Domiciliary occupational therapy for patients with stroke discharged from hospital: randomised controlled trial

British Medical Journal, March 4, 2000 by Louise Gilbertson, Peter Langhorne, Andrew Walker, Ann Allen, Gordon D Murray

(*) Primary outcomes.

At six months the results for primary outcomes were no longer statistically significant (table 2). More patients in the intervention than control group were, however, likely to have improved and the change in Barthel index scores in these patients was significantly better than in the controls.

Patient satisfaction

Overall, 44 patients in the intervention group and 43 in the control group returned a questionnaire about satisfaction with service delivery at home.[7] Patients in the intervention group were more likely to report satisfaction across all 12 questions (summary odds ratio for agreement with statements 1.8, 1.4 to 2.4). In particular they were significantly more likely to agree that "things were well prepared for returning home" and that they "knew who to contact with problems relating to my stroke."

Resource use

The groups were evenly matched at the six months' follow up for place of residence, readmissions to hospital, additional services and equipment provided, and costs incurred by patients and carers.[3] Staff costs (including travel) accounted for 85%-90% of all expenditure. We estimate that one whole time therapist could manage 80-90 patients per year at a cost of about 300-320 [pounds sterling] per patient and prevent 10 poor outcomes (deterioration in function) after discharge home--that is, costing about 2500 [pounds sterling] per poor outcome avoided.

Unblinding

The outcome assessor was asked to guess the allocation of the last 46 patients followed up, and she guessed correctly in 32 cases (69%, 56% to 83%). The commonest reason was knowing whether the patient had attempted an activities of daily living activity (in particular bathing), which should have been addressed in the occupational therapy programme.

Discussion

Methodological issues

Our trial shows that patients with stroke who have received multidisciplinary rehabilitation in hospital incorporating discharge planning and multidisciplinary follow up can still benefit from a short outreach programme for occupational therapy. The initial statistically significant benefits were diminished at the six month follow up, which could reflect the method of follow up (postal versus interview) or a transient effect of the rehabilitation input. It is possible that the early benefits were maintained at six months as the wide confidence intervals do not exclude this possibility. We have tried to ensure a rigorous but pragmatic evaluation of a new service using a rigorous randomisation procedure and independent intention to treat analysis. We do, however, acknowledge the difficulty in blinding rehabilitation trials. Unblinding of the outcome assessor may not have biased recording of outcomes since the main reason she guessed treatment allocation was differences in components of the outcome measures. The final (six month) outcomes were reported by postal questionnaire and so were not prone to observer unblinding. Patients' responses may have been influenced by their knowledge of their allocated group,[7] but it is difficult to exclude this possibility in a pragmatic trial with informed consent.