Effect of acute stroke unit care integrated with care continuum versus conventional treatment: A randomized 1-year study of elderly patients: the Göteborg 70+ Stroke Study. A randomized controlled trial of a stroke rehabilitation ward. Home or hospital for stroke rehabilitation? results of a randomized controlled trial : I: health outcomes at 6 months. A non-intensive stroke unit reduces functional disability and the need for long-term hospitalization. Benefit of a stroke unit: a randomized controlled trial. Improving stroke rehabilitation. A controlled study. The effect of systematic care planning after acute stroke in general hospital medical wards. Stroke unit versus general medical wards, II: neurological deficits and activities of daily living: a quasi-randomized controlled trial. Randomised controlled trial to evaluate early discharge scheme for patients with stroke. Model of hospital-supported discharge after stroke. Role of stroke rehabilitation units in managing severe disability after stroke. [Intensive rehabilitation after apoplexy--a controlled pilot study]. A randomized controlled trial of rehabilitation at home after stroke in southwest Stockholm. Does a short period of rehabilitation in the home setting facilitate functioning after stroke? A randomized controlled trial. Expanding the role of the stroke nurse: a pragmatic clinical trial. Treatment in a combined acute and rehabilitation stroke unit: which aspects are most important? Alternative strategies for stroke care: a prospective randomised controlled trial. Cost comparison of domiciliary and hospital-based stroke rehabilitation. DOMINO Study Group. Evaluation of an extended stroke unit service with early supported discharge for patients living in a rural community. A randomized controlled trial. Domiciliary occupational therapy for patients with stroke discharged from hospital: randomised controlled trial. Early assessment by a mobile stroke team: a randomised controlled trial. Outcome of subacute stroke rehabilitation: a randomized controlled trial. Outcomes of elderly stroke patients. Day hospital versus conventional medical management.
The aim of the study was to compare the effect of conventional treatment with the effect of acute stroke unit care integrated with geriatric stroke unit care continuum.
                A 1-year study was undertaken with 2:1 randomization to stroke unit care or conventional care, with assessment by an independent team. The study was composed of 249 elderly patients (aged >/=70 years) hospitalized for acute stroke, without previous cerebral lesion and without recognized need of care. Main outcome measures were patients at home after 1 year, ability in daily living activities, health-related quality of life score according to questionnaire, death or institutional care, and death or dependence.
                One hundred two patients (61%) in the stroke unit and 49 patients (59%) in the general ward group were alive and at home after 1 year (95% CI -10% to 16%). There were no significant differences in daily life activities or quality of life. In patients with concomitant cardiac disease, there was a reduction in death or institutional care after 3 months in the stroke unit group compared with the group receiving conventional care (28% versus 49%, respectively; 95% CI -40% to -3%). This effect did not remain after 1 year. Patients seeking care after 24 hours often had mild stroke and lived alone.
                There was no effect on the number of patients living at home after 1 year, but after 3 months of stroke unit care, a beneficial effect was found on mortality and the need for institutional care among those with concomitant heart disease. This study involved patients who were considerably older than those investigated in previous randomized studies of acute stroke unit care; thus, these findings will contribute to the specialized register of controlled trials in stroke. In S.E. Kent, during 1978 and 1979, 225 patients, representing 228 occurrences of hemiplegia, were referred to a new 20-bed stroke rehabilitation ward. These patients were randomly allocated to treatment in the special ward (group A 112 strokes) or to remain in conventional treatment locations (group C 116 strokes); the two groups were closely similar, except for the initial level of consciousness. Survivors were observed at four-month intervals to one year. There are indications of benefit for patients in group A by comparison with Group C in terms of treatment received (number treated by remedial therapists, the extent of treatment, and the arrangements for after-care), and in outcome (survival and the proportion returned to the community). The direction of the trend of advantage is consistent with another recent controlled trial, although not all modes of improvement are identical in the two trials. It is suggested that every health district should develop a comprehensive policy of stroke management. We wished to examine the effectiveness of an early hospital discharge and home-based rehabilitation scheme for patients with acute stroke.
                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.
                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).
