This review assessed the effect of early supported discharge for stroke rehabilitation at home in comparison with conventional care. The authors concluded that mild stroke patients could be rehabilitated in the community without negative consequences. The content and length of discharge programmes and usual care differed across the studies, as did measures of functional outcome.

To assess the effectiveness of early supported discharge programmes for stroke rehabilitation.

MEDLINE (from 1970 to June 2002), and EMBASE, MANTIS, Pascal and SciSearch (from 1995 to 2002) were searched; the search terms were listed. The bibliographies of selected studies were checked. Unpublished literature or data were not included in the review.

Study designs of evaluations included in the review

Only randomised controlled trials (RCTs) were eligible for inclusion.

Specific interventions included in the review

Studies that evaluated the efficacy of early supported discharge programmes for stroke rehabilitation were eligible for inclusion. Studies assessing the efficacy of early supported discharge (or stroke rehabilitation at home) compared with conventional or usual stroke rehabilitation were included. Conventional care varied across the studies and included rehabilitation on stroke or geriatric wards, and continued out-patient therapy in some cases.

Participants included in the review

Studies of patients who had experienced a radiologically confirmed ischaemic or haemorrhagic cerebrovascular accident were included in the review.

Outcomes assessed in the review

Studies that assessed functional outcomes and length of hospital stay were eligible for inclusion.

How were decisions on the relevance of primary studies made?

The authors did not state how the papers were selected for the review, or how many reviewers performed the selection.

The PEDro scoring system was used to assess the quality of the included studies (see Other Publications of Related Interest). Ten criteria were applied, all requiring yes or no answers. Each of the following criteria were given equal weighting of one point (where 10 represents the highest quality score): randomisation; allocation concealment; comparison of the baseline characteristics; blinding of the patient, therapist and assessor; adequate follow-up (were all randomised patients accounted for at the end of the study?); intention-to-treat analysis; and statistical comparisons between groups with point estimates and variability measures. Studies receiving a PEDro score of 4 or less were excluded from the review. Two reviewers independently assessed the studies for quality and any disagreements were resolved by a third reviewer.

The authors did not state how the data were extracted for the review, or how many reviewers performed the data extraction. Outcomes in the intervention and control groups within each trial were compared and the results were expressed as a dichotomous variable.

How were the studies combined?

The findings were combined in a brief narrative, grouped by outcome.

How were differences between studies investigated?

There was no investigation of differences between the studies. Study differences were evident from the tables of included studies.

Ten RCTs (15 publications), consisting of 1,286 patients, were included in the review.

Two studies received a PEDro score of 8, three scored 7, three were graded as 6, one scored 5, and one scored 4.

Hospital length of stay (8 RCTs).

Acute hospital length of stay was reduced in 6 studies as a result of early supported discharge programmes. Two studies found no significant difference in hospital stay between early supported discharge and usual care.

Functional outcomes (8 RCTs).

Eight studies that used the Barthel Index or the Modified Barthel Index found no significant difference in functional outcome between early supported discharge and conventional care.

One of 3 studies that compared the costs of early supported discharge programmes with usual care found a significant cost reduction with the home intervention. The other 2 studies found no significant difference in cost between the therapies.

Based on the findings, there is strong evidence that high-level independent stroke patients discharged from an acute hospital unit can be rehabilitated in the community by an interdisciplinary stroke rehabilitation team without negative consequences. Functional outcomes appeared to be similar in patients with equivalent stroke severity for those receiving early supported discharge programmes or usual in-patient care. Length of hospital stay appeared to be reduced with early discharge programmes in comparison with usual care. Limited evidence suggests that patients with moderate to severe deficits are unsuitable candidates for early supported discharge programmes.

The review question was well-defined with clear inclusion criteria. A number of relevant databases were searched, although no attempt to identify unpublished literature was made and the possibility of publication bias was not assessed. It was unclear whether any language restrictions were applied. There was no information on the number of reviewers who selected the studies and extracted the data, so it is not possible to comment on whether reviewer error or bias may have influenced the findings. The studies were assessed for quality, although this information was not utilised in the interpretation of the findings. One of the included studies received a quality score of 4 which, according to the authors' eligibility criteria, should have been excluded. The findings were appropriately combined and presented in a narrative format. The authors' conclusions were appropriately based on mild stroke patients, as the majority of studies included only patients from this group. The content and length of discharge programmes and usual care differed across the studies, as did the methods used to measure functional outcome; it is therefore unclear whether the study findings are comparable.

The authors did not state any implications for practice or further research.

Ontario Ministry of Health and Long-Term Care; Heart and Stroke Foundation of Ontario; Canadian Stroke Network.

Moseley AM, Herbert RD, Sherrington C, Maher CG. Evidence for physiotherapy practice: a survey of the Physiotherapy Evidence Database (PEDro). Aust J Physiother 2002;48:43-9.

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.