Community rehabilitation

National Guideline Centre (UK)

Chapter 13Community rehabilitation

13. Community rehabilitation

13.1. Introduction

Acute medical illness can be associated with a temporary reduction in our ability to carry out the normal activities of daily living. This can be due to the effect of the illness itself, side effects of treatment or becoming deconditioned from reduced activity whilst in hospital. Therefore rehabilitation is often needed during recovery from an acute medical illness so that patients can return to the same level of functioning and independence.

Whilst rehabilitation should start as soon as possible, there is some uncertainty over the clinical and cost effectiveness of the location of rehabilitation, as certain equipment and expert healthcare professionals (for example, physiotherapists or occupational therapists) may be needed to deliver the optimal rehabilitation therapy.

13.2. Review question: Does the provision of community-based rehabilitation services following acute medical illness improve patient outcomes?

For full details see review protocol in Appendix A.

Table 1

PICO characteristics of review question.

13.3. Clinical evidence

Twenty- nine studies (all RCTs) were included in the review;⁶^,¹³^,¹⁴^,¹⁹^,³⁸^,⁵⁶^,⁶⁴^,⁶⁵^,⁷⁶^,⁸⁸^,⁹⁰^,⁹¹^,⁹³^,⁹⁶^,¹¹³^,¹²²^,¹²⁶^,¹³¹^,¹³⁴^,¹⁵⁵^,¹⁶⁴^,¹⁷⁷^,¹⁹¹^,¹⁹²^,¹⁹⁸^,¹⁹⁹^,²⁰²^,²⁰⁸^,²¹¹^,²⁴³^,²⁴⁴^,²⁵¹ these are summarised in Table 2 and Table 3 below. Evidence from these studies is summarised in the GRADE clinical evidence summary below (Table 4).

Table 2

Summary of studies included in the review: Admission avoidance.

Table 3

Summary of studies included in the review: Early discharge.

Table 4

Clinical evidence summary: Community rehabilitation versus hospital rehabilitation after acute medical emergencies.

See also the study selection flow chart in Appendix B, study evidence tables in Appendix D, forest plots in Appendix C, GRADE tables in Appendix F and excluded studies list in Appendix G.

The studies were also divided by the aim of the intervention: a) avoiding hospital admission (n=3 studies) and b) facilitating early discharge from hospital after admission (n=26 studies).

Interventions in category A: admission avoidance is a service that provides active treatment by health care professionals outside hospital for a condition that otherwise would require acute hospital in-patient admission.

Interventions in category B: early discharge is a service that provides active treatment by health care professionals outside hospital for a condition that otherwise would require continued acute hospital in-patient care.

13.3.1. Admissions avoidance

Outcomes as reported in study (not analysable)

Activities of daily living (number of functions lost, score 0 to 6) (Ricauda 2004): Median (IQR): community rehab group =4 (2-5); hospital group = 4 (2-6), p=0.57.

Functional impairment (range 28 to 126; high score =greater independence) (Ricauda 2004). At 6 months: Median IQR: community rehab group =106 (67.5-121.5); hospital group = 96.5 (56.5-116.5), p=0.26.

National Institute of Health Stroke Scale Score (range 0-36; low score = improvement) (Ricauda 2004): At 6 months: Median IQR: community rehab group=8 (4-26); hospital group =8 (6-24), p=0.37.

Geriatric Depression Scale score (range 0-30) higher scores indicate depression (Ricauda 2004). At 6 months: Median IQR: community rehab group=10 (5-15); hospital group=17 (13-20), p<0.001.

Canadian Neurological Scale Score (range 0-10; higher score= improvement): At 6 months: Median IQR: community rehab group =10 (8.5-10.0); hospital group=9.5 (7.0-10.0), p=0.39.

13.3.2. Early discharge

Table 5

Clinical evidence summary: Community rehabilitation versus hospital rehabilitation after acute medical emergencies.

Outcomes as reported in study (not analysable)

One study (Cunliffe 2004) used Euroqol (Quality of life score): Euroqol (−0.59 to 1); at 3 months: mean difference 0.07 (95% CI −0.01 to 0.14); at 12 months: mean difference 0.02 (95% CI −0.06 to 0.09); Cunliffe 2004: GHQ - carer (36 to 0); at 3 months: mean difference −2.0 (95% CI −3.8 to −0.1); at 12 months, mean difference −1.1 (95% CI −3.7 to 1.5); mean GP visits over 12 months: community rehabilitation: 6 compared to the hospital group: 6.7, p=0.16.

One study (Roderick 2001) included quality of life data: quality of life median (IQR): physical health at 6 months; community rehabilitation group: 35.2 (26.5, 43.7) (n=49), hospital group: 32.7 (26.8, 39.2) (n=50); mental health at 6 months; community rehabilitation group: 57.4 (49.9, 62.9) (n=49), hospital group: 57.1 (50.6, 63.0) (n=50).

One study (Rodgers 1997) included quality of life data: quality of life median, (IQR): community rehabilitation group: 2 (1-5) compared to the hospital group: 3 (1-5); hospital length of stay median (IQR): Community rehabilitation group: 13 days (IQR 8-25) compared to the hospital group: 22 days (IQR 10-57), p<0.02; General health questionnaire for carers (30) median (range): community rehabilitation group: 5 (0-21) (n=22) compared to the hospital group: 5 (1-27) (n=19).

One study (Anderson 2000) included total hospital bed days: median (IQR): community rehabilitation group: 15 (8.0, 22.0) compared to the hospital group: 30 (17.3, 48.5), median difference -15, 95% CI −22.0 to −6.0; Readmission stay (days) median (IQR): community rehabilitation group: 6.0 (3.0 to 39.0) compared to hospital group: 4.0 (1.0 to 29.0), median difference 2.0, 95% CI −7.0 to 18.0, p=0.26.

One study (Bautz-Holter 2002) included length of stay: median: community rehabilitation group: 22 days compared to the hospital group: 31 days, p=0.09.

One study (Donnelly 2004) included length of stay: mean/median: community rehabilitation group: mean 42 days, median 31 days compared to the hospital group: mean 50 days, median 32 days.

One study (Indredavik 2000) included mean stroke unit length of stay: community rehabilitation group: 11 days compared to the hospital group: 11 days; mean hospital length of stay (stroke unit plus rehabilitation): community rehabilitation group: 18.6 days compared to the hospital group: 31.1 days; mean (range) number of GP visits at 1 year; community rehabilitation group: 7.5 (0-58) days compared to hospital group: 6.4 (0-35).

One study (Fleming 2004) included median (IQR) GP visits at 12 months: community rehabilitation group: 3 (1-6) compared to the hospital group: 4 (0-6); median (IQR) length of stay at discharge from index admission; community rehabilitation group: 8 (7-15), hospital group: 18 (8-34); median (IQR) hospital bed days from randomisation to 12 months; community rehabilitation group: 16 (8-35), hospital group: 34.5 (18-60); median (IQR) days either in hospital or in CHRS facility from randomisation to 12 months; community rehabilitation group: 60 (34-87), hospital group: 34.5 (18-63).

One study (Thorsen 2006) included Length of stay at index admission: community rehabilitation group: 14 days, hospital group: 30 days.

13.4. Economic evidence

Published literature

Six economic evaluations in 7 papers were identified with the relevant comparison and have been included in this review.³⁸^,⁵⁵^,⁹¹^,¹³⁰^,¹³¹^,¹⁷⁰^,²³⁸ These are summarised in the economic evidence profiles below (Table 6, Table 7 and Table 9) and the economic evidence tables in Appendix E.

Table 6

Economic evidence profile: Community based stroke rehabilitation versus inpatient rehabilitation.

Table 7

Economic evidence profile: Community based geriatric rehabilitation versus inpatient rehabilitation.

Four economic evaluations relating to this review question were identified but were excluded due to combination of limited applicability and methodological limitations.¹⁴⁷^,¹⁶⁸^,¹⁹³^,²¹⁰ These are listed in Appendix H, with reasons for exclusion given.

The economic article selection protocol and flow chart for the whole guideline can found in the guideline’s Appendix 41A and Appendix 41B.

Table 8

Economic evidence profile: Community based cardiac rehabilitation versus outpatient rehabilitation.

13.5. Evidence statements

Clinical

Admission avoidance

Three studies comprising 453 participants evaluated the role of community rehabilitation for improving outcomes in secondary care in adults and young people at risk of an AME, or with a suspected or confirmed AME. The evidence suggested that community rehabilitation may provide a benefit in reduced mortality (2 studies, moderate quality). The evidence suggested that there was no difference between the groups for quality of life - physical component summary (1 study, low quality) and quality of life score – mental component summary (1 study, moderate quality). However, there was a possible increase in length of treatment (1 study, low quality) in the community rehabilitation group.

Early discharge

Twenty six studies comprising 3852 participants evaluated the role of community rehabilitation for improving outcomes in secondary care in adults and young people at risk of an AME, or with a suspected or confirmed AME. The evidence suggested that community rehabilitation may provide a benefit in reduced GP presentations (2 studies, moderate quality), admissions to hospital at 6 months (5 studies, very low quality) and at 6 years (1 study, very low quality) and length of stay in hospital (8 studies, moderate quality) and length of stay in hospital and programme (3 studies, moderate quality). However, there was no effect on admissions at 12 months (7 studies, moderate quality) and mortality, although the trend was more deaths at 6 months (8 studies, very low quality) but fewer at 12 months (6 studies, very low quality) and no difference at 2-6 years (6 studies, moderate quality). However, there was a possible increase in adverse events (5 studies, very low quality). The evidence for quality of life with different scores suggested no effect or an improvement (9 studies, moderate quality). The evidence suggested that community rehabilitation may provide a benefit in terms of patient satisfaction (6 studies, very low to low quality). The evidence for carer satisfaction suggested no difference (6 studies, moderate quality) or an improvement (1 study, low quality) when reported using different scores and/or methodologies.

Economic

A UK cost–utility model found community-based rehabilitation following early supported discharge for stroke patients to be cost-effective (ICER: £6184) compared to usual care. This study was assessed as directly applicable with potentially serious limitations.
One cost-consequences analysis found that community-based rehabilitation following early supported discharge was less costly than inpatient rehabilitation for stroke patients (cost saving: £1491 per patient) and improved functionality (1.7 higher Barthel index score), lower mortality and higher care giver strain (0.24 higher care giver strain index score). This study was assessed as directly applicable with potentially serious limitations.
One cost-consequences analysis found that community-based rehabilitation was less costly (cost saving: £3238 per patient) and had better outcomes (less delirium, better quality of life, lower length of stay in hospital and in treatment, higher patient satisfaction, higher carer satisfaction and higher GP satisfaction) compared with inpatient rehabilitation for frail older people. This study was assessed as directly applicable with potentially serious limitations.
Three economic evaluations found that home-based cardiac rehabilitation was dominated by hospital-based outpatient rehabilitation for MI patients (cost: £480 more per patient). These studies were assessed as directly applicable with potentially serious to minor limitations.

13.6. Recommendations and link to evidence

Table

Provide a multidisciplinary community-based rehabilitation service for people who have had a medical emergency. A total of 29 studies were identified that assessed community rehabilitation compared to hospital rehabilitation. These studies were separated (more...)

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Appendices

Appendix A. Review protocol

Table 9

Review protocol: community rehabilitation.

