There's no place like home : an evaluation of early supported discharge for stroke

BACKGROUND AND PURPOSE: Because stroke management is aimed at facilitating community reintegration, it would be logical that the sooner the patient can be discharged home, the sooner reintegration can commence. The purpose of this study was to determine the effectiveness of prompt discharge combined with home rehabilitation on function, community reintegration, and health-related quality of life during the first 3 months after stroke. METHODS: A randomized trial was carried out involving patients who required rehabilitation services and who had a caregiver at home. When medically ready for discharge, persons with stroke were randomized to either the home intervention group (n=58) or the usual care group (n=56). The home group received a 4-week, tailor-made home program of rehabilitation and nursing services; persons randomized to the usual care group received services provided through a variety of mechanisms, depending on institutional, care provider, and personal preference. The main outcome measure was the Physical Health component of the Measuring Outcomes Study Short-Form-36 (SF-36). Associated outcomes measures included the Timed Up & Go (TUG), Barthel Index (BI), the Older Americans Resource Scale for instrumental activities of daily living (OARS-IADL), Reintegration to Normal Living (RNL), and the SF-36 Mental Health component. RESULTS: The total length of stay for the home group was, on average, 10 days, 6 days shorter than that for the usual care group. There were no differences between the 2 groups on the BI or on the TUG at either 1 or 3 months after stroke; however, there was a significantly beneficial impact of the home intervention on IADL and reintegration (RNL). By 3 months after stroke, the home intervention group showed a significantly higher score on the SF-36 Physical Health component than the usual care group. The total number of services received by the home group was actually lower than that received by the usual care group. CONCLUSIONS: Prompt discharge combined with home rehabilitation appeared to translate motor and functional gains that occur through natural recovery and rehabilitation into a greater degree of higher-level function and satisfaction with community reintegration, and these in turn were translated into a better physical health.     

Patients with severe stroke benefit most by interdisciplinary rehabilitation team approach

BACKGROUND: We evaluated the efficacy of a regular interdisciplinary stroke team approach on rehabilitation outcome. METHODS: We compared a stroke rehabilitation unit (SRU) with regular interdisciplinary stroke team conferences with general rehabilitation ward (GRW) without such conferences in the same rehabilitation hospital. One hundred and seventy-eight patients within 3 months after stroke were allocated to SRU or GRW, based on bed availability. Main outcome measures were the Functional Independence Measure, Stroke Impairment Assessment Set, length of hospital stay, discharge disposition and cost of hospitalization. RESULTS: The interval between stroke onset and admission to our hospital was significantly longer in the SRU (n = 91) group compared with the GRW group (n = 87, p < 0.05). Although comparable numbers of patients were discharged home (74.7% in the SRU vs. 71.3% in the GRW), significantly more patients (p < 0.0001) with severe disability were discharged home in the SRU group (47.4%) compared with the GRW group (0%). There were no significant differences in the increase in Functional Independence Measure score, Stroke Impairment Assessment Set score,length of hospital stay, or cost. CONCLUSION: Patients with severe stroke appeared to benefit most from regular interdisciplinary stroke team conferences in the SRU and had an improved discharge disposition.     

Can readmission after stroke be prevented? Results of a randomized clinical study: a postdischarge follow-up service for stroke survivors

BACKGROUND AND PURPOSE: About 50% of stroke survivors are discharged to their homes with lasting disability. Knowledge, however, of the importance of follow-up services that targets these patients is sparse. The purpose of the present study was to evaluate 2 models of follow-up intervention after discharge. The study hypothesis was that intervention could reduce readmission rates and institutionalization and prevent functional decline. We report the results regarding readmission. METHODS: This randomized study included 155 stroke patients with persistent impairment and disability who, after the completion of inpatient rehabilitation, were discharged to their homes. The patients were randomized to 1 of 2 follow-up interventions provided in addition to standard care or to standard aftercare. Fifty-four received follow-up home visits by a physician (INT1-HVP), 53 were provided instructions by a physiotherapist in their home (INT2-PI), and 48 received standard aftercare only (controls). Baseline characteristics for the 3 groups were comparable. Six months after discharge, data were obtained on readmission and institutionalization. RESULTS: The readmission rates within 6 months after discharge were significantly lower in the intervention groups than in the control group (INT1-HVP 26%, INT2-PI 34%, controls 44%; P=0.028). Multivariate analysis of readmission risk showed a significant favorable effect of intervention (INT1-HVP or INT2-PI) in interaction with length of hospital stay (P=0.0332), indicating that the effect of intervention was strongest for patients with a prolonged inpatient rehabilitation. CONCLUSIONS: Readmission is common among disabled stroke survivors. Follow-up intervention after discharge seems to be a way of preventing readmission, especially for patients with long inpatient rehabilitation.     