                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. 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. In a randomized controlled trial we compared the clinical outcome of acute stroke patients, 110 of whom were allocated to treatment in a stroke unit and 110 to treatment in general medical wards. No significant difference existed between these groups with regard to sex, age, marital status, medical history, or functional impairment on admission. Outcome was measured at 6 and 52 weeks after the stroke by the proportion of patients at home, the proportion of patients in an institution, the mortality, and the functional state. After 6 weeks 56.4% of the patients randomized to the stroke unit and 32.7% of the patients randomized to the general medical wards were at home (p = 0.0004), and after 52 weeks 62.7% and 44.6%, respectively, were at home (p = 0.002). After 6 weeks 36.3% of the patients from the stroke unit and 50.0% from the general medical wards were in an institution (p = 0.02); after 52 weeks 12.7% and 22.7%, respectively, were institutionalized (p = 0.016). After 6 weeks mortality was 7.3% for the stroke unit group and 17.3% for the general medical wards group (p = 0.027). After 52 weeks mortality was 24.6% for the stroke unit group and 32.7% for the general medical wards group (difference not significant). Functional state was significantly better for patients treated in the stroke unit after both 6 and 52 weeks. We conclude that care of patients with acute stroke in a stroke unit improves clinical outcome compared with treatment in general medical wards. Assessment of stroke rehabilitation is complicated by the heterogeneity of patients and settings and by difficulties in disentangling effects of organization from effects of types and amounts of treatment input.
                A prospective controlled study was undertaken in 245 stroke patients stratified into three groups according to prognosis and managed on a stroke rehabilitation unit (n = 124) or general medical wards (n = 121). Patients were randomly allocated to either setting 2 weeks after stroke and were comparable for baseline characteristics.
                Patients on general medical wards received more physiotherapy on average (16.2 +/- 7.2 versus 14.3 +/- 3.2 hours; P < .05) but similar amounts of occupational therapy (9.3 +/- 2.8 versus 9.5 +/- 3.2 hours) compared with stroke unit patients. More time was spent on individual rehabilitation on the stroke unit compared with general wards (P < .001). Functional abilities at discharge, destination of discharge, and length of hospital stay in patients with good prognosis were comparable in both settings. Patients with poor prognosis managed on general wards showed higher mortality (P < .05) and longer hospital stay (123.2 +/- 48.2 versus 52.3 +/- 19.8 days; P < .001), but functional abilities at discharge in survivors were comparable with those of stroke unit patients. Patients with intermediate prognosis had significantly better outcome on the stroke unit, with more patients being discharged home (75% versus 52%; P < .001), shorter average length of hospital stay (48.7 +/- 17.2 versus 104.6 +/- 28.6 days; P < .001), and better functional abilities at discharge (P < .05).
                Stroke units improve outcome and reduce hospital stay without increasing therapy time. Their effectiveness may be enhanced by patient selection. In a multidisciplinary study comprising 280 patients with acute cerebrovascular disease, the functional capacity was followed from the acute stage onwards with a test battery mainly measuring activities of daily living and motor capacity. Systematized care procedures with written care plans in accordance with the nursing process model, together with a booklet of guidelines in stroke care, were introduced during an experimental period in the care of 173 of the stroke victims. The remaining 107 patients received conventional care. The functional improvements were equal from a statistical standpoint in these two groups. However, in the group, which received special activities, there was a significant decrease in bed days, and a slightly larger number were able to return to their own homes. Compared with another stroke population from the same hospital, measured with the same functional instrument 7 years ago, the patients in this study seemed better off from a functional standpoint. For the individual severely-disabled patient, the care planning procedures seemed to be valuable and an effective way of promoting communication between different units. The difficulties in introducing new routines for documentation are discussed. The efficacy of stroke units has been extensively examined. It is unknown, however, whether the superiority of the stroke unit will remain after the increased focus on stroke treatment in general medicine. This study of patients admitted to the hospital early and with a short length of stay determines the effect and identifies certain important components of a stroke unit.
                Five hundred fifty patients aged 60 years or older with acute stroke were allocated by a quasi-randomized design to a stroke unit or a general medical ward based on date of birth in the month. Patients admitted within 24 hours of onset were enrolled. Outcomes after 7 months were death, proportion needing long-term care, and change in neurological and functional state assessed by the Scandinavian Stroke Scale and Barthel Index.