Appendix B. Clinical article selection

Figure 1Flow chart of clinical article selection for the review of Community rehabilitation

Appendix C. Forest plots

C.1. Community versus hospital rehabilitation – Admission avoidance

Figure 2Mortality

Figure 3Length of treatment

Figure 4Quality of life –SF 36- Physical component summary

Figure 5Quality of life –SF 36- Mental component summary

C.2. Community versus hospital rehabilitation - Early discharge

Figure 6Mortality

Figure 7Adverse events

Figure 8Quality of life (SF-36)

Table 10Quality of life (St. George’s Respiratory Questionnaire)

Table 11Quality of life (Life Satisfaction)

Figure 9Quality of life (SF-12)- PCS

Figure 10Quality of life (SF-12)- MCS

Figure 11Patient satisfaction

Figure 12Patient Satisfaction

Table 12Carer Satisfaction

Figure 13Carer Satisfaction

Figure 14Carer Satisfaction (Caregiver Strain Index)

Figure 15Length of stay (in-hospital)

Figure 16Length of stay in hospital and programme

Figure 17Admissions

Figure 18GP presentations

Figure 19Quality of life (MacNew-Global)

Appendix D. Clinical evidence tables

Cochrane reviews

Download PDF (360K)

Randomised controlled trials

Download PDF (1.0M)

Appendix E. Economic evidence tables

Appendix F. GRADE tables

Table 13

Clinical evidence profile: Community versus hospital for after acute medical emergencies (admission avoidance).

Table 14

Clinical evidence profile: Early Supported Discharge for after acute medical emergencies versus continued hospital treatment.

Appendix G. Excluded clinical studies

Table 15

Studies excluded from the clinical review.

Appendix H. Excluded economic studies

Table 16

Studies excluded from the economic review.

Publication Details

Copyright

Publisher

National Institute for Health and Care Excellence (NICE), London

NLM Citation

National Guideline Centre (UK). Emergency and acute medical care in over 16s: service delivery and organisation. London: National Institute for Health and Care Excellence (NICE); 2018 Mar. (NICE Guideline, No. 94.) Chapter 13, Community rehabilitation.

Table 1PICO characteristics of review question

Population	Adults and young people (16 years and over) with a suspected or confirmed AME or at risk of an AME.
Interventions	Community-based rehabilitation services.
Comparisons	Hospital-based rehabilitation services.
Outcomes	Mortality (CRITICAL) Avoidable adverse events (CRITICAL) Quality of life (CRITICAL) Patient and/or carer satisfaction (CRITICAL) Length of stay (CRITICAL) Number of presentations to ED (IMPORTANT) Number of admissions to hospital (IMPORTANT) Number of GP presentations (IMPORTANT)
Study design	Systematic reviews (SRs) of RCTs, RCTs, observational studies only to be included if no relevant SRs or RCTs are identified.

Table 2Summary of studies included in the review: Admission avoidance

Study	Intervention and comparison	Population	Outcomes	Comments
Admission avoidance Comparison: Community rehabilitation versus routine hospital services
Cowie 2012⁵⁶ RCT UK	Home based: 1 hour aerobic based exercise session- DVD and booklet The session started with a 15 min warm-up and ended with a 15 min cool-down. Participants in both home and hospital groups were educated on symptoms of unstable heart failure, and avoided exercise where instability was suspected. A physiotherapist telephoned the home group every 2 weeks to modify their exercise prescription where appropriate. For monitoring of adherence and exercise intensity, the home group completed a diary detailing every session completed Versus Hospital based 1 hour aerobic based exercise session- exercise session was a physiotherapist led class	n=60 Patients with heart failure (NYHA class II/III)	Quality of life	Follow-up at 8 weeks
Kalra 2000¹³⁴ RCT	Hospital outreach admission avoidance multi-disciplinary with joint care from community services. Care was provided by a mix of outreach and community staff including physiotherapy, occupational therapy, social worker and a speech therapist versus Hospital admission (inpatient stroke team care or admission to a stroke unit)	Patients recovering from a moderately severe stroke Median (IQR) age T=75 (72-84) C=77.7 (67-83)	Mortality;	Included in Cochrane (Shepperd 2008)
Ricauda 2004¹⁹² RCT	Hospital outreach admission avoidance (services operated from an accident and emergency department). 24 hour care available multi-disciplinary team: physiotherapist, occupational therapist, nursing, hospital geriatrician, social worker, speech therapist, psychologist Versus Hospital admission	Patients recovering from a stroke	Mortality; Length of treatment; Activities of daily living; Functional impairment; Living in an institutional setting; Canadian Neurological Scale Score; National Institute of Health Stroke Scale Score; Geriatric Depression Scale score	Included in Cochrane (Shepperd 2008)
Shepperd 2008²²³^,²²³ ²²³ Cochrane review	Admission avoidance hospital at home schemes compared to acute hospital inpatient care. The schemes may admit patients directly from the community or from the emergency room. Definition used by the authors: hospital at home is a service that can avoid the need for hospital admission by providing active treatment by health care professionals in the patient’s home for a condition that otherwise would require acute hospital in-patient care, and always for a limited time period. In particular, hospital at home has to offer a specific service to patients in their home requiring health care professionals to take an active part in the patients’ care.	Patients aged 18 years and over that were included in admission avoidance hospital at home schemes	Mortality, Re-admissions, Patient satisfaction, Carer satisfaction, Length of stay in hospital and hospital at home	10 studies in Cochrane review, of which 2 studies included in our evidence review.

Table 3Summary of studies included in the review: Early discharge

Study

Intervention and comparison

Population

Outcomes

Comments

Anderson, 2000⁷; Hackett 2002⁷^,¹¹³

RCT

Early hospital discharge and individually tailored home-based/community rehabilitation (median duration, 5 weeks) by a full time occupational therapist, a consultant in rehabilitation, physiotherapists, occupational therapists, social workers, speech therapists, and rehabilitation nurses. Efforts were made so that discharge from hospital could occur within 48 hours of randomisation.

Versus

Conventional care and rehabilitation in hospital, either on an acute-care medical geriatric ward or in a multidisciplinary stroke rehabilitation unit run by specialists in rehabilitation or geriatric medicine

Acute stroke patients that were medically stable and suitable to be discharged early from hospital to a community rehabilitation scheme and had sufficient physical and cognitive function.

Patients included in this study were mildly disabled

Mortality; SF-36 physical and mental component summary scores; patient satisfaction with therapy/recov ery; Falls; Caregiver strain index; Readmission to hospital at 6 months; Length of hospital stay

Included in Cochrane review Shepperd 2009

Arthur 2002¹³ (Smith 2011²²⁹, Smith 2004²²⁸)

Conducted in Canada

RCT

Intervention 1 (n=96): Home based exercise training. Patients attended individual, 1 hour exercise consultations with an exercise specialist at baseline and after 3 months of exercise training. Patients were advised to train a total of 5 times per week. Each exercise included a 10-15 minute warm up/down and 40 mins of aerobic training. Home patients were telephoned every 2 weeks for 6 months by the exercise specialist to monitor progress, assess and document adherence, revise the exercise prescription if necessary, and provide support and education.

Control (n=100): Hospital based exercise training. Patients were expected to attend supervise exercise sessions 3 times per week for 6 months. Classes were led by exercise specialists. Each exercise included a 10-15 min warm up/down and 40 minutes of aerobic training. Exercise logs were reviewed with the patient on a monthly basis

Patients referred after Coronary artery bypass grafting (CABG) to the Cardiac Health and Rehabilitation Centre at a university hospital group.

Inclusion: between 35 and 49 days post-CABG surgery, achieved between 40 and 80% of age and sex-predicted minimum MET level on a progressive cycle ergometry exercise test, able to read and write English.

Exclusion: recurrent angina, positive graded exercise test, unable to attend rehabilitation 3 times per week, unable to participate due to physical limitations, previously participated in an out-patient cardiac rehabilitation program

Mortality, Health related quality of life, hospitalisation at 6 years

Askim, 2004¹⁵

RCT

Extended service consisting of stroke unit treatment combined with a home based programme of follow-up care co-ordinated by a mobile stroke team that offers early supported discharge and works in close co-operation with the primary health care system during the first 4 weeks after discharge. The mobile team consisted of a nurse, a physiotherapist, an occupational therapist and the consulting physician.

Versus

Ordinary service defined as the stroke unit treatment of choice according to evidence-based recommendations.

Acute stroke patients with a Scandinavian Stroke Scale (SSS) score greater than 2 points and less than 58 points. I score such as this indicates that patients were moderately disabled

Mortality;

Length of stay in hospital or programme; Caregiver Strain index

Included in Cochrane review Shepperd 2009

Askim 2010A ¹⁴

RCT

Intensive Motor training (IMT) group: 3 additional sessions of motor training each week for the first 4 weeks after discharge and 1 additional session per week for the next 8 weeks; each session 30-50 minutes. Patients also encouraged to perform home exercises during this period

Versus

Standard treatment (ST) group: All patients were treated in a comprehensive stroke unit

Diagnosis of acute stroke according to WHO definition, modified Rankin Scale score <3 before admission, Berg Balance Scale score <45 points, Scandinavian Stroke Scale score >14 points, Scandinavian Stroke Scale leg item <6 points or Scandinavian Stroke Scale transfer item <12 points, Mini-Mental State Examination score >20 points; informed consent.

Mortality; Adverse events at 26 weeks

Included in Cochrane review Shepperd 2009

Bautz-Holter, 2002¹⁹

RCT

Early supported discharge with a multidisciplinary team for each stroke patient was offered and support and supervision was provided from the project team whenever needed. Four weeks after discharge, the patients in the ESD group were seen at the outpatient clinic

Versus

Conventional procedures for discharge and continued rehabilitation, which were anticipated to be less well organised

Acute stroke patients; not severely disabled prior to stroke; had no other medical condition likely to preclude rehabilitation and were medically stable.

Patients included were moderately to mildly disabled

Mortality; Admissions to hospital; Length of hospital stay; Admissions to hospital;

Included in Cochrane review Shepperd 2009

Caplan 2006³⁸

RCT

Early discharge hospital based outreach

Type of service: nurses, physiotherapy, occupational therapy, physician

Versus

Control group: in-patient hospital care

Elderly patients whose length of hospital stay exceeded 6 days, who were referred for geriatric rehabilitation and expected to return home and live reasonably independently

Mean age: treatment = 83.86 (7.8); control = 84.0 (7.02)

Mortality; Functional and cognitive status; Psychological well-being; patient and/or carer satisfaction;

Readmission at 6 months; Length of stay

Included in Cochrane review Shepperd 2009

Cunliffe 2004⁶⁴

RCT

Hospital at home (early discharge)

Type of service: provided by community services, GP had clinical responsibility, physiotherapy, occupational therapy, 3 dedicated nurses plus 7 rehabilitation assistants, provided care up to 4 weeks. Community care officer liaised with social services

Versus

Control group: in-patient hospital care

3 most common conditions were fractures (105/370, 28%), neurological conditions, mainly stroke (97/370, 26%), cardio-respiratory illnesses (50/370,14%). 247/370 (66%) lived alone

Median age: 80 years

Mortality; Readmission by 3 months; Quality of life; GP visits; length of stay in hospital

Included in Cochrane review Shepperd 2009

Dalal 2007⁶⁵

RCT

Home-based rehabilitation

Patients received a self-help package of 6 weeks’ duration (the Heart Manual) supported by a cardiac rehabilitation nurse. The cardiac rehab nurse made a home visit in the first week after discharge followed up by telephone calls over 6 weeks.

Versus

Hospital-based rehabilitation classes over 8-10 weeks. Classes lasted 2 hrs each and were conducted in groups of 8-10 people in the local hospital or for a small number of patients in one of the 2community centres.

Three different multidisciplinary teams delivered the programme. Patients were also encouraged to exercise at home.

n=230

Patients admitted with acute myocardial infarction

Mortality and quality of life

Follow-up 9 months

Donnelly, 2004⁷⁶

RCT

Earlier hospital discharge combined with community-based multidisciplinary stroke team rehabilitation comprising 0.33 coordinator, 1 occupational therapist, 1.5 physiotherapists, 1 speech and language therapist, and 2 rehabilitation assistants. On average the number of home visits over a 3-month period was 2.5 per week each lasting 45 minutes. Patients in the CST group were to be discharged as soon as their home was assessed.

Versus

Usual hospital rehabilitation comprising inpatient rehabilitation in a stroke unit and follow-up rehabilitation in a day hospital

Acute stroke patients with no pre-existing physical or mental disability that was judged to make further rehabilitation inappropriate.