Costs of stroke care according to handicap levels and stroke subtypes

BACKGROUND: If new advances in stroke management are to be put into practice, crucial information about their costs needs to be considered in relation to clinically pertinent variables (e.g. handicap level and stroke subtypes). Details of costs throughout the entire period of stroke care are essential in the political decision-making process, in order to avoid other budget-balancing approaches, which are not always satisfactory. Our aim was to perform an in-depth evaluation of the direct medical cost of stroke care in a large cohort. METHODS: We included 435 consecutive patients with brain infarction in 12 primary-care and referral neurology departments. Information on acute care was prospectively collected. Information on postacute care was collected by research nurses' visits to the patient's or a relative's home 18-40 months after the stroke onset. We thus collected detailed information on handicap levels, stroke subtypes, acute hospitalization costs, rehabilitation, nursing care and ambulatory costs. This enabled us to calculate costs over an 18-month period after the initial acute hospital discharge. RESULTS: By the 12th month after discharge, the costs amounted to 17,799 euros (16,440-19,158) per patient; the initial hospitalization accounted for 42% of this cost, rehabilitation for 29% and ambulatory care for 8%. These costs were mostly concentrated within the first 3- to 6-month period. After 46 months without recurrence, the cost of ambulatory care outweighed the cost of the first 6 months. Handicap levels explained 43% of the variance of costs (p < 0.0001) and, according to the Rankin scale divided into 3 classes (0-2, 3 and 4-5), cumulative costs over time differed considerably. Stroke subtypes were not discriminating variables except for lacunar strokes, which were significantly less costly than the other groups. CONCLUSIONS: By providing a fairly comprehensive figure for the details of direct costs of stroke care over time, our study gives some clues about the economic burden of stroke care which is mostly driven by a high handicap level. This suggests that any early intervention aimed at reducing the handicap level will probably dramatically reduce this burden.     

Management patterns and health care use after intracerebral hemorrhage. a cost-of-illness study from a societal perspective in Germany

BACKGROUND: The German cost-of-illness study of stroke is a multicenter study in 6 departments of internal medicine, 9 departments of general neurology and 15 departments of neurology with an acute stroke unit. The aims of this study are to describe the management patterns, cost of treatment and overall resource utilization after intracerebral hemorrhage (ICH) as well as the major differences to ischemic stroke (IS). METHODS: During a 12-month period, 30 participating centers with a special interest in stroke prospectively included 586 patients with ICH which were collected in a joint data bank. About 75% of all patients could be centrally followed up via structured telephone interviews after 3 and 12 months to assess further acute hospital and rehabilitation stays, outpatient resource utilization, functional outcome and quality of life. RESULTS: Mortality after 3 months (33.5%) was markedly higher than in patients with IS from the same hospitals. Accordingly, only 30.9% of patients had regained independent functional status after 3 months. Cumulative cost of treatment amounted to 5301 EUR for inpatient stay in the documenting hospital and 8920 EUR for the overall hospital stay including rehabilitation. Mean direct cost after discharge during the first year amounted to 4598 EUR and the loss of work force was equivalent to 5537 EUR in all surviving patients. CONCLUSION: This study provides a comprehensive overview of patient characteristics, treatment strategies and health care cost of ICH from a societal perspective in Germany.     

A randomised controlled trial of domiciliary and hospital-based rehabilitation for stroke patients after discharge from hospital.

