R.W.H. Heijnen1, T.D.E.M VAN DER WEIJDEN2, S.M.A.A. Evers3, M. Limburg4, B. Winkens5, J.M.G.A. Schols6
1. MD, PhD (candidate), Department of Family Medicine, CAPHRI School for Public Health and Primary Care, Maastricht University, The Netherlands; 2. PhD, Professor of Implementation of Clinical Practice Guidelines, Department of Family Medicine, CAPHRI School for Public Health and Primary Care, Maastricht University, The Netherlands; 3. PhD, Professor of Public Health Technology Assessment, Department of Health Services Research, CAPHRI School for Public Health and Primary Care, Maastricht University, The Netherlands; 4. MD, PhD, Professor of Neurology, Flevo Hospital, Almere, The Netherlands; 5. PhD, Assistant Professor of Statistics, Department of Methodology and Statistics, CAPHRI School for Public Health and Primary Care, Maastricht University, The Netherlands; 6. MD, PhD, Professor of Old Age Medicine, Department of Family Medicine and Department Health Services Research, CAPHRI School for Public Health and Primary Care, Maastricht University, The Netherlands. Corresponding author: Ron Heijnen, MD, PhD (candidate), Elderly Care Physician, Envida Group, Polvertorenstraat 6, 6211 LX Maastricht, The Netherlands, Phone: 0031 43 3875389, Fax: 0031 43 3874438,
E-mail: r.heijnen@MUMC.nl
Abstract
Background: A new stroke care model has been developed aiming at the early hospital discharge of stroke patients to a nursing home for systematic assessment with subsequent planning for rehabilitation. Our hypothesis was that this new model for stroke care improves the delivery of care without affecting quality of life, functional outcomes and satisfaction with care. Design: A non-randomised comparative trial. Setting: Two Dutch stroke services in the regions of Maastricht and Eindhoven. Participants: Acute stroke patients, over 18 years of age. Intervention: Hospital discharge of stroke patient within 5 days to a nursing home, followed by a systematic multidisciplinary assessment in a specialised nursing home assessment unit to determine the optimal rehabilitation track. Usual care consists of an average of 10 days of hospital care, followed by less extensive assessment. Measurements: The primary outcome measures were quality of life and activities of daily living. The primary and secondary outcomes – impairment, cognitive functioning, instrumental activities of daily life, mood, satisfaction with care, caregivers’ strain, length of stay, and medical complications – were assessed using validated instruments. Results: 239 acute stroke patients participated in this study: 122 in the intervention and 117 in the control group. We did not succeed in implementing early discharge from hospital, although the systematic assessment in the nursing home was accomplished. No clinically relevant differences were found between the groups for functional outcomes, quality of life or satisfaction with care. In comparison with the control group, a trend towards reduction in length of nursing home stay was found in the intervention group. Conclusion: Although the new care model failed to implement early discharge, more stroke patients in the intervention group were assessed by a multidisciplinary team in a nursing home in comparison with the usual care group, where more patients were discharged home after their initial hospital stay.
Key words: Stroke, nursing home, functional outcomes.
Introduction
Strokes have a profound effect on a person’s life and also present a large economic burden to society (1). Changes in the delivery of health care, driven by the need to optimise the delivery of care and reduce costs, have resulted in shorter hospital stays and a decrease in the number of acute care beds in hospitals (1). It is estimated that in the Netherlands the prevalence of strokes will rise until 2025 (2). Accordingly, managing the growing number of strokes demands creative solutions that will not have a negative impact on stroke outcomes.
Hospitalisation often leads to worsening of overall health condition by iatrogenic induced disability, therefore early hospital discharge is important, especially for the elderly (3). Early discharge from a hospital followed by assessment of stroke-induced disabilities and rehabilitation planning in a nursing home setting might be a solution for the Netherlands, where a considerable part of stroke rehabilitation for older stroke patients already takes place in nursing homes (4). Therefore the stroke service Maastricht Heuvelland introduced an innovative care model aimed at reducing hospital stays for stroke patients to 5 days, followed by assessment in a nursing home. A hospital stay of 5 days can be achieved, as shown earlier by Vos et al (5). The development and implementation of this care model are described elsewhere (6).
The positive effects of stroke unit care on the reduction of mortality, length of hospital stay and the number of long-term care admissions have been well-documented (7). Earlier studies on early supported discharge, with rehabilitation beginning in the acute phase continued with home-based rehabilitation, showed a decrease in the length of hospital stay and a reduction of institutional care, with no effect on outcomes such as activities of daily living, instrumental activities of daily life or cognitive functioning (8).
Results of other forms of stroke care organisation, including various types of home-based rehabilitation, have been inconclusive. A recent review showed little evidence of the effectiveness of these interventions on functional outcomes such as activities of daily living and quality of life in stroke (8).
In accordance with these findings, our hypothesis was that the new care model, consisting of early hospital discharge in combination with assessment and rehabilitation planning in a nursing home, may optimise care delivery and decrease the length of hospital stay even further, without negatively affecting functioning, quality of life or satisfaction with care.
We performed a non-randomised comparative study, consisting of an effect evaluation, an economic evaluation and a process evaluation. The innovative care model provided by the stroke service Maastricht Heuvelland, the intervention region, was compared to “care as usual” provided by the stroke service in the Eindhoven area. This paper describes the effect evaluation of the new care model on quality of life, functional outcomes, and satisfaction with care. To our knowledge, no study has addressed the effects of early discharge from hospital with subsequent assessment and rehabilitation planning in a nursing home on functional outcomes in stroke patients.
Methods
Patients
The patient population consisted of consecutive stroke patients admitted to hospital in both research regions during a period of 18 months. The diagnosis of stroke was made by a neurologist, and was based on the patient’s history, physical examination and neuro-imaging. Patients were eligible to participate if they met the following inclusion criteria: over 18 years of age and fluent in Dutch. Exclusion criteria were: a life expectancy of less than a few days, a previous diagnosis of dementia, hospital discharge to home within a few days and occurrence of complications requiring prolonged hospital care. Each patient with a recurrent stroke during the study period, could be included only once: i.e. these patients were not asked to participate a second time. Detailed information about the research protocol is published elsewhere (9).
Intervention
The intervention involved a critical care pathway for stroke patients admitted to the academic hospital in Maastricht. In this care pathway, every stroke patient is admitted directly to the hospital stroke unit. In the emergency ward, acute diagnostic tests are performed. In case of a confirmed stroke, the patient will be admitted to the stroke unit of the hospital, where further diagnosis and treatment, including thrombolysis if indicated, are performed.
Subsequently, the care model consists of a strict discharge regime from the neurology ward of the academic hospital. All necessary tests and treatment in the hospital are planned to occur within 5 days after admission. Thereafter, in principle, all stroke patients, regardless of age, will be discharged to the stroke ward in the nursing home, where a comprehensive assessment takes place. Only patients who can be discharged home within 5 days after admission and those who are medically unstable will not be transferred from the hospital to the nursing home within 5 days. A skilled elderly care physician examines each patient immediately on arrival in the nursing home and initiates the assessment program. In this program, a multidisciplinary team consisting of a physiotherapist, occupational therapist, psychologist, speech therapist and trained nurses examines the patient, performing a structured assessment protocol. Following this assessment, the team meets within five days of the patient’s admission to make recommendations for a rehabilitation program specifically tailored to the patient. After this multidisciplinary meeting, the patient and his family will be informed about the proposed rehabilitation track; if they approve, this track will be started.
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