15% less than the average patient cost of conventional treatment ($A16,016 or $US9,194 compared to $A18,350 or $US11,390 respectively). Although community services were more expensive in the intervention group, savings in hospital costs were substantial enough to offset the costs of these additional services.

Conclusions: Accelerated discharge from hospital followed by an intensive home-based rehabilitation program appears to reduce costs to the health care system without jeopardizing patient outcomes. Larger randomized controlled trials are needed to evaluate patient outcomes and economic consequences in specific patient subgroups, including the oldest elderly and those with cognitive impairment.

Reference: Anderson C, Ni Mhurchu C, Brown PM, Carter K. Stroke rehabilitation services to accelerate hospital discharge and provide home-base care: An overview and cost analysis. Pharmacoeconomics 2002; 20(8); 537-552.