This study compared the functional ability and perceived health status of stroke patients treated by a domiciliary rehabilitation team or by routine hospital-based services after discharge from hospital. Patients discharged from two acute and three rehabilitation hospitals in Nottingham were randomly allocated in three strata (Health Care of the Elderly, General Medical and Stroke Unit) to receive domiciliary or hospital-based care after discharge. Functional recovery was assessed by the Extended Activities of Daily Living (ADL) scale three and six months after discharge and perceived health at six months was measured by the Nottingham Health Profile. A total of 327 eligible patients of 1119 on a register of acute stroke admissions were recruited over 16 months. Overall there were no differences between the groups in their Extended ADL scores at three or six months, or their Nottingham Health Profile scores at six months. In the Stroke Unit stratum, patients treated by the domiciliary team had higher household (p = 0.02) and leisure activity (p = 0.04) scores at six months than those receiving routine care. In the Health Care of the Elderly stratum, death or a move into long-term institutional care at six months occurred less frequently in patients allocated to the routine service, about half of whom attended a geriatric day hospital. Overall there was no difference in the effectiveness of the domiciliary and hospital-based services, although younger stroke unit patients appeared to do better with home therapy while some frail elderly patients might have benefited from day hospital attendance.     

Stroke patients in south Madrid: function and motor recovery, resource utilization, and family support

BACKGROUND AND PURPOSE: The purpose of the present study was to describe the epidemiology of stroke disability and the use of health resources in South Madrid. METHODS: Among a population of 665 168 residents in South Madrid, patients with an acute stroke of clinical onset during March to July 1996 who were seen at a general hospital or at 1 of 3 primary care centers were evaluated at baseline (n=147) and at 3 months (n=110) and 6 months (n=112) after stroke. We assessed the frequencies of stroke and stroke-related residual disability per population unit, as well as the impairment, disability, secondary complications, use of health resources, and impact on quality of life. RESULTS: In patients > or =60 years old, the incidence of stroke with severe residual disability after 6 months was 75 per 10 000, was higher in men, and increased with age; the proportion of survivors among those examined at baseline was 20%. The use of hospital days per population unit was similar to that of reported European data, but the use of other health care resources was less. Patients frequently used bladder and nasal catheters and presented with shoulder pain. Social activities were infrequent and decreased after stroke. Access to technical aids was limited, and home adaptations were exceptional. The impact of stroke on health-related quality of life among patients and main caregivers was modest. CONCLUSIONS: The study shows that in South Madrid, (1) the use of health resources after stroke is low; (2) patients with stroke register low activities of daily living scores with a comparatively small impact on quality of life; and (3) relative to need, the use of rehabilitation, aids, and home adaptations and services was low.     

Home or hospital for stroke Rehabilitation? Results of a randomized controlled trial : II: cost minimization analysis at 6 months

BACKGROUND AND PURPOSE: The goal of the present study was to examine the resource and economic implications of an early hospital discharge and home-based rehabilitation scheme for patients with acute stroke. METHODS: A cost minimization analysis in conjunction with a randomized controlled trial was carried out at 2 affiliated teaching hospitals in the southern metropolitan region of Adelaide, South Australia, between 1997 and 1998. Eighty-six hospitalized patients with acute stroke who required rehabilitation were randomized to receive both early hospital discharge and home-based rehabilitation, or conventional in-hospital rehabilitation and community care. Direct and indirect costs related to stroke rehabilitation were calculated, including hospital bed days, home-based intervention program, community services, and personal expenses during the 6 months after randomization. RESULTS: The mean cost per patient was lower for patients randomized to the early hospital discharge and home-based rehabilitation ($8040) compared with those who received conventional care ($10 054). This cost saving was not statistically significant (P=0.14). However, sensitivity analyses indicated that the cost of home-based rehabilitation was consistently lower than that of conventional care except when hospital costs were assumed to be 50% less than those used in the main analysis. Multiple regression analysis demonstrated that the cost of the home-based program was significantly related to a patient's level of disability after adjustment for age, comorbidity, and the presence or absence of a caregiver. CONCLUSIONS: The early hospital discharge and home-based rehabilitation scheme was less costly than conventional hospital care for patients with stroke. Limitation of the provision of such services to patients with mild disability is likely to be most cost effective.     