                Seven months after admission there was a trend in favor of the stroke unit in all outcome measures, but no significant differences in clinical outcomes were found except for change in the Scandinavian Stroke Scale score. Recurrent stroke during hospitalization occurred more often in the general medical ward (P = .03). The stroke unit was significantly more aggressive in mobilization out of bed (P<.01) and use of parenteral fluid (P<.0001), aspirin (P<.0001), antipyretics (P<.0001), and antibiotics (P<.0001).
                Our study confirms the benefit of the stroke unit, but the effects on the most reliable clinical outcomes were modest and insignificant. Treatment in this stroke unit hastened recovery. More aggressive rehabilitation and use of parenteral fluid, aspirin, antipyretics, and antibiotics appeared in the stroke unit. To assess the clinical effectiveness of an early discharge policy for patients with stroke by using a community based rehabilitation team.
                Randomised controlled trial to compare conventional care with an early discharge policy.
                Two teaching hospitals in inner London.
                331 medically stable patients with stroke (mean age 71) who lived alone and were able to transfer independently or who lived with a resident carer and were able to transfer with help.
                167 patients received specialist community rehabilitation for up to 3 months after randomisation. 164 patients continued with conventional hospital and community care.
                Barthel score at 12 months. Secondary outcomes measured impairment with motoricity index, minimental state examination, and Frenchay aphasia screening test; disability with the Rivermead activity of daily living scales, hospital anxiety and depression scale, and 5 m walk; handicap with the Nottingham health profile; carer stress with caregiver strain index and patient and carer satisfaction. The main process measure was length of stay after randomisation.
                One year after randomisation no significant differences in clinical outcomes were found apart from increased satisfaction with hospital care in the community therapy group. Length of stay after randomisation in the community therapy group was significantly reduced (12 v 18 days; P < 0.0001). Patients with impairments were more likely to receive treatment in the community therapy group.
                Early discharge with specialist community rehabilitation after stroke is feasible, as clinically effective as conventional care, and acceptable to patients. Considerable reductions in use of hospital beds are achievable. Readmission rate within 6 months after a stroke is 40% to 50%. The purpose of the project was to evaluate whether an interdisciplinary stroke team could reduce length of hospital stay, readmission rate, increase patient satisfaction and reduce dependency of help.
                One hundred and ninety-eight patients with acute stroke were randomized into 103 patients whose discharge was supported by an interdisciplinary stroke team and 95 control patients who received standard aftercare. Baseline characteristics were comparable in the 2 groups. The patients were evaluated after 6 and 12 months regarding functional status and need for help.
                Length of hospital admission was insignificantly shorter in the intervention compared with the control group (35.2 versus 39.8 days). There was no significant difference in readmission, GP-visits, and primary health care services. Furthermore, there was no significant difference in functional scores or patient satisfaction.
                In this setting we could not show benefit of an interdisciplinary stroke team supporting patients at discharge perhaps because standard aftercare was very efficient already. Stroke unit rehabilitation tends to be directed toward stroke patients with moderately severe disabilities ("the middle group"). Data collected on a stroke rehabilitation unit, however, showed improving outcome over 3 years in patients with a poor prognosis (discharge home: 48% versus 16%, P < .02; discharge Barthel Index score: 9 versus 6, P < .05). The hypothesis that stroke rehabilitation units may improve outcome in severely disabled stroke patients was tested in this study.
                A randomized controlled study was undertaken in 71 patients with a poor prognosis who were treated either on a stroke rehabilitation unit (n = 34) or on general wards (n = 37) to compare outcome between the two groups. Data collected were also compared with those from a methodologically similar study undertaken 3 years ago.
                Severe stroke patients treated on the stroke rehabilitation unit had a significantly better outcome compared with general wards (mortality: 21% versus 46%, P < .05; discharge home 47% versus 19%, P < .01; median length of hospital stay: 43 versus 59 days, P < .02). The number of stroke unit patients being discharged home had increased significantly from the previous study, with a trend toward improvement in median discharge Barthel Index score.