Patients included were moderately (10-14) to mildly disabled (15-19)

Mortality; SF-36 physical and mental component; Quality of life (EuroQoL); patient satisfaction; Caregiver Strain index; Length of stay; Admissions to hospital at 12 months

Included in Cochrane review Shepperd 2009

Evans 1997B⁸⁸

RCT

Out-patient follow-up: Usual medical services but no scheduled rehabilitation therapies; patients received a mean of 0.6 (1.3) rehabilitation services during acute rehabilitation and 0.1 (0.2) during out-patient follow up.

Versus

In-patient comprehensive rehabilitation: patients received a mean of 18.0 (8.1) rehabilitation services during acute rehabilitation and 8.3 (10.9) during out-patient rehabilitation.

Presence of a physical limitation based on psychiatry exam; medically stable as indicated by an illness severity index of 1 (lowest mortality); first time hospitalisation for a disabling condition in any of 4 Major Diagnostic Categories (MDC 1 – nervous, 5 – circulatory, 8 – musculoskeletal and 21 – injury).

Nervous: 16% versus 17% between groups, circulatory: 16% versus 14%, musculoskeletal: 52% versus 60%, injury: 13% versus 9%

Mortality at 1 year; QoL: Life satisfaction at 1 year

Length of stay (days) at 1 year; Admissions to hospital at 1 year

Fleming 2004 ⁹³

RCT

Care Home Rehabilitation Services (CHRS): Occupational therapists assessed patients in the units and devised their treatment plans. Community Care Officers; rehabilitation assistants trained by the OTs. Physiotherapy; GP; District nurses. Treatment programmes were tailored to individual needs

Versus

Usual care

Hospitalised patients who were aged over 65 years; lived in the Social Services districts served by the CHRS scheme; wished to return to their own homes; no longer needed in-patient medical care; were unable to return home due to activity limitation that might be improved by a period of short-term rehabilitation in a care home setting; agreed to a period of rehabilitation in a care home setting; met Social Services criteria for eligibility for residential home care.

Principal diagnostic condition: cardio-respiratory disorder: 26/165 (16%), gastroenterology disorder 11/165 (7%), infection 3/165 (2%), neurological disorder: 23/165 (14%), orthopaedic disorder: 29/165 (18%), peripheral vascular disease: 5/165 (3%), non-specific condition: 64/165 (40%)

Mortality at 12 months; Length of stay at discharge from index admission;

Hospital bed days from randomisation to 12 months; Days either in hospital or in CHRS facility from randomisation to 12 months; Number of patients re-admitted to hospital at 12 months; GP visits at 12 months

Gladman 1993 ⁹⁶

RCT

Domiciliary rehabilitation service (DRS): provided by 2 half-time physiotherapists and 1 OT who assessed all patients referred to DRS at home and then organised or provided appropriate therapy and arranged other relevant help.

Versus

Hospital-based rehabilitation service (HRS): eligible for out-patient rehabilitation according to usual practices, that is, for those discharged from Health Care of the Elderly wards, the main option was a day hospital, while for those discharged from General Medical wards, outpatient physiotherapy or occupational therapy could be arranged.

Acute stroke (first or recurrent)

Mortality at 6 months

ESD Stroke Bergen trial: Hofstad 2013¹²² (Gjelsvik 2014⁹⁵)

Conducted in Norway

RCT

Intervention 1 (n=103): Early supported discharge from an outpatient ambulatory coordinating team during hospitalisation and for 5 weeks post-discharge at a community-based day unit. Multi-disciplinary outpatient visits at 3 and 6 months

Intervention 2 (n=104): Early supported discharge from an outpatient ambulatory coordinating team during hospitalisation and for 5 weeks post-discharge at the patient’s home. Multi-disciplinary outpatient visits at 3 and 6 months

Control (n=99): Usual care, which consists of treatment in a stroke unit, followed by transfer to the Department of Physical Medicine and Rehabilitation if needed based on a professional judgment. Other alternatives are discharge directly to home or discharge to inpatient treatment in a municipal health care institution.

All stroke patients admitted to the Department of Neurology at one University Hospital.

Inclusion: home-dwelling and live in the Municipality, Inclusion within 1-7 days after symptom onset, inclusion within 6-hours to 120 hours after admission to the Department of Neurology, NIHSS score at inclusion 2–26, or a two-point increase in mRS score if 0 or 1 previously, able to agree to the participation in the study

Exclusion: Serious psychiatric disorders, Alcohol or substance abuse, Other serious conditions of importance to the cerebral disorder and subsequent rehabilitation process, Poor knowledge of the Norwegian language before the stroke

Patient satisfaction at 6 months and length of stay

Small in-hospital component of interventions

Outpatient ambulatory coordinating team consisted of physiotherapist, occupational therapist, and a nurse trained for stroke patients.

Treatment by other specialists, particularly speech therapists is considered if needed in all arms.

Mortality not reported (20-30% ‘dropped out’ during the 6 months)

Indredavik 2000¹²⁶

Fjaertoft, 2004⁹⁰ Fjaertoft 2005⁹¹^,⁹²

RCT

Extended stroke unit service (ESUS): A mobile stroke team: offers early supported discharge and coordinates further rehabilitation and follow-up in close cooperation with the primary healthcare system; nurse, physiotherapist, occupational therapist, physician; evaluation of the needs of the patient; primary healthcare system informed about the patient; home visit; plan for further follow-up for necessary nursing, support, and rehabilitation. The mobile stroke team was responsible for coordination of the different agencies and activities.

Versus

Ordinary stroke unit service (OSUS): treatment in a combined acute and rehabilitation stroke unit and further follow-up organized by rehabilitation clinics and/or the primary healthcare system; systematic diagnostic evaluation, standardized observation of vital signs and neurological deficits, acute medical treatment program, very early mobilization and rehabilitation in a stroke unit.

Signs and symptoms of an acute stroke according to the World Health Organization definition of stroke; Scandinavian Stroke Scale (SSS) score between 2 and 57 points; living at home before the stroke; included within 72 hours after admission to the stroke unit and within 7 days after the onset of symptoms; lack of participation in other trials; and provision of informed consent

Mortality at 5 years

Length of stay in stroke unit at index admission;

Length of stay in hospital (stroke unit plus rehabilitation clinics) at index admission;

Length of stay in stroke unit at 1 year;

Length of stay in inpatient rehabilitation at 1 year; hospital Readmission days at 1 year

Number of GP visits at 1 year

Caregiver strain index

Included in Cochrane review Shepperd 2009

Jolly 2007¹³¹

Home-based rehabilitation (n=263)

This consisted of a manual, home visits and telephone contact. Patients who had had an MI were discharged home with The Heart Manual (second edition).

The Heart Manual was introduced to patients on an individual basis, either in hospital or on a home visit. At the first visit the facilitator discussed the progress with the patient and agreed action or exercise goals with the patient. Patients were then telephoned at about 3 weeks post-recruitment and a further visit took place 6 weeks post-recruitment.

A final visit took place at 12 weeks, when patients were encouraged to maintain their lifestyle changes and to continue with their exercise programme.

Versus

Hospital based rehabilitation (n=262)

all patients were offered an individualised rehabilitation programme consisting of risk factor counselling, relaxation and twice-weekly supervised exercise sessions for 12 weeks. The exercise was mainly walking, fixed cycling and rowing. The relaxation session and information sessions occurred once during each rehabilitation session and participants could opt to attend. Patients completed the programme after attending 24 sessions.

Any adult patient was eligible if they had had one of the following events within the previous

12 weeks: an acute MI and had been informed of their diagnosis; a coronary angioplasty with or without stenting; a CABG operation.

Mortality (2 years); Quality of life (6 months)

Maltais 2008¹⁵⁵

Conducted in Canada

RCT

Intervention 1 (n= 126): Home-based rehabilitation. A qualified exercise specialist initiated the program in the patient’s home and subsequently made weekly telephone calls for 8 weeks to reinforce and detect problems. Patients were loaned portable ergocycles.

Control (n=126): Hospital-based outpatient rehabilitation. Training program combined aerobic and strength exercises at a rate of 3 sessions per week for 8 weeks.

Training was monitored by a qualified exercise specialist, who could modify training, in a ratio of 4 to 5 participants for 1 trainer.

Patients from pulmonary clinics of 8 university-based and 2 community-based centres.

Inclusion: stable COPD, 40 years or older, were current or former smokers of at least 10 pack-years, had an FEV₁ less than 70% of the predicted value and FEV₁-FVC ratio less than 0.70; had MRC dyspnoea score of at least 2.

Exclusion: diagnosis of asthma, congestive left heart failure as the primary disease, terminal disease, dementia, or an uncontrolled psychiatric illness.

Mortality, Quality of life, Serious adverse event (COPD exacerbation), Hospitalisation at 1 year

Both groups received the same education intervention which consisted of an educational flipchart and 6 skill-oriented, self-help, patient workbook modules.

Mayo, 2000¹⁶⁴

RCT

Rehabilitation at home after prompt discharge from hospital with the immediate provision of follow-up services by a multidisciplinary team offering nursing, physical therapy (PT), occupational therapy (OT), speech therapy (ST), and dietary consultation. Duration of intervention was 4 weeks for all participants.

Versus

Usual care practices for discharge planning and referral for follow-up services. These included physiotherapy, occupational therapy and speech therapy, as requested by the patient’s care provider and offered through extended acute-care hospital stay; inpatient or outpatient rehabilitation; or home care via local community health clinics.

Acute stroke patients with motor deficits after stroke who had caregivers willing and able to provide live-in care for the subject over a 4-week period after discharge from the hospital.

Patients included were mildly disabled

Mortality; SF-36 Mental summary component and SF-36 physical summary component; Length of stay (hospital);

Length of stay (hospital + rehabilitation)

Included in Cochrane review Shepperd 2009

Ozdemir 2001 ¹⁷⁷

RCT

Rehabilitation in the patients’ homes. Family members shown how convenient bed positioning and exercises should be performed by patient and family members. No neuromuscular facilitation. Family provided therapy at least 2 hours a day, 7 days a week. Splints, orthoses and devices were provided. A team consisting of a rehabilitation physician and a physiotherapist regularly visited the patients for 2 hours once a week and instructed family caregivers and provided medical support to the patients.

Versus

Intensive multidisciplinary rehabilitation services as inpatients in the rehabilitation clinic. Therapeutic exercises (range of motion, passive stretching, muscle strengthening, mobilisation) and neuromuscular facilitation for 2 hours a day, 5 days a week. Physical agents such as ice, hot packs, TENS and ultrasound were used when necessary. Regular occupational therapy but no speech therapy. Hand and/or wrist splints, ankle-foot orthoses, tripods and canes were provided if needed. Patients evaluated daily by a physician. Stroke-related symptoms and complications were treated with multi-disciplinary approaches.

Aged under 80 years, diagnosed with stroke (first or recurrent) between 1996 and 1999

Adverse events at 9 weeks

RASMUSS EN 2016¹⁹¹

RCT

Denmark

Home based stroke rehabilitation for 4 weeks after discharge

Patients were treated by a multi-disciplinary, intersectoral and interventional team for providing coordinated and home based rehabilitation.

The team included a nurse, physiotherapists, occupational therapists and physicians experienced in stroke treatment. Prior to home based training a physician evaluated each intervention inpatient to secure that the inpatient was able and fit to participate.

The nurse participated in the home training if nursing intervention was needed.

At home inpatients were tested and trained in difficult activities with or without assistive devices.

Versus

Control

Control patients were treated following standard care procedures in the stroke unit.

n= 41

Stroke patients with focal neurological deficits hospitalised in a stroke unit for more than 3 days and in need of rehabilitation.

-: Length of hospital stay

-: Quality of life

Roderick 2001¹⁹⁸

RCT

Domiciliary stroke team: physiotherapist and occupational therapist who met daily to plan activity and fortnightly with a consultant geriatrician to review patients, using a goal-setting approach. Outpatient speech and language therapy provided.

Versus

Five day hospitals were involved; care was coordinated by multi-disciplinary teams who gave therapy in both individual and group sessions.