Cost-effectiveness and cost offset of a collaborative care intervention for primary care patients with panic disorder

BACKGROUND: A collaborative care (CC) intervention for patients with panic disorder that provided increased patient education and integrated a psychiatrist into primary care was associated with improved symptomatic and functional outcomes. This report evaluates the incremental cost-effectiveness and potential cost offset of a CC treatment program for primary care patients with panic disorder from the perspective of the payer. METHODS: We randomly assigned 115 primary care patients with panic disorder to a CC intervention that included systematic patient education and approximately 2 visits with an on-site consulting psychiatrist, compared with usual primary care. Telephone assessments of clinical outcomes were performed at 3, 6, 9, and 12 months. Use of health care services and costs were assessed using administrative data from the primary care clinics and self-report data. RESULTS: Patients receiving CC experienced a mean of 74.2 more anxiety-free days during the 12-month intervention (95% confidence interval [CI], 15.8-122.0). The incremental mental health cost of the CC intervention was $205 (95% CI, -$135 to $501), with the additional mental health costs of the intervention explained by expenditures for antidepressant medication and outpatient mental health visits. Total outpatient cost was $325 (95% CI, -$1460 to $448) less for the CC than for the usual care group. The incremental cost-effectiveness ratio for total ambulatory cost was -$4 (95% CI, -$23 to $14) per anxiety-free day. Results of a bootstrap analysis suggested a 0.70 probability that the CC intervention was dominant (eg, lower costs and greater effectiveness). CONCLUSION: A CC intervention for patients with panic disorder was associated with significantly more anxiety-free days, no significant differences in total outpatient costs, and a distribution of the cost-effectiveness ratio based on total outpatient costs that suggests a 70% probability that the intervention was dominant, compared with usual care.     

Multidisciplinary rehabilitation for people with Parkinson's disease: a randomised controlled study

OBJECTIVE: To determine whether a programme of multidisciplinary rehabilitation and group support achieves sustained benefit for people with Parkinson's disease or their carers. METHODS: The study was a randomised controlled crossover trial comparing patients and carers who had received rehabilitation four months before assessment with those who had not. Patients were recruited from a neurology clinic, attended a day hospital from home weekly for six weeks using private car or hospital transport, and received group educational activities and individual rehabilitation from a multidisciplinary team. Patients were assessed at entry and at six months using a 25 item self assessment Parkinson's disease disability questionnaire, Euroqol-5d, SF-36, PDQ-39, hospital anxiety and depression scale, and timed stand-walk-sit test. Carers were assessed using the carer strain index and Euroqol-5d. RESULTS: 144 people with Parkinson's disease without severe cognitive losses and able to travel to hospital were registered (seven were duplicate registrations); 94 had assessments at baseline and six months. Repeated measures analysis of variance comparing patients at the 24 week crossover point showed that those receiving rehabilitation had a trend towards better stand-walk-sit score (p = 0.093) and worse general and mental health (p = 0.002, p = 0.019). Carers of treated patients had a trend towards more strain (p = 0.086). Analysis comparing patients before and six months after treatment showed worsening in disability, quality of life, and carer strain. CONCLUSIONS: Patients with Parkinson's disease decline significantly over six months, but a short spell of multidisciplinary rehabilitation may improve mobility. Follow up treatments may be needed to maintain any benefit.     

