Papers

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

Louise Gilbertson, research occupational therapist ^a,  Peter Langhorne, senior lecturer ^b,  Andrew Walker, health economist ^c,  Ann Allen, helper ^a,  Gordon D Murray, professor of medical statistics ^d. 

^a Department of Occupational Therapy, Glasgow Royal Infirmary, Glasgow G4 0SF, ^b Academic Section of Geriatric Medicine, Glasgow Royal Infirmary, ^c Greater Glasgow Health Board, Dalian House, Glasgow G3 8YU, ^d Department of Community Health Sciences, Medical Statistics Unit, University of Edinburgh Medical School, Edinburgh EH8 9AG

Correspondence to: P Langhorne P.Langhorne{at}clinmed.gla.ac.uk

	Abstract

Top Abstract Introduction Participants and methods Results Discussion References

Objective: To establish if a brief programme of domiciliary occupational therapy could improve the recovery of patients with stroke discharged from hospital.
Design: Single blind randomised controlled trial.
Setting: Two hospital sites within a UK teaching hospital.
Subjects: 138 patients with stroke with a definite plan for discharge home from hospital.
Intervention: Six week domiciliary occupational therapy or routine follow up.
Main outcome measures: Nottingham extended activities of daily living score and "global outcome" (deterioration according to the Barthel activities of daily living index, or death).
Results: 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.
Conclusion: 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.

	Introduction

Top Abstract Introduction Participants and methods Results Discussion References

Discharge home from hospital can be a critical stage in the rehabilitation of patients with stroke. The early recovery and new skills achieved in hospital may be difficult to transfer to the home environment. ^{1 2} Poor coordination of planning of discharge, lack of access to services, psychosocial problems, and reduced quality of life are also common experiences at this time. ^{1 3} Home based rehabilitation has been proposed to address these needs, and recent trials indicate that interventions for occupational therapy at home are feasible and possibly effective. ^{4 5} We therefore aimed to establish a brief outreach service for occupational therapy and to evaluate whether it could improve the recovery of patients with stroke discharged home from hospital.

	Participants and methods

Top Abstract Introduction Participants and methods Results Discussion References

Study population
Patients with a clinical diagnosis of stroke (excluding subarachnoid haemorrhage) who were admitted to a Glasgow royal infirmary NHS trust were eligible if they had been referred to the occupational therapy department and if a discharge date had been set. We excluded only patients for whom the service might be inappropriate (full recovery, discharge to institutional care, terminal illness), those living outside the hospital area, and those unable to take part in the trial (severe cognitive or communication problems preventing consent, completion of outcome measures, or the agreement of simple goals for recovery).

Assignment
Eligible patients were contacted by the study therapist (LG) who obtained baseline data and informed consent. Patients were told the study would compare two types of follow up; routine services (control group) or routine services plus domiciliary occupational therapy (intervention). The therapist telephoned an independent central office where baseline data were logged before allocation. Patients were randomly allocated to either intervention by a computer generated schedule stratified by sex and attendance at a day hospital contained in sequentially numbered opaque sealed envelopes. The study was approved by the local ethics committee.

Interventions

Routine services
Routine services included inpatient multidisciplinary rehabilitation, a predischarge home visit for selected patients, the provision of support services and equipment, regular multidisciplinary review at a stroke clinic, and selected patients referred to a medical day hospital.

Intervention service
The intervention service was designed to be client centred and was developed through focus group sessions with patients, carers, and local occupational therapy staff.³ From these sessions a six week domiciliary programme was developed (comprising around 10 visits lasting 30-45 minutes) tailored to recovery goals identified by the patient such as regaining self care or domestic or leisure activities. The therapist worked with the patient to achieve these goals and also liaised with other agencies for advice, services, and equipment.

Outcomes
Baseline data were collected before randomisation, with follow up by interview after the intervention period (eight weeks) and postal outcome questionnaire at six months. The primary outcomes were the Nottingham extended activities of daily living scale and the "global outcome" of deterioration according to the Barthel activities of daily living index, or death.⁶ Secondary outcomes included the Barthel index, satisfaction with outpatient services,⁷ resource use (staff time, hospital readmission, provision of equipment and services), and measures of subjective health.³

Statistical analyses
All outcome data were coded, checked, and analysed on an intention to treat basis by an independent statistician. As there was a modest imbalance at baseline in severity of stroke a post hoc decision was made to explore the effects of adjusting the analysis for the baseline Barthel index. The total Nottingham score was well approximated by a normal distribution, and so the primary analysis was by two sample t test, supported by an analysis of covariance, adjusting for baseline Barthel index and the two stratification factors of sex and referral to a day hospital. The global outcome was analysed with logistic regression, with and without adjustment for the two stratifying factors. The distribution of the Barthel index was skewed towards the upper end of the score, but normal based methods were still used as this allowed adjustment for the baseline assessment.

	Results

Top Abstract Introduction Participants and methods Results Discussion References

Around 650 patients were admitted with suspected stroke or transcient ischaemic attack during an 18 month period, of whom 523 were admitted for at least three days with functional problems; we excluded 385 patients, and we randomised 67 patients to the intervention group and 71 to the control group, representing 58% (138/237) of patients with residual stroke disability who returned to a local private address (figure).

