Cost analysis of early supported hospital discharge for stroke

Age and Ageing,  May, 1998  by Paul McNamee,  Jakob Christensen,  Jennifer Soutter,  Helen Rodgers,  Neil Craig,  Pauline Pearson,  John Bond

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Introduction

Stroke is one of the major causes of mortality and morbidity in older people and places a burden on scarce health care resources [1, 2]. As the incidence of stroke increases with age [3] and leaves many people with serious disability [4, 5], there is growing pressure to ensure that stroke management is cost effective [61. Recent studies indicate that the way hospital rehabilitation is organized can affect mortality and morbidity [7, 8]. However, there is uncertainty over how services should be best provided after discharge. While previous studies indicate no differences in health outcomes between different types of post-discharge rehabilitation [9, 10], they provide conflicting evidence over whether costs are lower with community-based rehabilitation. However, recent research suggests that such care can generate greater improvement in physical functioning at modest additional cost [11].

None of the studies however have fully considered the net costs of the interventions. Furthermore, no research has directly considered whether shorter hospital stays combined with community rehabilitation is a feasible, cost-effective alternative to conventional management of stroke. This paper considers the costs of an early supported discharge service operated by Newcastle City Health Trust versus conventional hospital care for stroke using data from a pilot study using a randomized controlled trial design.

Methods

Description of the service

The early supported discharge service was established in February 1995 as part of a pilot project to establish the feasibility of an early supported discharge policy following acute stroke. An interdisciplinary team was created, consisting of full-time service co-ordinator, physiotherapist and occupational therapist, and part-time speech therapist and social worker. In addition, a home care bank was set up, with district nurse and occupational therapy technician input obtained when required. A budget for loan equipment was also available and medical cover was provided by the patient's general practitioner with consultant support if required. In addition to carrying but rehabilitation within patients' homes after discharge, members of the team acted as an `in-reach' service, planning and organizing discharge and community rehabilitation arrangements during hospitalization.

Randomization and sampling

All patients admitted to either Freeman Hospital, Newcastle General Hospital or Royal Victoria Infirmary in Newcastle upon Tyne with acute stroke between 1 February 1995 and 31 January 1996 were assessed for eligibility to take part in the study against the criteria in Table 1.

Table 1. Eligibility criteria for study participation

Resident in the study district Admitted from a private address Not previously severely handicapped (pre-stroke Oxford Handicap Scale 0-3 [12]) Admitted within 72 h of onset of stroke Medically stable 72 h after stroke Barthel score of between 5 and 19 at 72 h post-stroke No co-morbidity likely to affect rehabilitation

In total, 402 patients were admitted with stroke, of whom 119 were eligible to participate. Consent was sought from patients and carers for data collection, after which patients were randomized. Permission to approach patients randomized to early supported discharge was then obtained from their hospital consultant and general practitioner before further consent was sought from patients and carers. Nine patients refused consent to data collection and a further 18 were unable to participate for other reasons (11 were participating in stroke drug trials and seven were excluded for other reasons: either previous serious neglect, self-discharge, delayed diagnosis, alcoholism or admission from hostel). Thus, the study population consisted of 92 patients, with 46 randomized to early supported discharge and 46 to conventional hospital care.

Data collection

Data on age, sex and neurological deficit were collected at admission. Barthel activities of daily living index (ADL) information was collected at 7 days post-stroke and at discharge [13]. Patients were assessed at 3 and 6 months post-stroke. Data relating to physical health outcomes were collected using the Nottingham Extended Activities of Daily Living Scale [14], depression was assessed using the Wakefield Depression Inventory [15] and overall health status measured by the Dartmouth COOP charts [16]. Caret stress was measured at 3 months by the General Health Questionnaire [17] and carer global health status by the Dartmouth COOP charts. As the focus here is purely on costs, 6-month health outcome data will be reported separately [18].

Resource use data were collected from hospital records and interview schedules on length of hospital stay following admission, length of hospital stay for re-admissions and the frequency of use of a range of community services (day hospital, general practitioner and outpatient care). In addition, for those randomized to receive the early supported discharge service, the frequency and duration of physiotherapy, occupational therapy, speech therapy, district nursing, social work and home care visits were calculated from records kept by the early supported discharge team. For the conventional care group, the level of receipt of these services was estimated from staff records (hospital-based input) and interview schedules (community-based input). As travel time was only recorded for early supported discharge patients, travel times per visit were estimated for conventional care patients using the average for the early supported discharge group.