Utilization of health care resources after stroke. A population-based study of 258 hospitalized cases followed during the first year

ABSTRACT In a prospective population-based study the cumulative utilization of health care resources (and the rehabilitation outcome) was followed in consecutive stroke patients 3, 6 and 12 months after the onset of the disease. The study group comprised 258 patients diseased during the period February 1st 1986-January 31th 1987. The pattern of various forms of hospital beds and non-hospital facilities in open care utilized during the first post-stroke year was analysed at 1986 year's cost level. The mean utilization of acute hospital beds during the initial phase was 15 days; at an expenditure cost of 26,670 SEK (3,683). The mean utilization of acute hospital and of geriatric beds during the first year was 19 and 59 days respectively. Thus the total hospital bed days amounted to a mean of 78 days; at a mean expenditure of 87,000 SEK (12,000); 70% of the patients were discharged from hospital care to independent living after 36 days. The acute care hospital provided 36% and geriatric care 64% of the beds needed before discharge. The expenditure of non-hospital facilities was mean 19,000 SEK (2600); thus total expenditure for health care amounted to 106,000 SEK (14,600). The relation between non-hospital and hospital care was approximately 1 to 5. Severity of the stroke influenced markedly the pattern and the total utilization of both hospital and non-hospital care. Patients with major stroke utilized health care resources at an expenditure 3.5 times that used by patients with minor stroke. Age of the patient also influenced health care utilization. However, age had no influence on mean utilization of acute hospital beds but influenced the utilization of geriatric beds and non-hospital facilities. The large amount of acute hospital bed days used by the older patients depended entirely on their increased number. When only patients with major stroke were analysed, the impact of age on health care utilization became less prominent. The effort to prevent and/or minimize the disability following stroke stands out as the dominant and most desirable approach to save resources and human suffering.     

Home forced use in an outpatient rehabilitation program for adults with hemiplegia: a pilot study

The objective of this study was to examine the effectiveness of a program of traditional outpatient neurological rehabilitation that included home forced use. In total, 17 patients with chronic stroke and 1 patient with subacute stroke (mean time poststroke = 27.6 months) completed an individualized program consisting of seven 2-hour treatment sessions composed of 1 hour of occupational therapy and 1 hour of physical therapy. Therapy sessions were completed over a 2- to 3-week period and included instruction on the use of a restraining mitt at home during functional activities. The Wolf Motor Function Test (WMFT) was used to assess upper extremity impairment and function at baseline, midway through treatment, and posttreatment. Patients demonstrated statistically significant improvements (P < 0.05 corrected for multiple comparisons) in mean time for completion in 12 of 17 WMFT subtasks when comparing baseline to posttreatment. The preliminary results suggest that the forced-use component of constraint-induced therapy may be effective when applied within a traditional outpatient rehabilitation program. However, additional investigation is required to examine the effectiveness of using forced use within typical outpatient rehabilitation under more experimentally controlled conditions.     

Access to rehabilitation professionals by individuals with stroke one month after hospital discharge from a stroke unit in Brazil is insufficient regardless of the pandemic

ObjectiveTo compare access to rehabilitation professionals by individuals with stroke one month after hospital discharge from a stroke unit in Brazil, before and during the COVID-19 pandemic.Materials and methodsThis longitudinal and prospective study included individuals aged 20 years or older without previous disabilities admitted into a stroke unit due to a first stroke. Individuals were divided into two groups: before (G1) and during (G2) the COVID-19 pandemic. Groups were matched for age, sex, education level, socioeconomic status, and stroke severity. One month after hospital discharge, individuals were contacted via telephone to collect data regarding their access to rehabilitation services based on the number of referred rehabilitation professionals. Then, between-group comparisons were conducted (α = 5%).ResultsThe access to rehabilitation professionals was similar between groups. Rehabilitation professionals accessed included medical doctors, occupational therapists, physical therapists, and speech therapists. The first consultation after hospital discharge was mainly provided by public services. Despite the pandemic, telehealth was not frequent in any period evaluated. In both groups, the number of accessed professionals (G1 = 110 and G2 = 90) was significantly lower than the number of referrals (G1 = 212 and G2 = 194; p < 0.001).ConclusionsAccess to rehabilitation professionals was similar between groups. However, the number of accessed rehabilitation professionals was lower than that of referred ones during both periods. This finding indicates a compromised comprehensiveness of care for individuals with stroke, regardless of the pandemic.     