Confirmed diagnosis of stroke; aged 55 years or over; residents of East Dorset; needed further rehabilitation for disability caused by stroke; physically able to attend the day hospital; any previous disability was not too severe that it would prevent further rehabilitation; no signs of advanced dementia.

Mortality at 6 months;

SF-36 Physical health at 6 months; SF-36 Mental health at 6 months; Length of stay at 6 months; Number of patients readmitted at 6 months; Number of patients attending GP at 6 months

Rodgers, 1997¹⁹⁹

RCT

Early Supported Discharge with home care from the Stroke Discharge Team (community based). The team consisted of an occupational therapist, physiotherapist, speech and language therapist, social worker and occupational therapy technician. The stroke discharge rehabilitation service was available 5 days per week but the home care component of the service was available 24 hours per day and 7 days per week if required. The stroke discharge service was withdrawn gradually and a contact name and number was provided to patients in case of subsequent queries or problems.

Versus

Inpatient and outpatient care was provided for the control group by conventional hospital and community services. Discharge planning and services post discharge for patients randomised to conventional care were arranged and provided according to the usual practice of each participating ward or unit.

Acute stroke patients that were not severely handicapped prior to the incident stroke with no other condition likely to preclude rehabilitation.

Patients included were moderately disabled

Mortality; Length of hospital stay;

Readmission to hospital; Quality of life; Carer strain

Included in Cochrane review Shepperd 2009

Ronning 1998 ²⁰²

RCT

Health services in the municipality (after initial short length of stay in acute stroke unit or general medical ward): most municipalities have a nursing home that provides rehabilitation through a multidisciplinary staff (in-patient or day patient) and further ambulatory rehabilitation by a visiting physical therapist, speech therapist and/or nurse. Municipalities offer access to primary health care including physical therapy, occupational therapy, speech therapy and nurse support.

Versus

Hospital rehabilitation unit (after initial short length of stay in acute stroke unit or general medical ward): patients had access to a coordinated multidisciplinary rehabilitation team of nurses; physical, occupational and speech therapists; a social worker and a neurologist.

Acute (first or recurrent) stroke patients aged 60 or older, with a Scandinavian Stroke Scale (SSS) score between 12 and 52, who were conscious on admission, and who could cooperate in the rehabilitation programme (that is, scored at least 4 points on the subject orientation section of the SSS); patients with malignant diseases not in the terminal stages were included.

Mortality at 7 months; length of stay in hospital;

SF-36 Mental Health; Summary score at 7 months; SF-36 Physical Health Summary score at 7 months

Rudd 1997²⁰⁸

RCT

Early discharge with a planned course of domiciliary physiotherapy, occupational therapy, and speech therapy, with visits as frequently as considered appropriate (maximum one day visit from each therapist) for up to 3 months after randomisation.

Versus

Usual care with no augmentation of social services resources.

Stroke patients able to perform functional independent transfer or able to perform transfer with assistance

Mortality; Length of stay in hospital; Admissions to hospital; patient satisfaction with therapy/recov ery;

Caregiver strain index; Carer satisfaction

Included in Cochrane review Shepperd 2009

Santana 2016²¹¹

RCT

Portugal

Early home supported discharge group (EHSD) –rehabilitation in the stroke unit and at home

EHSD team of therapists included 2 physiotherapists, 2 occupational therapists and a psychologist.

Patients and carers received education on healthy behaviours and information about stroke, its consequences, how to best participate in rehabilitation and how to find help within their communities.

EHSD team worked with the patients to provide approximately 8 home based training sessions for a month

Versus

Usual care group

Patients received rehabilitation as part of standard care in the stroke unit. Patients received information from the case manager about services available in the community, but no further specific input was provided.

n=190

Stroke patients aged 25-85 years admitted to the stroke unit with an initial Functional Independence

Measure of up to 100

Length of stay

Shepperd 2009²²⁵

Studies comparing early discharge hospital at home with acute hospital in-patient care.

The authors used the following definition to determine if studies should be included in the review: hospital at home is a service that provides active treatment by health care professionals in the patient’s home for a condition that otherwise would require acute hospital in-patient care, and always for a limited time period.

In particular, hospital at home has to offer a specific service to patients in their home requiring health care professionals to take an active part in the patients’ care.

The review included evaluations of early discharge hospital at home schemes that include patients aged 18 years and over. Patients were either recovering from a stroke, following elective surgery, or were older people with a mix of conditions.

Mortality, Re-admissions, Patient satisfaction, Carer satisfaction, Length of stay in hospital and hospital at home

26 studies in Cochrane review, of which 10 studies included in our review

Thorsen 2005²⁴³ Thorsen 2006 ²⁴⁴ von Koch 2000²⁵² von Koch 2001

251

RCT

Early supported hospital discharge (after initial medical care and rehabilitation in the stroke unit) to a home rehabilitation group (HRG). An outreach team of occupational therapists, physiotherapists and a speech-and-language pathologist provided services; the duration, frequency and content of the intervention were decided on together with the patient and his or her family

Versus

Conventional rehabilitation group (CRG) (after initial medical care and rehabilitation in the stroke unit). If required, and after evaluation by specialists, patients in CRG received additional rehabilitation in the Geriatrics or Rehabilitation Department. The content and duration did not adhere to a standardised programme but rather reflected services available within the District Health Authority.

Mild to moderate impairments after first or recurrent stroke according to clinical criteria of the WHO

Mortality at 5 years;

Falls at 5 years;

Length of stay at index admission;

Number of patients presenting to GPs at 5 years;

Readmission to hospital

Table 4Clinical evidence summary: Community rehabilitation versus hospital rehabilitation after acute medical emergencies

Outcomes	No of Participants (studies) Follow up	Quality of the evidence (GRADE)	Relative effect (95% CI)	Anticipated absolute effects
Outcomes	No of Participants (studies) Follow up	Quality of the evidence (GRADE)	Relative effect (95% CI)	Risk with Control	Risk difference with Community (admission avoidance) versus hospital (95% CI)
Mortality	413 (2 studies) 6-12 months	⊕⊕⊕⊝ MODERATE^b due to imprecision	RR 0.74 (0.52 to 1.04)	Moderate
Mortality	413 (2 studies) 6-12 months	⊕⊕⊕⊝ MODERATE^b due to imprecision	RR 0.74 (0.52 to 1.04)	314 per 1000	82 fewer per 1000 (from 151 fewer to 13 more)
Length of treatment	120 (1 study) Unclear	⊕⊕⊝⊝ LOW^a^,^b due to risk of bias, imprecision		The mean length of treatment in the control groups was 22.2 days	The mean length of treatment in the intervention groups was 15.9 higher (8.1 to 23.7 higher)
Quality of life-SF 36 physical component summary	40 (1 study) 8 weeks	⊕⊕⊝⊝ LOW^b due to imprecision		-	The mean quality of life-SF 36 physical component summary in the intervention groups was 0.18 higher (6.35 lower to 6.71 higher)^*
Quality of life-SF 36 mental component summary	40 (1 study) 8 weeks	⊕⊕⊕⊝ MODERATE^b due to imprecision			The mean quality of life-SF 36 mental component summary in the intervention groups was 3.81 lower (11.08 lower to 3.46 higher)^*

(a): Downgraded by 1 increment if the majority of the evidence was at high risk of bias, and downgraded by 2 increments if the majority of the evidence was at very high risk of bias.

(b): Downgraded by 1 increment if the confidence interval crossed one MID or by 2 increments if the confidence interval crossed both MIDs.

*: Higher scores better.

Table 5Clinical evidence summary: Community rehabilitation versus hospital rehabilitation after acute medical emergencies

