Effect of stroke early supported discharge on length of hospital stay: analysis from a national stroke registry

Abstract

ObjectiveThe first observational study to investigate the impact of early supported discharge (ESD) on length of hospital stay in real-world conditions.DesignUsing historical prospective Sentinel Stroke National Audit Programme (SSNAP) data (1 January 2013–31 December 2016) and multilevel modelling, cross-sectional (2015–2016; 30 791 patients nested within 55 hospitals) and repeated cross-sectional (2013–2014 vs 2015–2016; 49 266 patients nested within 41 hospitals) analyses were undertaken.SettingHospitals were sampled across a large geographical area of England covering the West and East Midlands, the East of England and the North of England.ParticipantsStroke patients whose data were entered into the SSNAP database by hospital teams.InterventionsReceiving ESD along the patient care pathway.Primary and secondary outcome measuresLength of hospital stay.ResultsWhen adjusted for important case-mix variables, patients who received ESD on their stroke care pathway spent longer in hospital, compared with those who did not receive ESD. The percentage increase was 15.8% (95% CI 12.3% to 19.4%) for the 2015–2016 cross-sectional analysis and 18.8% (95% CI 13.9% to 24.0%) for the 2013–2014 versus 2015–2016 repeated cross-sectional analysis. On average, the increased length of hospital stay was approximately 1 day.ConclusionsThis study has shown that by comparing ESD and non-ESD patient groups matched for important patient characteristics, receiving ESD resulted in a 1-day increase in length of hospital stay. The large reduction in length of hospital stay overall, since original trials were conducted, may explain why a reduction was not observed. The longer term benefits of accessing ESD need to be investigated further.Trial registration numberhttp://www.isrctn.com/ISRCTN15568163.

Large-scale implementation of stroke early supported discharge: the WISE realist mixed-methods study

“…23,38,72 Chapter 4 added to this debate by highlighting the importance of access to a social worker as part of the ESD team. 1 What was not possible to investigate in this study was whether or not access to ESD (despite an additional day in hospital) was associated with improved patient outcomes over the longer term. Recent observational studies in Sweden suggest patient and care-giver benefits related to the provision of ESD in regular clinical practice, in line with our previous study findings from England.…”

“…One important aspect of the ESD consensus score was to determine if a service meets the recommended WTE level of core staff per 100 patients. 1 Therefore, services that were resourced appropriately and had the adequate number of staff per patients were awarded a higher ESD consensus score. In this study, we found that it was the lower WTE amount of core staff per 100 patients within the most .…”

“…We employed a linear multilevel model framework for both study designs whereby patients (level 1) were clustered within admitting hospitals (level 2) in an approach consistent with previous observational studies of this type. 1,31,32,70,71 Within our multilevel models, we adjusted for a range of patient and hospital characteristics as covariates. We chose multilevel modelling to evaluate the effect of ESD on length of hospital stay because it could accommodate and appreciate the variation that existed within and between different admitting hospitals.…”

Evaluating stroke early supported discharge using cost-consequence analysis

“…This implies that resourcing a service that adheres to the core components of ESD service delivery requires costs to be appreciated on a per patient basis so that recommended staff to patient ratios are met. Our previous findings would suggest that further consequences of these additional cost implications may relate to additional patient benefit via the ESD service's ability to deliver a more responsive and intensive service [38].…”

“…In this study, the consequence of higher service costs on a per patient basis was association with greater adherence to evidencebased core components, as measured by our ESD consensus score. One important aspect of the ESD consensus score was to determine if a service meets the recommended WTE level of core staff per 100 patients [38]. Hence, services that met the recommended number of staff per patients, were awarded a higher ESD consensus score.…”