Home or hospital for stroke rehabilitation? results of a randomized controlled trial : I: health outcomes at 6 months

BACKGROUND AND PURPOSE: We wished to examine the effectiveness of an early hospital discharge and home-based rehabilitation scheme for patients with acute stroke. METHODS: This was a randomized, controlled trial comparing early hospital discharge and home-based rehabilitation with usual inpatient rehabilitation and follow-up care. The trial was carried out in 2 affiliated teaching hospitals in Adelaide, South Australia. Participants were 86 patients with acute stroke (mean age, 75 years) who were admitted to hospital and required rehabilitation. Forty-two patients received early hospital discharge and home-based rehabilitation (median duration, 5 weeks), and 44 patients continued with conventional rehabilitation care after randomization. The primary end point was self-reported general health status (SF-36) at 6 months after randomization. A variety of secondary outcome measures were also assessed. RESULTS: Overall, clinical outcomes for patients did not differ significantly between the groups at 6 months after randomization, but the total duration of hospital stay in the experimental group was significantly reduced (15 versus 30 days; P<0.001). Caregivers among the home-based rehabilitation group had significantly lower mental health SF-36 scores (mean difference, 7 points). CONCLUSIONS: A policy of early hospital discharge and home-based rehabilitation for patients with stroke can reduce the use of hospital rehabilitation beds without compromising clinical patient outcomes. However, there is a potential risk of poorer mental health on the part of caregivers. The choice of this management strategy may therefore depend on convenience and costs but also on further evaluations of the impact of stroke on caregivers.     

Direct costs during the first year after intracerebral hemorrhage

OBJECTIVES: Knowledge of resource use and associated costs of treatment, care and rehabilitation at hospitals and in the health care and social service sectors is limited. This study presents data on the total resource use during the first year after spontaneous intracerebral hemorrhage. METHODS: All patients hospitalized because of stroke at a university hospital in Copenhagen, Denmark, during a 1-year period 1994-1995 were included in a database. The patients were followed until 1 year after the stroke, and data on resource use during and after the hospital stay were collected prospectively. This study investigates a subgroup comprising 90 patients with intracerebral hemorrhage. Resource use is described and costs are calculated. RESULTS: The cost of the hospital stay including acute care and rehabilitation had a mean of 90200 DKK (US$16100). The total cost of health care and social services during the first year had a mean of 123200 DKK (US$22000). Costs decreased significantly with age, but when differences of 30 days case fatality between age groups were considered, the association between costs and age disappeared. CONCLUSIONS: The mean cost of treatment, care and rehabilitation during the first year after intracerebral hemorrhage was 123200 DKK, of which the primary hospital stay constituted 73%.     

Cognitive-behavioural intervention for depression after stroke: five single case studies on effects and feasibility

The purpose of the study was to investigate whether or not a cognitive-behavioural intervention for depression after stroke has an effect and is feasible. A single-subject quasi experimental design (SSED) was used with an AB design and follow-up. The participants were five first episode stroke patients attending outpatient rehabilitation in a rehabilitation centre in The Netherlands. Mood and quality of life were measured on four occasions over four weeks (baseline phase A). During the eight week intervention phase (B) a visual analogue measure of mood was administered three times a week. Immediately after the intervention, and one and three months later, the baseline measures were repeated. The intervention (phase B) was based on cognitive-behavioural principles: recognising negative thoughts and challenging them, learning principles of relaxation, and planning of pleasurable activities. Following intervention three patients reported they had improved, three patients reported a minor improvement in quality of life, and four patients reported a more positive mood. Three months later three patients reported fewer depressive symptoms. Both patients and therapist were positive about the intervention and three months later, in daily life, all patients still applied the strategies. It was concluded that despite some ambiguous results, it seems that the cognitive-behavioural intervention has an effect on patients' mood. The intervention was rated as feasible by both patients and therapists.     