View larger version (30K): [in this window] [in a new window]   Trial profile

Baseline characteristics
The intervention group tended to have more severe strokes at baseline than the control group: hemianopia, a lower Barthel index, and longer hospital stay (table 1). Three patients in the intervention group were incorrectly diagnosed with stroke (all had malignancies), and one patient in the intervention group and one in the control group were given a discharge date but never discharged. These patients remained in their allocated groups throughout this analysis.

Functional outcomes
The unadjusted analysis at eight weeks (table 2) showed that the intervention group had a mean Nottingham score 4.8 points higher than that of the control group (95% confidence interval 0.5 to 10.0, P=0.08). In the corresponding adjusted analysis the mean difference was 5.7 points (1.2 to 10.3, P=0.02). Significantly fewer patients in the intervention group experienced a poor global outcome (odds ratio 0.43, 0.21 to 0.89, P=0.02). A similar pattern was seen with the Barthel index scores (table 2).

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 per patient and prevent 10 poor outcomes (deterioration in function) after discharge homethat is, costing about £2500 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

Top Abstract Introduction Participants and methods Results Discussion References

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.

Comparison with other studies
The main weakness of our study is its comparatively small size, which meant it was prone to baseline differences between patient groups and had limited power to detect a modest effect on functional outcomes. Our power calculations were based on previous studies, which in comparison with our trial provided a comparatively prolonged therapy input to the intervention group and little input to controls. ^{2 4 5} We were therefore probably trying to detect smaller differences between intervention and control patients than was originally anticipated. Interestingly, a recent trial showing a positive impact of domiciliary occupational therapy also had a control group that received minimal input.⁸ The apparently transient benefit of our intervention has been observed previously and used to justify a more prolonged therapy input. ^{4 5} Reducing the longer term impact of stroke remains a major challenge.⁹

Implications
Our results lend support to the principle of extending routine stroke rehabilitation from the inpatient period to postdischarge period. Our resource analysis shows that the service costs are significant but that one therapist could manage 80-100 patients per year and prevent about 10 deteriorating in function after discharge home. We did not attempt to reduce hospital stay, but two recent British trials of early hospital discharge with a domiciliary multidisciplinary rehabilitation have shown a shortening of the period of inpatient care with no apparent adverse effect on patient outcomes. ^{10 11} If confirmed, this potentially offers a way of improving postdischarge rehabilitation without incurring major additional service costs.

	Acknowledgments

We thank the patients and carers who contributed to the study.

Contributors: LG planned and conducted the trial and drafted the final report. PL planned and supervised the trial; he will act as guarantor for the paper. AW provided health economic input and analysis. AA contributed to the design and conduct of the trial. GDM provided independent data analysis and statistical advice. All authors contributed to the redrafting and approval of the final report.

	Footnotes

Funding: Chest Heart and Stroke Scotland provided the funding for this study. Additional support came from Glasgow Royal Infirmary NHS Trust and the chief scientists office, Scottish Office, which funded a research training fellowship for LG.

Competing interests: None declared.

	References

Top Abstract Introduction Participants and methods Results Discussion References

1.	Forster A, Young J. Stroke rehabilitation: can we do better? BMJ 1992; 305: 1446-1447.
2.	Corr S, Bayer A. Occupational therapy for stroke patients after hospital discharge. Clin Rehab 1995; 9: 291-296[Abstract/Free Full Text].
3.	Gilbertson L. A randomised controlled trial of home based occupational therapy for stroke patients. MSc thesis. University of Glasgow, 1998.
4.	Drummond AER, Walker MF. A randomised controlled trial of leisure rehabilitation. Clin Rehab 1995; 9: 283-290[Abstract/Free Full Text].
5.	Logan PA, Gladman JRF, Lincoln NB. A randomised controlled trial of enhanced social service occupational therapy for stroke patients. Clin Rehab 1997; 11: 107-113[Abstract/Free Full Text].
6.	Wade DT. Measurement in neurological rehabilitation. Oxford: Oxford University Press, 1992.
7.	Dennis MS, O'Rourke S, Slattery J, Staniforth T, Warlow C. Evaluation of a stroke family care worker: results of a randomised controlled trial. BMJ 1997; 314: 1071-1077[Abstract/Free Full Text].
8.	Walker MF, Gladman JRF, Lincoln N, Siemonsma P, Whiteley T. Occupational therapy for stroke patients not admitted to hospital: a randomised controlled trial. Lancet 1999; 354: 278-280[CrossRef][Medline].
9.	Gladman J, Barer D, Langhorne P. Specialist rehabilitation after stroke. Effective in the short term, but more work needed in the long term. BMJ 1996; 312: 1623-1624[Free Full Text].
10.	Rudd AG, Wolfe CDA, Filling K, Beech R. Randomised controlled trial to evaluate early discharge scheme for patients with stroke. BMJ 1997; 315: 1039-1044[Abstract/Free Full Text].
11.	Rodgers H, Soutter J, Kaiser W, Pearson P, Dobson R, Skilbeck C, et al. Early supported hospital discharge following acute stroke: pilot study results. Clin Rehab 1997; 11: 280-287[Abstract/Free Full Text].

(Accepted 13 December 1999)