                Stroke rehabilitation units may improve outcome in severe stroke patients. This improvement appears to be due to the development of innovative management strategies that reduce mortality and institutionalization and enable caregivers to support more disabled stroke patients at home. In a prospective, randomized, controlled trial we compared the clinical outcome for 65 acute stroke patients where 31 were treated in a stroke unit and 34 in general medical units. In the stroke unit the treatment principles of Bobath were used, and teamwork was essential in the treatment. The inclusion period was nine months. Patients were followed up at a control six months after hospital discharge. The two groups were comparable as concerned age, sex, number of patients > or = 75 years and functional impairment at hospital admission. The mortality was similar in the two groups of patients. Significantly fewer patients from the stroke unit group were referred to nursing homes, when the patients in function group five (those most severely ill) were excluded. The functional status at the six months post discharge control was similar in the two groups. The in-patient time was without significant difference between the two groups when patients referred to nursing homes were excluded. The need for primary nursing after discharge was similar in the two groups. We conclude from our pilot study that better organisation in a general medical ward would in some aspects improve the prognosis of a major proportion of stroke patients. This study describes the methodology, patient outcome, and use of hospital and rehabilitation services at 3 months of a population-based randomized controlled trial. The purpose was to evaluate rehabilitation at home after early supported discharge from the Department of Neurology, Huddinge Hospital, for moderately disabled stroke patients in southwest Stockholm.
                The patients were eligible if they were continent, independent in feeding, had mental function within normal limits, and had impaired motor function and/or aphasia 1 week after stroke. Patients were randomized either to early supported discharge with continuity of rehabilitation at home for 3 to 4 months or to routine rehabilitation service in a hospital, day care, and/or outpatient care. The home rehabilitation team consisted of two physical therapists, two occupational therapists, and one speech therapist; one of the therapists was assigned as case manager for the patient. The rehabilitation program at home emphasized a task- and context-oriented approach. The activities were chosen on the basis of the patient's personal interests. Spouses were offered education and individual counseling. A total of 81 patients were followed up for a minimum of 3 months. Patient outcome was assessed by the Frenchay Social Activity Index, Extended Katz Index, Barthel Index, Lindmark Motor Capacity Assessment, Nine-Hole Peg Test, walking speed over 10 m, reported falls, and subjective dysfunction according to the Sickness Impact Profile. Patient use of hospital and home rehabilitation service and patient satisfaction with care were studied.
                Overall there were no statistical significant differences in outcome. Multivariate logistic regression analysis suggested a systematic positive effect for the home rehabilitation group in social activity, activities of daily living, motor capacity, manual dexterity, and walking. A considerable difference in resource use during such a 3-month period was seen. A 52% reduction in hospitalization was observed: from 29 days in the routine rehabilitation group to 14 days in the home rehabilitation group. Patient satisfaction was in favor of the latter group.
                Early supported discharge with continuity of home rehabilitation services for the majority of moderately disabled stroke patients during the first 3-month period after acute stroke is not less beneficial than routine rehabilitation and can be a rehabilitation service of choice if follow-up at 6 and 12 months confirms the suggested effectiveness and considerable reduction in use of health care. To assess the effect of three weeks of rehabilitation in the home setting for younger patients with stroke with the aim of improving activity level.
                A randomized controlled study with blinded evaluations at discharge, three weeks, three months and one year after discharge.
                Home of the patient or the ordinary day rehabilitation clinic at the university hospital.
                Fifty-eight patients (median age 53 years) consecutively discharged from inpatient rehabilitation with a first occurrence of stroke participated in training directly after discharge. Intervention: Rehabilitation was given for 9 hours/week over three weeks. The home group received individually tailored training, based on the patient's needs and desires, with a focus on activities in their natural context. Support and information were also given. The intervention in the day clinic group was aimed mainly at improved functions.
                The main outcome was activity, assessed with the Assessment of Motor and Process Skill (AMPS). The impairment level was also evaluated. Costs were estimated.
                There were no significant differences between the groups on any of the four assessments. However, there seemed to be an earlier improvement on some measures (including AMPS) for the home group. For both groups there was a greater improvement on the activity level than on the impairment level. the costs of the home group were less than half of the costs of the day clinic group.