Outcomes	No of Participants (studies) Follow up	Quality of the evidence (GRADE)	Relative effect (95% CI)	Anticipated absolute effects
Outcomes	No of Participants (studies) Follow up	Quality of the evidence (GRADE)	Relative effect (95% CI)	Risk with Hospital Rehabilitation	Risk difference with Community Rehabilitation (95% CI)
Mortality	3495 (20) 3 months – 6 years	⊕⊕⊕⊝ MODERATE^a	RR 1.03 (0.84 to 1.25)	Moderate
Mortality	3495 (20) 3 months – 6 years	⊕⊕⊕⊝ MODERATE^a	RR 1.03 (0.84 to 1.25)	91 per 1000	3 more per 1000 (from 15 fewer to 23 more)
Mortality	1214 (8 studies) 6 months	⊕⊝⊝⊝ VERY LOW^a^,^b^,^c due to risk of bias, inconsistency, imprecision	RR 1.26 (0.79 to 2.03)	Moderate
Mortality	1214 (8 studies) 6 months		RR 1.26 (0.79 to 2.03)	91 per 1000	24 more per 1000 (from 19 fewer to 94 more)
Mortality	1033 (6 studies) 12 months	⊕⊝⊝⊝ VERY LOW^a^,^b^,^c due to risk of bias, inconsistency, imprecision	RR 0.86 (0.63 to 1.18)	Moderate
Mortality	1033 (6 studies) 12 months		RR 0.86 (0.63 to 1.18)	163 per 1000	23 fewer per 1000 (from 60 fewer to 29 more)
Mortality	1248 (6 studies) 2-6 years	⊕⊕⊕⊝ MODERATE^a	RR 0.97 (0.78 to 1.20)	Moderate
Mortality	1248 (6 studies) 2-6 years	⊕⊕⊕⊝ MODERATE^a	RR 0.97 (0.78 to 1.20)	116 per 1000	3 fewer per 1000 (from 26 fewer to 23 more)
Adverse events	513 (5 studies) 9 weeks - 6 years	⊕⊝⊝⊝ VERY LOW^a^,^b^,^c due to risk of bias, inconsistency, imprecision	RR 1.20 (0.85 to 1.68)	Moderate
Adverse events	513 (5 studies) 9 weeks - 6 years		RR 1.20 (0.85 to 1.68)	367 per 1000	73 more per 1000 (from 55 fewer to 250 more)
Quality of life SF-36 Physical component summary score	623 (5 studies) 7 months	⊕⊕⊕⊝ MODERATE^a due to risk of bias		The mean quality of life in the control groups was 39.6 units	The mean quality of life in the intervention groups was 1.04 higher (0.99 lower to 3.07 higher)
Quality of life SF-36 Mental component summary scores	623 (5 studies) 7 months	⊕⊕⊕⊝ MODERATE^a due to risk of bias		The mean quality of life in the control groups was 55.7	The mean quality of life in the intervention groups was 0.86 higher (1.04 lower to 2.77 higher)
Quality of life St. George’s Respiratory Questionnaire	184 (1 study) 12 months	⊕⊕⊕⊝ MODERATE^a due to risk of bias		The mean quality of life in the control groups was −3.5	The mean quality of life in the intervention groups was 1 lower (4.14 lower to 2.14 higher)
Quality of life Life Satisfaction	85 (1 study) 12 months	⊕⊕⊕⊝ MODERATE^a due to risk of bias		The mean quality of life in the control groups was 19.9	The mean quality of life in the intervention groups was 0.3 higher (4.06 lower to 4.66 higher)
Quality of life (MacNew-Global)	104 (1 study) 9 months	⊕⊕⊕⊝ MODERATE^a due to risk of bias		The mean quality of life in the control groups was 5.67	The mean quality of life (Macnew-global) in the intervention groups was 0.07 lower (0.51 lower to 0.37 higher)
Quality of life- SF 12 (PCS)	525 (1 study) 6 months	⊕⊕⊕⊝ MODERATE^a due to risk of bias			The mean quality of life SF 12 (PCS) in the intervention groups was 0.28 lower (2.14 lower to 1.58 higher)
Quality of life-SF 12 (MCS)	525 (1 study) 6 months	⊕⊕⊕⊝ MODERATE^a due to risk of bias			The mean quality of life SF 12 (MCS) in the intervention groups was 1.14 lower (2.83 lower to 0.55 higher)
Patient satisfaction	467 (4 studies) 6 months	⊕⊝⊝⊝ VERY LOW^a^,^b^,^c due to risk of bias, inconsistency, imprecision		The mean patient satisfaction in the control groups was 4.28	The mean patient satisfaction in the intervention groups was 0.32 higher (0.18 lower to 0.82 higher)
Patient satisfaction	348 (2 studies) 6-12 months	⊕⊕⊝⊝ LOW^a^,^c due to risk of bias, imprecision	RR 1.15 (0.93 to 1.43)	Moderate
Patient satisfaction	348 (2 studies) 6-12 months	⊕⊕⊝⊝ LOW^a^,^c due to risk of bias, imprecision	RR 1.15 (0.93 to 1.43)	512 per 1000	77 more per 1000 (from 36 fewer to 220 more)
Carer satisfaction	104 (1 study) 6 months	⊕⊕⊝⊝ LOW^a^,^c due to risk of bias, imprecision		The mean carer satisfaction in the control groups was 4.08	The mean carer satisfaction in the intervention groups was 0.39 higher (0.01 lower to 0.79 higher)
Carer satisfaction	145 (1 study) 12 months	⊕⊕⊕⊝ MODERATE^a due to risk of bias	RR 1 (0.86 to 1.17)	Moderate
Carer satisfaction	145 (1 study) 12 months	⊕⊕⊕⊝ MODERATE^a due to risk of bias	RR 1 (0.86 to 1.17)	825 per 1000	0 fewer per 1000 (from 115 fewer to 140 more)
Carer satisfaction Caregiver Strain Index	532 (5 studies) 12 months	⊕⊕⊕⊝ MODERATE^a due to risk of bias		The mean carer satisfaction in the control groups was 6	The mean carer satisfaction in the intervention groups was 0.16 standard deviations higher (0.01 lower to 0.34 higher)
Length of stay in hospital	1389 (8) in-hospital	⊕⊕⊕⊝ MODERATE^a due to risk of bias		The mean length of stay in hospital and programme in the control groups was 25 days	The mean length of stay in hospital in the intervention groups was 1.38 lower (2.47 to 0.3 lower)
Length of stay in hospital and programme	486 (3 studies) unclear	⊕⊕⊕⊝ MODERATE^a due to risk of bias		The mean length of stay in hospital and programme in the control groups was 34 days	The mean length of stay in hospital and programme in the intervention groups was 7.74 lower (14.2 to 1.28 lower)
Admissions to hospital	1745 (13 studies) 3 months – 6 years	⊕⊕⊕⊝ MODERATE^a due to risk of bias	RR 0.98 (0.86 to 1.11)	Moderate
Admissions to hospital	1745 (13 studies) 3 months – 6 years	⊕⊕⊕⊝ MODERATE^a due to risk of bias	RR 0.98 (0.86 to 1.11)	243 per 1000	5 fewer per 1000 (from 34 fewer to 27 more)
Admissions to hospital	451 (5 studies) 6 months	⊕⊝⊝⊝ VERY LOW^a^,^c due to risk of bias, imprecision	RR 0.9 (0.61 to 1.33)	Moderate
Admissions to hospital	451 (5 studies) 6 months	⊕⊝⊝⊝ VERY LOW^a^,^c due to risk of bias, imprecision	RR 0.9 (0.61 to 1.33)	224 per 1000	22 fewer per 1000 (from 87 fewer to 74 more)
Admissions to hospital	1150 (7 studies) 12 months	⊕⊕⊕⊝ MODERATE^a due to risk of bias	RR 1.03 (0.88 to 1.20)	Moderate
Admissions to hospital	1150 (7 studies) 12 months	⊕⊕⊕⊝ MODERATE^a due to risk of bias	RR 1.03 (0.88 to 1.20)	253 per 1000	8 more per 1000 (from 30 fewer to 51 more)
Admissions to hospital	144 (1 study) 6 years	⊕⊝⊝⊝ VERY LOW^a^,^c due to risk of bias, imprecision	RR 0.8 (0.6 to 1.08)	Moderate
Admissions to hospital	144 (1 study) 6 years	⊕⊝⊝⊝ VERY LOW^a^,^c due to risk of bias, imprecision	RR 0.8 (0.6 to 1.08)	622 per 1000	124 fewer per 1000 (from 249 fewer to 50 more)
GP presentations	166 (2 studies) 6 months - 5 years	⊕⊕⊕⊝ MODERATE^a due to risk of bias	RR 0.94 (0.86 to 1.04)	Moderate
GP presentations	166 (2 studies) 6 months - 5 years	⊕⊕⊕⊝ MODERATE^a due to risk of bias	RR 0.94 (0.86 to 1.04)	933 per 1000	56 fewer per 1000 (from 131 fewer to 37 more)

(a): Downgraded by 1 increment if the majority of the evidence was at high risk of bias, and downgraded by 2 increments if the majority of the evidence was at very high risk of bias.

(b): The point estimate varies widely across studies, unexplained by subgroup analysis.

(c): Downgraded by 1 increment if the confidence interval crossed 1 MID or by 2 increments if the confidence interval crossed both MIDs.

Table 6Economic evidence profile: Community based stroke rehabilitation versus inpatient rehabilitation

Study

Applicability

Limitations

Other comments

Incremental cost

Incremental effects

Cost effectiveness

Uncertainty

Fjaertoft 2005⁹¹

[Norway]

Partially applicable^(a)

Potentially serious limitations^(b)

Study design: RCT

Intervention: Treatment in stroke unit followed by early supported discharge

Treatment duration: NR

Subgroup: Early discharge

-£1491^(c)

Barthel index (0-20, lower indicates increased disability)(MD): 1.72
Mortality (RR): 0.87
Caregiver strain index (13 question tool; Better indicated by lower values) (SMD): 0.24

n/a

Stratification by functional level

Incremental costs:

0-1 = £1477

2-3 = -£2743

4-5 = -£2962

Simple sensitivity analyses with the 5 most expensive cost components increased/decreased by 25% - Author states that only marginally impacted results (not shown).

National Audit Office 2010¹⁷⁰[UK]

Partially applicable^(d)

Potentially serious limitations^(e)

Design: decision model

Intervention: Early supported discharge (ESD): programme of home-based care (physiotherapy; occupational therapy and speech therapy) available up to a period of 3 months, with no more than one visit per day from each type of therapist

Treatment duration: unclear, possibly 1 year.

Subgroup: Early discharge

£804^(f)

0.13 QALYs

£6184 per QALY gained

Deterministic uncertainty conducted on the level of discount rate (varying it from 0 to 6%) and on the extent of coverage of the ESD scheme to all stroke patients. The model findings were not sensitive to these changes.

Not clear as to whether probabilistic sensitivity analysis was conducted.

: Abbreviations: MD: mean difference; SMD: standardised mean difference; n/a: not applicable; NR: not reported; QALYs: quality-adjusted life-years; RCT: randomised controlled trial; RR: risk ratio.

(a): QALYs not used. Some uncertainty about the applicability of Norwegian resource use and unit costs. Resource use from >10 years ago year; unit cost year unclear.

(b): RCT-based analysis so from one study by definition therefore not reflecting all evidence in area. Some uncertainty about whether time horizon is sufficient. Limited sensitivity analysis.

(c): Converted using 2005 purchasing power parities.¹⁷⁶

(d): NAO Costs and outcomes discounted at a different rate. EQ5D data not available so mapped from disease-specific measure.

(e): Unclear how the health outcomes, health and social care costs of each health states were calculated. Not clear whether the study considered the costs of long-term care such as residential care (nursing homes and residential homes). Unclear as to whether the unit costs used from Beech et al (1997) were updated to take into account of inflation or whether recent official data were used (for example, unit costs from PSSRU).

(f): Cost year unclear.

Table 7Economic evidence profile: Community based geriatric rehabilitation versus inpatient rehabilitation

Study

Applicability

Limitations

Other comments

Incremental cost

Incremental effects

Cost effectiveness

Uncertainty

Caplan 2006A³⁸

[Australia]

Partially applicable^(a)

Potentially serious limitations^(b)

Study design: RCT

Intervention: Home rehabilitation provided by a hospital-based multidisciplinary outreach service. The team includes nurses, physiotherapists, occupational therapists and doctors. Patients were visited a mean of 20 times during the rehabilitation episode. Equipment were provided free for up to 3 months

Treatment duration: variable.

Subgroup: Early discharge

-£3238^(c)

Delirium: Acute phase

−1.1% Delirium: rehabilitation phase

−2.6% Overall length of episode of care:

−5.21Length of rehabilitation phase: - 7.12 days Hospital bed days:

−19.78 days Mini Mental State Examination (MMSE) (score out of 30): 0.08

Depression (Geriatric Depression Score GDS):

- 0.04 Patient satisfaction: 0.6 Carer satisfaction:

0.39 General practitioner satisfaction: 0.28

n/a

No sensitivity analysis reported

: Abbreviations: n/a: not applicable; QALYs: quality-adjusted life-years; RCT: randomised controlled trial;

(a): Some uncertainty regarding the applicability of resource use and unit costs from Australia (2002) to the current NHS context. QALYs were not used as an outcome measure.

(b): RCT-based analysis so from one study by definition therefore not reflecting all evidence in area. There is also some uncertainty about whether time horizon is sufficient to reflect all the possible downstream differences in costs and outcomes. No sensitivity analysis is reported.

(c): Converted to 2002 UK pounds using purchasing power parities.¹⁷⁶

Table 8Economic evidence profile: Community based cardiac rehabilitation versus outpatient rehabilitation

Study

Applicability

Limitations

Other comments

Incremental cost

Incremental effects

Cost effectiveness

Uncertainty

Cowie 2014⁵⁵ [UK]

Partially applicable^(a)

Potentially serious limitations^(b)

Study design: cost analysis of a RCT

Intervention: exercise training delivered in a home setting

Treatment duration: 5 years.

Subgroup: admissions avoidance

£480

n/a

Increasing the cost of hospital training by 100% still resulted in hospital training being cost saving.

Jolly et al 2009, Jolly et al 2007

¹³⁰^,¹³¹[UK]

Directly applicable

Potentially serious limitations^(c)

Study design: RCT

Intervention: Exercise programme after Myocardial infarction

Treatment duration: 9-12 weeks

Subgroup: admission avoidance

£41

Change in EQ-5D score: −0.022

Hospital dominates

Sensitivity analyses were carried out around missing data and a major variable for each of the interventions. This did not change the decision outcome.

Taylor et al 2007 ²³⁸[UK]

Directly applicable

Minor limitations^(d)

Study design: RCT

Intervention: Exercise programme after myocardial infarction

Treatment duration: 6-10 weeks

Subgroup: admission avoidance

£78

QALYs: −0.06

Hospital dominates

: Abbreviations: n/a: not applicable; QALYs: quality-adjusted life-years; RCT: randomised controlled trial.

(a): Only costs were measured, no details on mortality or quality of life. Costs were measured over 5 years but not discounted.

(b): RCT-based analysis, so from one study by definition therefore not reflecting all evidence in area. Only looks at impact on hospital admission costs, no primary care or outpatient costs were considered in the analysis.

(c): RCT-based analysis, so from 1 study by definition therefore not reflecting all evidence in area. Did not include survival into quality of life measure to obtain QALY.

(d): RCT-based analysis, so from 1 study by definition therefore not reflecting all evidence in area. Length of follow-up may not be deemed long enough. Further sensitivity analysis for all assumptions could be conducted. Outcomes had high confidence intervals around incremental values.

