1.1

Introduction

Although dedicated stroke units (SUs) have been introduced only recently in France (in comparison with other European countries), the process has been highly formalized . Many randomized and controlled trials have shown that SUs can improve patient prognosis, with a positive effect on three distinct risks: death, death or institutionalization and death or dependency . Efficacy factors notably include the early implementation (i.e. within 24 hours of the stroke) of rehabilitation measures such as physiotherapy, occupational therapy and speech therapy .

Care in the SU is not solely dedicated to the treatment of brain damage and its immediate anatomical and functional consequences; it also involves discharge support and educational measures for the patient and his/her carers. Several services have been developed with the two-fold aim of accelerating and supporting home or institutional discharge. Indeed, the efficacy of early supported discharge (ESD) relative to conventional techniques was examined in several studies. Knowledge of this efficacy and of any related limitations is important, since it could help shape the efficiency measures to be implemented in French SUs. This type of support is also in phase with the needs and preference expressed by the patients’ families and carers. Studies on caregiver needs have underlined the fact that the family’s main concern following a stroke is to not have continuity of care after discharge from hospital .

In the present article, we review studies on ESD. These studies have already been examined in meta-analysis and systematic reviews . Our main objective was to analyze the influence of ESD on the handicap’s various components, while bearing in mind that not all the techniques described in the literature are suited to the situation in France and that they mainly apply to patients with mild or moderate functional impairments rather than severe impairments.

1.2

Literature analysis methods

We performed a literature search within the Medline and Cochrane databases by using the keywords “early supported discharge”, “discharge” and “stroke” and then a step-by-step approach.

We selected randomized, controlled studies and meta-analyses on ESD in stroke patients. The goal of ESD is to improve support and enable rehabilitation at home on one hand and to reduce the length of stay in the SU or neurology department on the other.

We sought to distinguish between the overall effects of ESD (as described in the meta-analyses) from the specific effects reported in each randomized trial. Indeed, the objectives, methods and context of these various trials were often different. Furthermore, some effects have been described in only a small number of studies. The various effects were grouped together on the basis of the components of the International classification of functioning and handicap (ICFH), i.e. functions, activities (functional tests), participation in personal activities of daily living (pADL: grooming, dressing, transfers, etc.) and instrumental activities of daily living (iADL: domestic and social activities) and the patient’s environment, including relatives/carers. We considered health economic aspects separately.

1.3

Results

The selected studies are presented in Table 1 ; most had already been examined in reviews and one meta-analysis .

1.4

Discussion

Our review of the literature suggests that ESD partially reduces the risk of death or dependency and the risk of death or institutionalization and may have a positive effect on participation in iADL, in comparison with the various countries’ conventional discharge systems. In addition, ESD reduces the total duration of hospitalization in the SU and the overall cost of care without decreasing efficacy (except in comparison with specialized neurological rehabilitation ). However, the studies performed in cities across Europe, Canada and Australia show a number of disparities, which depend on the respective healthcare systems.

When evaluating the efficacy of ESD, there are advantages and disadvantages in considering only the results of meta-analyses. The most obvious advantage is that the recent meta-analysis featured a high total number of patients (over 1000) and analyzed the raw data provided by the investigating centres in which the randomized studies had been performed. This explains why the greater efficacy appeared more clearly – especially for the participation in iADL, which is a major challenge in any type of home care. However, a number of disadvantages and drawbacks should be noted. The first is that this kind of study does not take account of the differences between the conventional health systems which are being compared with ESD. In this respect, one can note that the Norwegian and Swedish systems involve both relatively intense community rehabilitation care (including physiotherapy, occupational therapy and speech therapy) and social care . This could help explain why some studies did not show any (or only minor) differences between ESD and standard care. In contrast, the systems in the UK, Canada and Australia often provide less support for rehabilitation at home and thus comparative studies could more easily favour ESD. A second point is that the respective patient profiles were relatively heterogeneous. Several trials excluded patients with serious disorders and/or those who had not recovered complete or even partial autonomy for transfers, walking or food intake during the initial hospitalization in the SU or the neurology unit . In contrast, other studies (mainly those in Norway) included more severely affected patients . Variability in the inclusion criteria explains why the ratio between included patients and examined patients was, in some cases, very low (see Table 1 ) and prompts caution in generalizing conclusions drawn in the corresponding investigations. Another problem is that two of the studies included in the meta-analysis aimed at comparing ESD with institutional neurological rehabilitation, which differs in nature from standard care in the community. A last point is that certain authors have combined the risk of death with that of dependency or institutionalization to show a positive effect of ESD. This technique has been frequently used to evaluate the effectiveness of healthcare systems, especially after a stroke . There is indeed a spectrum between good recovery, poor recovery and death, which is used in outcome scales (such as the Rankin scale). However, one can gain the impression that the ESD’s efficacy is relatively poor on each parameter. The lack of an overall effect on pADL reinforces this impression. These misgivings explain our decision to provide a detailed analysis of the results of each study for the different components of handicap.

An important point to consider is the definition of patients who are eligible for ESD. As mentioned above, the studies’ inclusion criteria were highly variable. The technique is certainly applicable to patients having suffered a “mild” or “moderate” stroke. Indeed, all studies have included these types of patients and one can easily imagine that relatively early home discharge does not pose too many practical problems and that the family circle/carers (when present) can adapt to the new situation. However, for severe stroke patients who are still dependent at the time of discharge from the SU, ESD is not the most appropriate solution. Indeed, ESD is less effective than institutional rehabilitation in patients with a BI below 50 . Moreover, the early home discharge of severely dependent patients poses important logistic and human problems, which cannot be rapidly solved.