                With the present results, both rehabilitation programmes could be recommended, however, further studies are needed to define patients who may specifically benefit from the home rehabilitation programme. Costs should be taken into consideration. This paper reports a study evaluating whether expanding a specialist nursing role to provide outreach education and support to stroke patients and carers after discharge from hospital is effective in promoting recovery.
                Building therapeutic relationships with patients and carers is a key component of the nursing role in stroke rehabilitation, although this is limited by the constraints of service organization.
                A pragmatic randomized controlled trial was undertaken. Patients with a diagnosis of stroke were randomized to receive continued support from a stroke nurse (n = 87) or usual care and follow-up (n = 89) after discharge from hospital. Patients were recruited from two hospitals in the north-west of England from November 1999 to April 2001. Patient dependence (Barthel Index), general health (Nottingham Health Profile), activities of living (Frenchay Activity of Living Index), depression (Beck Depression Inventory) and carer strain (Carer Strain Index) were assessed at 3 and 12 months after stroke.
                The continued intervention of a stroke nurse after discharge was associated with improved patient perceptions of general health at 12 months (median difference 42.6, P = 0.012), and in particular reduced negative emotional reaction (P = 0.037) and perceived social isolation (P = 0.002). In addition, the intervention reduced carer strain at 3 months (P = 0.045), and reduced deterioration in physical dependence from 3 to 12 months (P = 0.049).
                The provision of continued intervention from a stroke nurse after discharge from hospital, focusing on education and support, has tangible benefits for patients and carers. We have previously shown that treatment of acute stroke patients in our stroke unit (SU) compared with treatment in general ward (GWs) improves short- and long-term survival and functional outcome and increases the possibility of earlier discharge to home. The aim of the present study was to identify the differences in treatment between the SU and the GW and to assess which aspects of the SU care which were most responsible for the better outcome.
                Of the 220 patients included in our trial, only 206 were actually treated (SU, 102 patients; GW, 104 patients). For these patients, we identified the differences in the treatment and the consequences of the treatment. We analyzed the factors that we were able to measure and their association with the outcome, discharge to home within 6 weeks.
                Characteristic features in our SU were teamwork, staff education, functional training, and integrated physiotherapy and nursing. Other treatment factors significantly different in the SU from the GW were shorter time to start of the systematic mobilization/training and increased use of oxygen, heparin, intravenous saline solutions, and antipyretics. Consequences of the treatment seem to be less variation in diastolic and systolic blood pressure (BP), avoiding the lowest diastolic BP, and lowering the levels of glucose and temperature in the SU group compared with the GW group. Univariate analyses showed that all these factors except the level of glucose were significantly associated with discharge to home within 6 weeks. In the final multivariate Cox regression model, shorter time to start of the mobilization/training and stabilized diastolic BP were independent factors significantly associated with discharge to home within 6 weeks.
                Shorter time to start of mobilization/training was the most important factor associated with discharge to home, followed by stabilized diastolic BP, indicating that these factors probably were important in the SU treatment. The effects of characteristic features of an SU, such as a specially trained staff, teamwork, and involvement of relatives, were not possible to measure. Such factors might be more important than those actually measured. Organised specialist care for stroke improves outcome, but the merits of different methods of organisation are in doubt. This study compares the efficacy of stroke unit with stroke team or domiciliary care.
                A single-blind, randomised, controlled trial was undertaken in 457 acute-stroke patients (average age 76 years, 48% women) randomly assigned to stroke unit, general wards with stroke team support, or domiciliary stroke care, within 72 h of stroke onset. Outcome was assessed at 3, 6, and 12 months. The primary outcome measure was death or institutionalisation at 12 months. Analyses were by intention to treat.
                152 patients were allocated to the stroke unit, 152 to stroke team, and 153 to domiciliary stroke care. 51 (34%) patients in the domiciliary group were admitted to hospital after randomisation. Mortality or institutionalisation at 1 year were lower in patients on a stroke unit than for those receiving care from a stroke team (21/152 [14%] vs 45/149 [30%]; p<0.001) or domiciliary care (21/152 [14%] vs 34/144 [24%]; p=0.03), mainly as a result of reduction in mortality. The proportion of patients alive without severe disability at 1 year was also significantly higher on the stroke unit compared with stroke team (129/152 [85%] vs 99/149 [66%]; p<0.001) or domiciliary care (129/152 [85%] vs 102/144 [71%]; p=0.002). These differences were present at 3 and 6 months after stroke.