Recommendations	7. Provide a multidisciplinary community-based rehabilitation service for people who have had a medical emergency.
Research recommendation	-
Relative values of different outcomes	Quality of life, mortality, avoidable adverse events, patient and/or carer satisfaction and number of admissions to hospital were considered by the guideline committee to be critical outcomes. Number of GP presentations, readmission, length of hospital stay and number of presentations to the Emergency Department were considered by the committee to be important outcomes.
Trade-off between benefits and harms	A total of 29 studies were identified that assessed community rehabilitation compared to hospital rehabilitation. These studies were separated into admission avoidance or early discharge studies. Stratum - Admissions avoidance: Three studies suggested that community rehabilitation may provide benefits in reduced mortality.. The evidence suggested that there was no difference between the groups for quality of life (physical component and mental component). There was no evidence for the following outcomes: avoidable adverse events, quality of life, patient and/or carer satisfaction, number of presentation to the ED, number of admissions to hospital or number of GP presentations. Stratum - Early discharge: Evidence from 26 studies suggested that community rehabilitation provides a benefit in fewer GP presentations, admissions to hospital at 6 months and at 6 years and reduced length of stay in hospital and in programme. However, there was no effect on admissions at 12 months; mortality trends suggested more deaths at 6 months, fewer at 12 months and no difference at 2-6 years. However, there was a possible increase in adverse events. The evidence for quality of life with different scores suggested no effect or an improvement. There was potential benefit in terms of patient satisfaction. The evidence for carer satisfaction suggested no difference or an improvement when reported using different scores and/or methodologies. There was no evidence for the outcome relating to number of presentations to the ED. The committee considered that the data were consistent with a benefit for rehabilitation in the community, which also has high patient acceptability. The committee agreed that rehabilitation in the community should be offered to patients as an alternative to routine hospital inpatient rehabilitation, depending on their clinical condition and after discussion of risks and benefits. Community rehabilitation is a viable alternative to hospital inpatient treatment for selected patients, and would be the preferred option to maintain patients’ independence.
Trade-off between net effects and costs	Two included studies assessed the cost effectiveness of early supported discharge and rehabilitation following acute admissions for stroke. The studies showed that early supported discharge with rehabilitation in the community is cost effective (either dominant - or has an incremental cost effectiveness ratio (ICER) less than £20,000 per QALY gained). Three economic evaluations found home-based cardiac rehabilitation to be more costly and less effective than hospital outpatient based rehabilitation. One study assessed the cost effectiveness of community-based geriatric rehabilitation compared to inpatient rehabilitation. This study showed that geriatric rehabilitation in the community was dominant (more effective and less costly) compared to inpatient rehabilitation. The committee considered the clinical evidence which showed improvement in patient-centred outcomes, including patient and/or carer satisfaction. However, there was lack of evidence regarding improved functional outcomes and independence for elderly patients which the committee believed, based on their clinical experience, would be improved. The committee were of the view that patients’ quality of life could be enhanced by improved independence and satisfaction. Overall, the committee considered the possible improvements in health outcomes and cost savings to outweigh the costs of providing community based rehabilitation for patients recovering from an AME. Community rehabilitation services are quite common across the country, for example, early supported discharge for suitable patients who have had an acute stroke. But for some parts of the country, providers and commissioners may have to set up or expand the capacity of existing services (including training or hiring of additional staff, including physiotherapists. The rehabilitation services could be integrated within the intermediate care services. The impact of such services should be to free up hospital beds and improved patient outcomes.
Quality of evidence	Admission avoidance: The evidence was graded moderate for mortality and length of stay due to imprecision. Length of treatment data was graded as low due to risk of bias and imprecision. The outcome of quality of life (physical and mental component summary) was graded low to moderate due to imprecision Early discharge: The evidence was graded very low to moderate due to risk of bias, imprecision and inconsistency. Economic evaluations One study of cardiac rehabilitation was assessed as directly applicable with minor limitations. The rest of the evidence was assessed as partially applicable (because of the setting and/or the measure of health outcome) with potentially serious limitations.
Other considerations	As with all forms of rehabilitation, the ‘dose’ of the intervention may be relatively small in terms of the amount of time the practitioner can devote to each patient. The committee noted that rehabilitation would often need to be delivered or reinforced by different disciplines, requiring coordination between those disciplines and the various community and social care agencies to ensure that care was focused on the goals for each patient, involved (and, where necessary, educated) the patient and family or carers, and was integrated between sectors, particularly community nursing. Further discussion on integrated care can be found in Chapter 38. The majority of the evidence was in the stroke population and there was insufficient evidence on other clinical conditions making generalisations more difficult. However, a sub-group analysis by population did not explain heterogeneity within the outcomes. In some specific conditions, such as stroke, the evidence is stronger on outcomes relating to independence (not evaluated specifically in trials on other clinical conditions). The committee agreed that community rehabilitation should be focused on maximising and maintaining independence and thereby reduce the overall burden on the healthcare system.

Table 9Review protocol: community rehabilitation

Review question: Does the provision of community-based rehabilitation services following acute medical illness improve patient outcomes?
Objective	To determine if wider provision of community-based rehabilitation prevents people staying in hospitals longer than necessary while not impacting on patient and carer outcomes.
Rationale	Community-based healthcare services are vital to prevent unnecessary hospital admission and to facilitate early hospital discharge. It is also likely that these resources are less costly than hospital care.
Population	Adults and young people (16 years and over) with a suspected or confirmed AME presenting to an acute medical unit.
Intervention	Community-based rehabilitation services.
Comparison	Hospital-based rehabilitation services.
Outcomes	Mortality during study period (Dichotomous) CRITICAL Avoidable adverse events during study period (Dichotomous) CRITICAL Quality of life during study period (Continuous) CRITICAL Patient and/or carer satisfaction during study period (Dichotomous) CRITICAL Length of stay during study period (Continuous) IMPORTANT Number of presentations to ED during study period (Dichotomous) IMPORTANT Number of admissions to hospital after 28 days of first admission (Dichotomous) CRITICAL Number of GP presentations during study period (Dichotomous) IMPORTANT Readmission up to 30 days (Dichotomous) IMPORTANT
Search criteria	The databases to be searched are: Medline, Embase, the Cochrane Library Date limits for search: None Language: English only
The review strategy	Systematic reviews (SRs) of RCTs, RCTs, observational studies only to be included if no relevant SRs or RCTs are identified.
Analysis	Data synthesis of RCT data. Meta-analysis where appropriate will be conducted. Studies in the following subgroup populations will be included: Frail elderly People with serious mental illness In addition, if studies have pre-specified in their protocols that results for any of these subgroup populations will be analysed separately, then they will be included. The methodological quality of each study will be assessed using the Evibase checklist and GRADE.

Figure 1Flow chart of clinical article selection for the review of Community rehabilitation

Figure 2Mortality

Figure 3Length of treatment

Figure 4Quality of life –SF 36- Physical component summary

Figure 5Quality of life –SF 36- Mental component summary

Figure 6Mortality

Figure 7Adverse events

Figure 8Quality of life (SF-36)

Table 10Quality of life (St. George’s Respiratory Questionnaire)

Table 11Quality of life (Life Satisfaction)

Figure 9Quality of life (SF-12)- PCS

Figure 10Quality of life (SF-12)- MCS

Figure 11Patient satisfaction

Figure 12Patient Satisfaction

Table 12Carer Satisfaction

Figure 13Carer Satisfaction

Figure 14Carer Satisfaction (Caregiver Strain Index)

Figure 15Length of stay (in-hospital)

Figure 16Length of stay in hospital and programme

Figure 17Admissions

Figure 18GP presentations

Figure 19Quality of life (MacNew-Global)

Table 13Clinical evidence profile: Community versus hospital for after acute medical emergencies (admission avoidance)

Quality assessment							No of patients		Effect		Quality	Importance
No of studies	Design	Risk of bias	Inconsistency	Indirectness	Imprecision	Other considerations	Community (admission avoidance) versus hospital	Control	Relative (95% CI)	Absolute	Quality	Importance
Mortality 6-12 months
2	randomised trials	serious¹	no serious inconsistency	no serious indirectness	serious²	none	42/204 (20.6%)	31.4%	RR 0.74 (0.52 to 1.04)	82 fewer per 1000 (from 151 fewer to 13 more)	⨁⨁◯◯ LOW	CRITICAL
Length of treatment (Better indicated by lower values)
1	randomised trials	serious¹	no serious inconsistency	no serious indirectness	serious²	none	60	60	-	MD 15.9 higher (8.1 to 23.7 higher)	⨁⨁◯◯ LOW	CRITICAL
Quality of life-SF 36 physical component summary (follow-up 8 weeks; Better indicated by higher values)
1	randomised trials	no serious risk of bias	no serious inconsistency	no serious indirectness	very serious²	None	20	20	-	MD 0.18 higher (6.35 lower to 6.71 higher)	⨁⨁◯◯ LOW	CRITICAL
Quality of life-SF 36 mental component summary (follow-up 8 weeks; Better indicated by higher values)
1	randomised trials	no serious risk of bias	no serious inconsistency	no serious indirectness	serious²	None	20	20	-	MD 3.81 lower (11.08 lower to 3.46 higher)	⨁⨁⨁◯ MODERATE	CRITICAL

1: Downgraded by 1 increment if the majority of the evidence was at high risk of bias, and downgraded by 2 increments if the majority of the evidence was at very high risk of bias

2: Downgraded by 1 increment if the confidence interval crossed 1 MID or by 2 increments if the confidence interval crossed both MIDs.

Table 14Clinical evidence profile: Early Supported Discharge for after acute medical emergencies versus continued hospital treatment