ESD has not demonstrated any efficacy in terms of the various motor, perceptual and cognitive impairments. However, such an effect is difficult to demonstrate in rehabilitation settings. With one exception , there are no data indicating increased participation in pADL, as assessed by the BI. Only one (Norwegian) study has suggested that there might be an effect on the Rankin scale, which considers the severity of impairment, personal autonomy and death. Conversely, an important observation relates to the benefit suggested by the meta-analysis and the Swedish study in terms of participation in iADL. It could be that ESD directly acts on the person’s life context and enables optimal adaptation to their environment. Another interesting result is that the ESD is sometimes associated with a more favourable outcome in subjective health status and quality of life, in the first months and even up to 1 year .

One essential aspect relates to ESD’s ability to reduce the duration of the initial stay in the SU and thus to lower the overall cost of care. This is an important observation, which shows that organisational improvement can yield gains in both efficacy and overall cost. Indeed, this may help optimize the resources dedicated to stroke patients. However, the overall cost of care after discharge from the SU also depends on the health system in the country in question.

The two studies which compared ESD with institutional rehabilitation care must be considered separately. In fact, their results were divergent. The most convincing study (performed in Norway ) found that specialized rehabilitation was more effective than ESD, with the same number of care sessions and cost in both systems. Although the second study (performed in Belfast, Northern Ireland) found in favour of ESD-based care, the level of rehabilitation activity in the “specialized” rehabilitation unit was very low.

In conclusion, ESD is a useful technique for stroke patients with slight or moderate levels of handicap. It reduces the length of hospitalization in the SU and the overall cost of care, while helping to reduce the risk of death or institutionalization and improving participation in the iADL. ESD could be introduced in the French system, especially in order to provide patients with rehabilitation care under free-living conditions. Lastly, the ESD technique has been rightfully included in the Stroke Unit Discharge Guideline .

2.1

Introduction

En comparaison avec d’autres pays européens, l’introduction en France des unités neurovasculaires (UNV) est récente mais très systématisée . De nombreux essais randomisés et contrôlés ont montré qu’elles permettent d’améliorer le devenir des patients, avec un effet positif sur trois risques distincts : décès isolé, décès ou institutionnalisation et décès ou dépendance . Parmi les facteurs d’efficacité, il faut citer la mise en place précoce (24 premières heures) de la réadaptation en kinésithérapie, ergothérapie et orthophonie .

Les processus de soins en UNV ne doivent pas être dédiés uniquement à l’atteinte cérébrale et à ses conséquences anatomiques et fonctionnelles immédiates. Ils impliquent aussi des mesures d’accompagnement de la sortie et d’éducation du patient et de son entourage. Un certain nombre de services se sont développés dont le double objectif a été d’accompagner et d’accélérer la sortie vers le domicile ou d’autres structures d’accueil. Cette sortie précoce accompagnée (SPA) appelée early supported discharge a fait l’objet de plusieurs études ayant comparé son efficacité à celle des techniques conventionnelles. La connaissance de cette efficacité et de ses limites est importante, car elle devrait permettre d’orienter les mesures à mettre en œuvre dans les UNV françaises pour accroître leur efficience. Cet accompagnement va d’ailleurs dans le sens des demandes des proches. Les études des besoins des aidants ont souligné que la principale crainte de la famille après un accident vasculaire cérébral (AVC) était de ne pas avoir une continuité de la prise en charge après la sortie de l’hôpital .

Ici, nous avons donc réévalué ces travaux sur la SPA, qui ont déjà fait l’objet de méta-analyses et revues globales . Notre objectif principal était d’analyser l’influence de la SPA sur les différentes composantes de la situation de handicap, tout en sachant que les techniques décrites ne sont pas toutes adaptées à la situation française et qu’elles s’appliquent essentiellement aux patients présentant des déficiences et un défaut de participation de sévérité moyenne ou modérée et non à ceux ayant des difficultés sévères.

2.2

Méthodes d’analyse de la littérature

Nous avons effectué une recherche bibliographique à partir des systèmes Medline et Cochrane avec les mots clefs early supported discharge , discharge , stroke , puis une recherche de proche en proche.

Seules ont été retenus les études comparatives randomisées et les méta-analyses sur la SPA des patients AVC. L’objectif de la SPA est, d’une part, d’améliorer l’accompagnement pendant le séjour en UNV et de gérer la rééducation et les problèmes sociaux après le retour au domicile, d’autre part, de raccourcir la durée d’hospitalisation dans les UNV ou les services spécialisés de neurologie.

Nous avons voulu distinguer les effets globaux de cette prise en charge, tels qu’ils ont été décrits dans les méta-analyses, des effets spécifiques rapportés dans chaque essai randomisé. Effectivement, les objectifs, les méthodes et le contexte de ces essais étaient souvent différents. De plus, certains effets ont été décrits dans un nombre limité d’études. Ces effets spécifiques ont été regroupés en se fondant sur les composantes de la Classification internationale du fonctionnement et du handicap (ICFH), c’est-à-dire les fonctions, les activités (tests fonctionnels), la participation aux activités de vie quotidienne personnelles (AVQp : toilette, habillage, transferts…) et instrumentales (AVQi : domestiques et sociales) et l’environnement, notamment les proches. Nous avons envisagé séparément les aspects médico-économiques.

2.3

Résultats

Les études retenues ont été présentées dans le Tableau 1 . La plupart d’entre elles ont fait l’objet de deux méta-analyses .

Tableau 1

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