                Stroke units are more effective than a specialist stroke team or specialist domiciliary care in reducing mortality, institutionalisation, and dependence after stroke. The DOMINO study (DOMiciliary rehabilitation In NOttingham) was a randomized controlled trial comparing domiciliary and hospital-based rehabilitation for stroke patients after discharge from hospital, stratified according to the ward at hospital discharge. The outcomes of these patients have been reported previously. In this paper, we present estimates of health service costs of care. No difference in outcome had been found between the overall services, but we have found the hospital-based costs to be 27% cheaper. However, different cost-effectiveness patterns are observable when the strata are analysed. Patients from geriatric wards had been shown to be 2.4 times less likely to die or become institutionalized by 6 months if allocated to a day hospital service, although the cost of this service was 25% more than that of the domiciliary service. Patients from the Stroke Unit who had received domiciliary rehabilitation had been shown to have greater household and leisure abilities at 6 months than those treated in outpatient departments, but the domiciliary service was found to cost 2.6 times more. Patients from general medical wards had similar outcomes whether treated at home or in outpatient departments, but the cost of the latter service was 56% of the former. Some patients may be best cared for in day hospitals and others may do better if treated at home, but for these groups the clinical advantages are achieved at an expense greater than that incurred by the alternative services. Other patients may do as well if treated in outpatient departments as at home, but the former approach is cheaper. A range of services is required for stroke patients leaving hospital. To evaluate the effect of an extended stroke unit service (extended service), with early supported discharge and co-ordination of further rehabilitation in co-operation with the primary health care system in three rural municipalities.
                A randomized controlled trial comparing extended service with ordinary stroke unit service (ordinary service).
                Sixty-two eligible patients with acute stroke living in the rural municipalities of Malvik, Melhus and Klaebu.
                The primary outcome was the proportion of patients who were independent according to Modified Rankin Scale (mRS) (independence = mRS < or = 2) 52 weeks after onset of stroke. Secondary outcomes were mRS at 6 and 26 weeks and Barthel Index (BI), Nottingham Health Profile (NHP) and Caregiver Strain Index (CSI) at 6, 26 and 52 weeks. Mortality and length of stay were registered during the 52 weeks.
                Twelve patients (39%) in the extended service group versus 16 patients (52%) in the ordinary service group were independent according to mRS at 52 weeks (p = 0.444). The odds ratio for independence (extended service versus ordinary service) was 0.33 (95% confidence interval (CI) 0.088-1.234). According to outcome by secondary measures there were no significant differences except less social isolation on NHP in the extended service group at 26 weeks (p = 0.046). There were no significant differences in length of stay.
                An extended stroke unit service with early supported discharge seems to have no positive effect on functional outcome for patients living in rural communities, but might give a trend toward better quality of life. There were no significant differences in length of stay. To establish if a brief programme of domiciliary occupational therapy could improve the recovery of patients with stroke discharged from hospital.
                Single blind randomised controlled trial.
                Two hospital sites within a UK teaching hospital.
                138 patients with stroke with a definite plan for discharge home from hospital.
                Six week domiciliary occupational therapy or routine follow up.
                Nottingham extended activities of daily living score and "global outcome" (deterioration according to the Barthel activities of daily living index, or death).
                By eight weeks the mean Nottingham extended activities of daily living score in the intervention group was 4.8 points (95% confidence interval -0.5 to 10.0, P=0.08) greater than that of the control group. Overall, 16 (24%) intervention patients had a poor global outcome compared with 30 (42%) control patients (odds ratio 0.43, 0.21 to 0.89, P=0.02). These patterns persisted at six months but were not statistically significant. Patients in the intervention group were more likely to report satisfaction with a range of aspects of services.
                The functional outcome and satisfaction of patients with stroke can be improved by a brief occupational therapy programme carried out in the patient's home immediately after discharge. Major benefits may not, however, be sustained. There is overwhelming evidence of the effectiveness of specialist stroke rehabilitation, but more limited evidence of the effectiveness of organised stroke care during the acute phase of stroke.