Quality assessment							No of patients		Effect		Quality	Importance
No of studies	Design	Risk of bias	Inconsistency	Indirectness	Imprecision	Other considerations	Community Rehabilitation	Hospital Rehabilitation	Relative (95% CI)	Absolute	Quality	Importance
Mortality (follow-up 3 months - 6 years)
20	randomised trials	serious¹	no serious inconsistency	no serious indirectness	no serious imprecision	None	229/1768 (13%)	9.1%	RR 1.013 (0.84 to 1.25)	1 more per 1000 (from 15 fewer to 23 more)	⨁⨁⨁◯ MODERATE	CRITICAL
Mortality (follow-up median 6 months)
8	randomised trials	serious¹	serious²	no serious indirectness	very serious³	None	64/628 (10.2%)	9.1%	RR 1.26 (0.79 to 2.03)	24 more per 1000 (from 19 fewer to 94 more)	⨁◯◯◯ VERY LOW	CRITICAL
Mortality (follow-up 1 years)
6	randomised trials	serious¹	serious²	no serious indirectness	serious³	None	61/518 (11.8%)	16.3%	RR 0.86 (0.63 to 1.18)	23 fewer per 1000 (from 60 fewer to 29 more)	⨁◯◯◯ VERY LOW	CRITICAL
Mortality (follow-up 2-6 years)
6	randomised trials	serious¹	no serious inconsistency	no serious indirectness	no serious imprecision	None	104/622 (16.7%)	1.61%	RR 0.97 (0.78 to 1.20)	3 fewer per 1000 (from 26 fewer to 23 more)	⨁⨁⨁◯ MODERATE	CRITICAL
Adverse events (follow-up 9 weeks - 6 years)
5	randomised trials	serious¹	serious²	no serious indirectness	serious³	None	100/258 (38.8%)	32.5%	RR 1.20 (0.85 to 1.68)	73 more per 1000 (from 55 fewer to 250 more)	⨁◯◯◯ VERY LOW	CRITICAL
Quality of life (follow-up median 7 months; measured with: SF-36 Physical component summary score; Better indicated by lower values)
5	randomised trials	serious¹	no serious inconsistency	no serious indirectness	no serious imprecision	None	311	312	-	MD 1.04 higher (0.99 lower to 3.07 higher)	⨁⨁⨁◯ MODERATE	CRITICAL
Quality of life (follow-up median 7 months; measured with: SF-36 Mental component summary scores; Better indicated by lower values)
5	randomised trials	serious¹	no serious inconsistency	no serious indirectness	no serious imprecision	None	311	312	-	MD 0.86 higher (1.04 lower to 2.77 higher)	⨁⨁⨁◯ MODERATE	CRITICAL
Quality of life (follow-up 12 months; measured with: St. George’s Respiratory Questionnaire; Better indicated by higher values)
1	randomised trials	serious¹	no serious inconsistency	no serious indirectness	no serious imprecision	None	89	95	-	MD 1 lower (4.14 lower to 2.14 higher)	⨁⨁⨁◯ MODERATE	CRITICAL
Quality of life (follow-up 12 months; measured with: Life Satisfaction; Better indicated by higher values)
1	randomised trials	serious¹	no serious inconsistency	no serious indirectness	no serious imprecision	None	42	43	-	MD 0.3 higher (4.06 lower to 4.66 higher)	⨁⨁⨁◯ MODERATE	CRITICAL
Quality of life (follow-up 8 weeks; measured with MacNew-Global; Better indicated by higher values))
1	randomised trials	serious¹	no serious inconsistency	no serious indirectness	no serious imprecision	None	60	44	-	MD 0.07 lower (0.51 lower to 0.37 higher)	⨁⨁⨁◯ MODERATE	CRITICAL
Patient satisfaction (follow-up median 6 months; Better indicated by higher values)
4	randomised trials	very serious¹	serious²	no serious indirectness	serious³	None	268	146	-	MD 0.32 higher (0.18 lower to 0.82 higher)	⨁◯◯◯ VERY LOW	IMPORTANT
Patient satisfaction (follow-up 6-12 months)
2	randomised trials	serious¹	no serious inconsistency	no serious indirectness	serious³	None	89/178 (50%)	51.2%	RR 1.15 (0.93 to 1.43)	77 more per 1000 (from 36 fewer to 220 more)	⨁⨁◯◯ LOW	IMPORTANT
Carer satisfaction (follow-up 6 months; Better indicated by higher values)
1	randomised trials	serious¹	no serious inconsistency	no serious indirectness	serious³	None	70	34	-	MD 0.39 higher (0.01 lower to 0.79 higher)	⨁⨁◯◯ LOW	IMPORTANT
Carer satisfaction (follow-up 12 months)
1	randomised trials	serious¹	no serious inconsistency	no serious indirectness	no serious imprecision	None	68/82 (82.9%)	82.5%	RR 1 (0.86 to 1.17)	0 fewer per 1000 (from 115 fewer to 140 more)	⨁⨁⨁◯ MODERATE	CRITICAL
Carer satisfaction (follow-up median 12 months; measured with: Caregiver Strain Index; Better indicated by lower values)
5	randomised trials	serious¹	no serious inconsistency	no serious indirectness	no serious imprecision	None	282	250	-	SMD 0.16 higher (0.01 lower to 0.34 higher)	⨁⨁⨁◯ MODERATE	IMPORTANT
Length of stay in hospital (follow-up in-hospital; Better indicated by lower values)
8	randomised trials	serious¹	no serious inconsistency	no serious indirectness	no serious imprecision	None	745	644	-	MD 1.38 lower (2.47 to 0.3 lower)	⨁⨁⨁◯ MODERATE	CRITICAL
Length of stay in hospital and programme (follow-up 6 months - 3 years; Better indicated by lower values)
3	randomised trials	serious¹	no serious inconsistency	no serious indirectness	no serious imprecision	None	261	225	-	MD 7.74 lower (14.2 to 1.28 lower)	⨁⨁⨁◯ MODERATE	CRITICAL
Admissions to hospital (follow-up 3 months - 6 years)
13	randomised trials	serious¹	no serious inconsistency	no serious indirectness	no serious imprecision	None	246/890 (27.6%)	24.3%	RR 0.98 (0.86 to 1.11)	5 fewer per 1000 (from 34 fewer to 27 more)	⨁⨁⨁◯ MODERATE	CRITICAL
Admissions to hospital (follow-up 6 months)
5	randomised trials	serious¹	no serious inconsistency	no serious indirectness	very serious³	None	43/244 (17.6%)	22.4%	RR 0.9 (0.61 to 1.33)	22 fewer per 1000 (from 87 fewer to 74 more)	⨁◯◯◯ VERY LOW	CRITICAL
Admissions to hospital (follow-up 12 months)
7	randomised trials	serious¹	no serious inconsistency	no serious indirectness	no serious imprecision	None	168/576 (29.2%)	25.3%	RR 1.03 (0.88 to 1.20)	8 more per 1000 (from 30 fewer to 51 more)	⨁⨁⨁◯ MODERATE	CRITICAL
Admissions to hospital (follow-up 6 years)
1	randomised trials	very serious¹	no serious inconsistency	no serious indirectness	serious³	None	35/70 (50%)	62.2%	RR 0.8 (0.6 to 1.08)	124 fewer per 1000 (from 249 fewer to 50 more)	⨁◯◯◯ VERY LOW	CRITICAL
GP presentations (follow-up 6 months - 5 years)
2	randomised trials	serious¹	no serious inconsistency	no serious indirectness	no serious imprecision	None	74/84 (88.1%)	93.3%	RR 0.94 (0.86 to 1.04)	56 fewer per 1000 (from 131 fewer to 37 more)	⨁⨁⨁◯ MODERATE	IMPORTANT
Quality of life (follow-up 6 months; measured withSF12 - PCS; Better indicated by higher values)
1	randomised trials	serious¹	no serious inconsistency	no serious indirectness	no serious imprecision	None	263	262	-	MD 0.28 lower (2.14 lower to 1.58 higher)	⨁⨁⨁◯ MODERATE	CRITICAL
Quality of life (follow-up 6 months; measured withSF12 - MCS; Better indicated by higher values)
1	randomised trials	serious¹	no serious inconsistency	no serious indirectness	no serious imprecision	None	263	262	-	MD 1.14 lower (2.83 lower to 0.55 higher)	⨁⨁⨁◯ MODERATE	CRITICAL

1: Downgraded by 1 increment if the majority of the evidence was at high risk of bias, and downgraded by 2 increments if the majority of the evidence was at very high risk of bias.

2: The point estimate varies widely across studies, unexplained by subgroup analysis.

3: Downgraded by 1 increment if the confidence interval crossed 1 MID or by 2 increments if the confidence interval crossed both MIDs.