Cognitive-behavioural intervention for depression after stroke: Five single case studies on effects and feasibility

The purpose of the study was to investigate whether or not a cognitive-behavioural intervention for depression after stroke has an effect and is feasible. A single-subject quasi experimental design (SSED) was used with an AB design and follow-up. The participants were five first episode stroke patients attending outpatient rehabilitation in a rehabilitation centre in The Netherlands. Mood and quality of life were measured on four occasions over four weeks (baseline phase A). During the eight week intervention phase (B) a visual analogue measure of mood was administered three times a week. Immediately after the intervention, and one and three months later, the baseline measures were repeated. The intervention (phase B) was based on cognitive-behavioural principles: recognising negative thoughts and challenging them, learning principles of relaxation, and planning of pleasurable activities. Following intervention three patients reported they had improved, three patients reported a minor improvement in quality of life, and four patients reported a more positive mood. Three months later three patients reported fewer depressive symptoms. Both patients and therapist were positive about the intervention and three months later, in daily life, all patients still applied the strategies. It was concluded that despite some ambiguous results, it seems that the cognitive-behavioural intervention has an effect on patients' mood. The intervention was rated as feasible by both patients and therapists.     

Home based management in multiple sclerosis: results of a randomised controlled trial

BACKGROUND: Home based medical care is a popular alternative to standard hospital care but there is uncertainty about its cost-effectiveness. OBJECTIVES: To compare the effectiveness and the costs of multidisciplinary home based care in multiple sclerosis with hospital care in a prospective randomised controlled trial with a one year follow up. METHODS: 201 patients with clinically definite multiple sclerosis were studied. They were randomised in a ratio 2:1 to an intervention group (133) or a control group (68). They were assessed at baseline and one year after randomisation with validated measures of physical and psychological impairment and quality of life (SF-36 health survey). The costs to the National Health Service over the one year follow up were calculated by a cost minimisation analysis. RESULTS: There were no differences in functional status between the home based care group and the hospital group. There was a significant difference between the two groups favouring home based management in four SF-36 health dimensions-general health, bodily pain, role-emotional, and social functioning (all p < or = 0.001). The cost of home based care was slightly less (822 euros/patient/year) than hospital care, mainly as a result of a reduction in hospital admissions. CONCLUSIONS: Comprehensive planning of home based intervention implemented by an interdisciplinary team and designed specifically for people with multiple sclerosis may provide a cost-effective approach to management and improve the quality of life.     

Changes in functional outcome in inpatient stroke rehabilitation resulting from new health policy regulations in Italy

This study was designed to assess whether enforcement of new health policy regulations in Italy limiting fully paid hospital stay to 60 days has actually caused a decrease in rehabilitation outcomes of stroke patients. Final sample included 370 out of 398 consecutive patients hospitalized between 1993 and 1996 for first stroke sequelae. Rehabilitation results were compared between subgroups of patients admitted before and after new Italian regulations. Length of stay was significantly ( p < 0.001) shorter in 1996 than in previous years. However, between 1993 and 1996 a significant ( p < 0.05) decrease in effectiveness on mobility and a significant ( p < 0.05) increase in "low responders" on both daily living activities and mobility was observed. Moreover, in 1995–96 the precocious discharge of patients compromised stabilization of recovery with subsequent functional worsening. After discharge, outpatient rehabilitation treatment was able to conserve achieved mobility status, but not functional status on daily living activities. We suggest revising the present regulation for medical rehabilitation services to one based on FRGs (functional related groups), so that the appropriate treatment can be carried out for each patient.     

A non-intensive stroke unit reduces functional disability and the need for long-term hospitalization

In a prospective controlled trial we compared the clinical outcome for unselected acute stroke patients in a non-intensive stroke unit (n = 110) and in general medical wards (n = 183). The patients were comparable in age, marital state and functional impairment on admission. Case fatality rates over the first year after the stroke were similar in the two groups. By three months after the stroke, 15% of the survivors initially admitted to the stroke unit and 39% of those admitted to general medical wards remained hospitalized (p less than 0.001). The corresponding figures by one year after the cerebrovascular accident were 12% and 28%, respectively (p less than 0.05). A greater proportion of surviving stroke unit patients was independent in walking (0.10 greater than p greater than 0.05), personal hygiene (p less than 0.05) and dressing (p less than 0.001). Essential features of the stroke unit are team work headed by a stroke nurse, staff, patient and family education and very early onset of rehabilitation. We conclude that this strategy improves functional outcome and reduces the need for long-term hospital care.