                To determine the impact on outcome of access to a mobile team during the acute phase of stroke among patients admitted to general wards.
                308 patients admitted to one of two hospitals within 5 days of the onset of a clinically diagnosed stroke.
                Randomised controlled trial. STUDY GROUPS: Following admission, patients in the intervention arm were visited by members of a mobile stroke team who advised clinical staff on appropriate and timely investigation and management. They co-ordinated early input from therapy groups and identified those ready for transfer to the stroke rehabilitation unit. Patients in the control arm were not visited by the mobile stroke team.
                All-cause mortality measured at 6 weeks and 12 months.
                There was no statistically significant difference observed between study groups in mortality at 6 weeks (95% CI(adj) -7.4 to 7.4%) nor at 12 months ( 95% CI(adj) -4.1 to 15.9%). There were also no differences observed between study groups in morbidity outcomes or health-related quality of life measured at 12 months.
                The trial was terminated before the necessary sample size was collected but findings suggest that the mobile stroke team failed to confer significant long-term mortality benefit compared with general ward-based care alone. Organized acute stroke treatment reduces mortality, functional deficits, and the need of institutionalization after stroke. It is largely unknown whether the effects of treatment are due to early or subacute efforts. The aim of this randomized, controlled study was to test the hypothesis that rehabilitation of stroke patients in the subacute phase in a hospital rehabilitation unit is beneficial in reducing death and dependency and increasing health-related quality of life.
                251 patients initially treated in the hospital were randomized to subacute rehabilitation in a hospital rehabilitation unit (n = 127) or to the health services in the municipality (n = 124) and were followed up for 7 months.
                The combined outcome of patients being dead or dependent (Barthel Index score of < 75) was 23% in the hospital group and 38% in the municipality group (P=.01). Seven-month survival rates were 90.6% and 83.9% (P=.11), respectively. Dependency in activities of daily living was 12.6% in the hospital group and 25.0% in the municipality group (P=.07). Patients with a BI score of < 50 before rehabilitation had significantly better outcome in the hospital rehabilitation unit, with fewer patients becoming dependent (P=.005) and patients having higher Scandinavian Stroke Scale (P=.026) and BI scores (P=.005). No significant differences in health-related quality of life were found. Many patients treated in the municipalities (30%) did not receive any organized rehabilitation in this study.
                Subacute rehabilitation of stroke patients in a hospital-based rehabilitation unit improves outcome. Patients with moderate or severe stroke appear to benefit most. Much controversy exists over the value of geriatric day hospitals in the rehabilitation of elderly patients, and cerebrovascular accident is a particularly common diagnosis among patients referred to these day hospitals. We carried out a prospective, randomized study to compare the outcomes of elderly stroke patients managed by a geriatric team using a day hospital facility versus conventional medical management.
                One hundred twenty elderly patients with acute stroke were randomized to inpatient care on a stroke ward under the care of either a neurologist or a geriatric team. Those under the care of neurologists were hospitalized until the attending physician felt that the patients had reached full rehabilitation potential. Patients under the care of the geriatric team were discharged home as soon as the team felt they were able to cope and given follow-up rehabilitation at the day hospital. Family or community support was arranged when necessary for both treatment groups. On recruitment, patient demographics, medical history, clinical features related to stroke, and functional ability as measured by the Barthel Index were noted. Subjects were reviewed at 3 and 6 months to assess functional level, hospital and outpatient services received, general well-being, mood, and level of satisfaction. Costs of treatment of the two groups were also compared.
                Functional improvement (Barthel Index score) was greater in the group managed by the geriatricians with a day hospital facility compared with the conventional group at 3 months (P = .03). There were also fewer outpatient visits among the day hospital patients at 6 months (P = .03). No significant difference was found in costs between the two treatment groups.
                Compared with conventional medical management, care in the geriatric day hospital hastened functional recovery and reduced outpatient visits in elderly stroke patients without additional cost.
Stroke patients who receive organised inpatient care in a stroke unit are more likely to be alive, independent, and living at home one year after the stroke. The benefits were most apparent in units based in a discrete ward. No systematic increase was observed in the length of inpatient stay.