Table 15Studies excluded from the clinical review

Reference	Reason for exclusion
Adler 1978²	Not relevant: patients following elective surgery
Aimonino 2001³	Patients not treated for acute medical emergency (advanced dementia patients) - please note not linked to Tibaldi 2004²⁴⁵
Aimonino 2000⁴	Conference abstract; later published as Ricauda 2004¹⁹²
Allen 1999⁵	Not RCT; description of a website
Anderson 2016¹⁰	Systematic review is not relevant to review question or unclear PICO. Exercise training versus usual care
Anderson 2000A⁶	Conference abstract of protocol only
Anderson 2002A⁹	No clinical outcomes; Costs only
Anderson 2002B⁸	Not RCT; Systematic review
Anonymous 1982B¹	Not relevant comparison
Anon 2000⁸¹	Systematic review: eligible papers ordered
Armstrong 2008B¹¹	Not RCT; Retrospective single arm study
Arrigo 2008¹²	No hospital-based comparison
Askim 2010¹⁴	Incorrect interventions. Hospital and community components
Aujesky 2011¹⁶	RCT but no community care (self- administered injections)
Bakken 2012¹⁷	Not RCT; not relevant
Barnes 2003¹⁸	Not RCT; review
Beech 2004²⁰	Not RCT; service evaluation
Bernhaut 2002²¹	Not RCT, service evaluation
Bethell 1990²²	Not substitute for usual care; control group received no intervention, only advice what exercises they could do by themselves
Beynon 2009²³	Not RCT; literature review
Blackburn 2000²⁴	Not RCT; not relevant; costs only
Blair 2011²⁵	Not RCT; systematic review
Board 2000²⁶	Not relevant; costs only
Booth 2004²⁷	Not relevant; patients following bypass surgery
Boston 2001²⁸	Not RCT; prospective non-randomised comparative study
Bowman 1998²⁹	Not RCT; review
Boxall 2005³⁰	Inappropriate comparison. not hospital-based care
Brooks 2002³¹	Not RCT; retrospective case study
Brooks 2003³²	Not RCT; retrospective documentary analysis
Brunner 2008³³	Not RCT; other experimental design
Bryan 2010³⁴	Not RCT; literature review
Buckingham 2016³⁵	Cochrane review – relevant references ordered
Buus 2013³⁶	Protocol only; no study data
Campbell 2001³⁷	No clinical outcomes; costs only
Caplan 2004⁴¹	Comparison is not hospital-based care
Caplan 2006³⁹	Not RCT; service evaluation
Caplan 2012⁴⁰	Not RCT; systematic review- screened for relevant references
Carroll 2005⁴²	Not RCT; review
Chaiyawat 2010⁴³	Conference abstract
Chaiyawat 2010⁴⁴	Conference abstract
Chang 2015⁴⁵	No hospital-based comparison. Not review population. Psychiatric
Chappell 1993⁴⁶	Not relevant; retrospective cost analysis
Chard 2006⁴⁷	Not RCT; review
Chen 2012A⁴⁸	Not relevant; costs associated with acquired brain injury
Coast ⁴⁹	Not relevant; majority of patients with trauma and elective surgery
Cobelli 1996⁵⁰	Not RCT; review
Coburn 1989⁵¹	Not RCT; quasi-experimental; cost
Cohen 1994⁵²	Not RCT; review
Colprim 2012⁵⁴	Not RCT; quasi-experimental study
Colprim 2014⁵³	Not RCT; prospective cohort study
Cowie 2014⁵⁵	Not RCT; economic analysis
Craig 2014⁵⁷	Not RCT; review
Crawford-Faucher 2010⁵⁸	Not RCT; systematic review - screened for relevant references
Crotty 2000⁶⁰	Not RCT; audit of trauma patients
Crotty 2000A⁵⁹	RCT but not relevant as trauma patients only (hip fracture)
Crotty 2002⁶²	RCT but not relevant as trauma patients only (hip fracture)
Crotty 2003⁶¹	RCT but not relevant as trauma patients only
Cunliffe 2002⁶³	Not RCT; qualitative study; abstract only
Dalal 2003⁶⁶	Not RCT; non-randomised prospective study
Daskapan 2005⁶⁷	No extractable outcomes
Deutsch 2006⁶⁸	Not RCT; retrospective study
Dias 2013 ⁶⁹	RCT but not relevant (does not compare to inpatient rehabilitation)
Dolansky 2010⁷⁰	Not RCT
Dombi 2009⁷¹	Not RCT; commentary on costs
Donaldson 1982⁷²	Not RCT; retrospective study
Donath 2001⁷³	Not RCT; Commentary
Donlevy 1996A⁷⁴	Not relevant; article is on cross-training to provide care at home on discharge
Donnelly 2002⁷⁵	Not RCT; not relevant; questionnaire survey
Dorney-Smith 2011⁷⁷	Not RCT; case study of the cost of nurse-led hostels for the homeless
Dow 2004⁷⁸	Not RCT; case study
Dow 2007⁷⁹	Not RCT; qualitative study
Duffy 2010⁸⁰	RCT but wrong comparison (control group not in hospital)
Early supported discharge trialists 2005⁸²	Systematic review: all eligible papers ordered
Eldar 2000A⁸³	Not RCT; review
Elder 2001⁸⁴	Not RCT; literature review
Emme 2014⁸⁵	RCT; but no relevant outcomes
Emme 2014A⁸⁶	RCT; but no relevant outcomes
Eron 2004⁸⁷	Not RCT; no data
Feltner 2014⁸⁹	Not RCT; systematic review- screened for relevant references
Gaspoz 1994⁹⁴	Not RCT; prospective cohort study
Glasby 2008⁹⁷	Not RCT; qualitative study
Glick 1998⁹⁸	Not relevant – observing outcome of aneurysmal subarachnoid haemorrhage
Gobbi 2004⁹⁹	Not RCT; and not relevant
Gracey 1992¹⁰⁰	Not RCT; case studies
Graham 2013¹⁰¹	Not RCT; description of organisation of rehabilitation services
Grande 2004¹⁰²	RCT on bereavement. Not relevant.
Gregory 2009¹⁰⁴	Not RCT; retrospective study
Gregory 2010¹⁰³	Not RCT; Cross-sectional study
Griffiths 2000¹⁰⁷	Not RCT; exploratory analyses
Griffiths 2000A¹⁰⁸	RCT but not relevant comparison (in-patients only)
Griffiths 2001¹⁰⁶	RCT but not relevant comparison; both arms in-patient care (nurse led versus consultant managed)
Griffiths 2005¹¹¹	Not RCT; systematic review-screened for relevant references
Griffiths 2004¹⁰⁹	Systematic review is not relevant to review question or unclear PICO. hospital-based care
Griffiths 2006¹¹⁰	Not RCT; review
Griffiths 2006A¹⁰⁵	Not RCT; review
Gunnell 2000¹¹²	Not relevant; majority of patients with trauma and elective surgery
Hannan 2003¹¹⁴	Not RCT
Hansen 1992¹¹⁵	Cochrane excluded list: Hospital at home early discharge (study did not evaluate hospital at home, but a model for follow-up visits at home after discharge from hospital)
Hardy 2001¹¹⁶	Not RCT; description of a service; and mainly trauma patients
Hauser 1991¹¹⁷	Not RCT; retrospective study
Heseltine 2001¹¹⁸	Not RCT; review on cost
Higgins 2001¹¹⁹	Inappropriate comparison. No hospital-based comparison
Hill 1978¹²⁰	RCT but not relevant to today’s approach of managing MI as thrombolytic therapy made admission necessary (Cochrane)
Hoenig 2010¹²¹	Conference abstract
Hughes 1990¹²³	RCT but has wrong comparison (not in hospital)
Ince 2014¹²⁴	Incorrect interventions. Hospital at home
Indredavik 1999¹²⁵	Not RCT and compares stroke unit rehabilitation with general medical ward treatment
Indredavik 2008¹²⁷	RCT but no relevant outcomes
Jakobsen 2013¹²⁸	Methodology of RCT only
Jolly 2005¹²⁹	RCT but study aborted prematurely due to language barriers with participants. No data
Jones 1999¹³²	Costs only
Jones 2014¹³³	Not RCT; case study with little data
Karapolat 2008¹³⁵	No outcomes of interest
Kehusmaa 2010¹³⁶	The outpatient group did not include community rehabilitation.
Kenny 2002¹³⁷	Not RCT and not relevant
Knapp 1994¹³⁸	Not review population. psychiatric. comparison to a psychiatric hospital-based care
Konrad 2012¹³⁹	Not RCT; retrospective study
Koopman 1996¹⁴⁰	RCT but excluded as home care was self-administered
Kornowski 1995¹⁴¹	Not RCT; observational study
Kortke 2006¹⁴²	Not RCT; open clinical study (non-randomised)
Korzeniowska-Kubacka 2014¹⁴³	Not RCT; prospective observational study
Langhorne 2000¹⁴⁴	Cochrane systematic review withdrawn from publication and superseded by Shepperd 2008²²³
Langhorne 2005¹⁴⁵	Not RCT; review
Lappegard 2012¹⁴⁶	Not RCT; retrospective study
Last 2000¹⁴⁸	Not RCT, service description
Lewis 2007¹⁴⁹	Not RCT; commentary
Lewis 2011¹⁵⁰	Not RCT; research protocol only
Lewis 2012¹⁵²	Not RCT; commentary/conceptual paper
Lewis 2013¹⁵¹	Not RCT; case studies without data
Lim 2003¹⁵³	RCT but not relevant comparison
Linertova 2011¹⁵⁴	Not RCT; Systematic review
Marks 1994¹⁵⁷	Not review population. admission for serious mental illness
Marchionni 2003¹⁵⁶	No extractable outcomes
Martin 1994¹⁵⁸	RCT but wrong comparison (control group not in hospital)
Mason 2003¹⁵⁹	Not RCT; description of a service
Mather 1976¹⁶⁰	No description of the type of service patients at home received (excluded by Cochrane too)
Matukaitis 2005¹⁶¹	Not RCT. Pilot study and no comparison study
Mayhew 2006¹⁶²	Not RCT; health economics only
Mayo 1998¹⁶³	Conference abstract of study protocol only; duplicate of full paper Mayo 2000¹⁶⁴
McNamee 1998¹⁶⁵	Health economic evaluation
Melin 1992¹⁶⁶	Not relevant: patients with long-term care needs were recruited. Hospital at Home was substitute for long-term care and not necessarily in-hospital
Meyer 2009¹⁶⁷	Not RCT; case studies
Muijen 1992¹⁶⁹	RCT but patients treated for acute, severe mental illness (psychiatric ward versus home); not relevant to AME guideline
Nicholson 2001¹⁷²	Health economics only
Nissen 2007¹⁷³	Not in English (Danish)
Nordly 2014¹⁷⁴	Protocol only; no study data
Nyatanga 2014¹⁷⁵	Not RCT; commentary/conceptual paper
Pace 2014¹⁷⁸	No comparator
Palmer Hill 2000¹⁷⁹	Not relevant: patients recovering from knee replacement
Pandian 2013¹⁸⁰	Trial register only; no data
Pandian 2015¹⁸¹	No extractable outcomes
Patel 2004¹⁸²	Health economic evaluation
Penque 1999¹⁸³	Not RCT; retrospective study
Pittiglio 2011¹⁸⁵	Not RCT; not relevant
Piotrowicz 2010¹⁸⁴	Incorrect comparison- home based- telemonitored cardiac rehab versus home based standard cardiac rehab
Plochg 2005¹⁸⁶	Not RCT; process evaluation
Pozzilli 2002¹⁸⁷	RCT BUT not relevant (Multiple Sclerosis patients)
Pradella 2015¹⁸⁸	No hospital-based comparison
Prior 2012 ¹⁸⁹	Not RCT
Puig-Junoy 2007¹⁹⁰	Health economic evaluation
Richards 1998 ¹⁹⁵	Not relevant; majority of patients with trauma and elective surgery
Richards 1998A¹⁹⁴	Not relevant; correction to excluded trial with majority of patients with trauma and elective surgery
Richardson ¹⁹⁶	Health economic evaluation
Robinson 2009¹⁹⁷	Not RCT; description of new model of acute care
Rodriguez-Cerrillo 2010²⁰¹	Not RCT; Non-randomised prospective study
Rodriguez-Cerrillo 2012A²⁰⁰	Not RCT; no comparison group to home treatment
Rosbotham-Williams 2002²⁰³	Not RCT; review
Round 2004²⁰⁴	Not RCT; prospective cohort study
Rout 2011²⁰⁵	Not RCT; review
Rowley 1984²⁰⁶	Not RCT. No comparison group
Ruckley 1978²⁰⁷	Not relevant: patients following elective surgery
Rudkin 1997²⁰⁹	No service provided in community
Sartain 2002²¹²	Paediatric patient population
Saysell 2004²¹³	Not RCT; pilot study of intermediate palliative care in care home
Schachter 2014²¹⁴	Not RCT; study protocol only
Scheinberg 1986²¹⁵	RCT but does not state what the control group intervention is
Schneller 2012²¹⁶	Not RCT; case study
Schou 2014²¹⁷	RCT; but no relevant outcomes
Scott 2010²¹⁸	Not RCT; literature review
Senaratne 1999²¹⁹	Cost evaluation
Shepperd 2016²²⁶	Cochrane review- already included in the hospital at home evidence review
Shepperd 1998²²²	Not RCT; systematic review
Shepperd 1998A²²¹	Costs only; no clinical outcomes
Shepperd 2005A²²⁰	Not RCT; editorial
Shepperd 2009A²²⁴	Not RCT; systematic review
Sindhwani 2011²²⁷	Incorrect study design. cohort study
Standen 2016²³⁰	Inappropriate intervention –virtual reality system for home based rehabilitation of the arm following stroke
Stephenson 1984²³¹	Not RCT; conceptual paper
Steventon 2012²³²	Not RCT; retrospective analysis
Stewart 1999²³³	RCT but control group not in hospital.
Stromberg 2003²³⁴	RCT but only nurse-led follow up appointments in hospital. No actual community care given
Subirana Serrate 2001²³⁵	Not RCT; health economics evaluation
SUIJKER 2016²³⁶	Study to be considered for inclusion in the community nurse review
Suwanwela 2002²³⁷	RCT but excluded because intervention was managed by Red Cross volunteers and family members.
Taylor 2015²³⁹	Systematic review: all eligible papers ordered
Teasell 2003²⁴⁰	Systematic review: all eligible papers ordered
Teng 2003²⁴¹	Health economic evaluation
Thorne 2001²⁴²	Not RCT; service description
Tibaldi 2004²⁴⁵	RCT but no relevant outcomes (carer stress data incomplete)
Trappes-Lomax 2006²⁴⁶	RCT but comparison group not appropriate; did not receive ‘usual’ hospital care.
Tuntland 2015²⁴⁷	No hospital-based comparison
Upton 2014²⁴⁸	Not RCT; not relevant
Utens 2010²⁴⁹	Study protocol of RCT only
Wakefield 2008²⁵³	RCT but all self-care; wrong comparison
Widen Holmqvist 1995²⁵⁴	Not RCT; observational study
Widen Holmqvist 1996²⁵⁵	Health economic evaluation
Winkel 2008²⁵⁶	Not RCT; systematic review
Wolfe 2000²⁵⁷	RCT but excluded from Cochrane because intervention does not substitute for inpatient care; not valid comparison
Woodend 2008²⁵⁸	RCT but wrong control group; both at home with no actual care provided.
Woodhams 2012²⁵⁹	Not RCT; literature review
Young 2003B²⁶²	Not RCT; audit
Young 2005B²⁶³	Not RCT; quasi-experimental study
Young 2010B²⁶¹	RCT but not relevant outcomes
Ytterberg 2010²⁶⁴	No outcomes of interest
Vester-andersen 2015²⁵⁰	All components were hospital-based
Wu 2008²⁶⁰	No hospital-based comparison
Zhong 2015²⁶⁵	Incorrect study design. retrospective cohort
Zwisler 2016²⁶⁶	Systematic review- checked and ordered relevant references.

Table 16Studies excluded from the economic review

Reference	Reason for exclusion
Larsen 2006¹⁴⁷	This study was assessed as not applicable because the resource use was from non-UK studies pre 2005. The study is primarily a cost minimisation analysis under the assumption that the intervention is more effective. However, the only clinical outcome that is assessed is ‘poor outcomes’. This clinical outcome is not all encompassing and therefore cannot definitively conclude whether total health outcomes are better for the intervention. Likewise the cost analysis only looks at intervention cost, bed day costs and nursing home costs. This doesn’t fully capture total costs and likewise costing nursing home costs can be difficult as not all nursing home costs fall on the NHS. For these reasons the study was selectively excluded.
Saka 2009²¹⁰	This study was assessed as partially applicable with very serious limitations. The reporting in the study is quite unclear and it is not clear how early supported discharge (ESD) is costed and what drives the increased costs with ESD.
Miller 2005¹⁶⁸	This study was assessed as partially applicable with very serious limitations. The study is described as a cost-utility analysis but no QALY data reported.
Aimonino Ricauda 2005¹⁹³	This study was assessed as not applicable as it relies on unit costs from 1995.

Chapter 13Community rehabilitation

13. Community rehabilitation

13.1. Introduction

13.2. Review question: Does the provision of community-based rehabilitation services following acute medical illness improve patient outcomes?

13.3. Clinical evidence

13.3.1. Admissions avoidance

13.3.2. Early discharge

13.4. Economic evidence

Published literature

13.5. Evidence statements

Clinical

Admission avoidance

Early discharge

Economic

13.6. Recommendations and link to evidence

References

Appendices

Appendix A. Review protocol

Appendix B. Clinical article selection

Figure 1Flow chart of clinical article selection for the review of Community rehabilitation

Appendix C. Forest plots

C.1. Community versus hospital rehabilitation – Admission avoidance

Figure 2Mortality

Figure 3Length of treatment

Figure 4Quality of life –SF 36- Physical component summary

Figure 5Quality of life –SF 36- Mental component summary

C.2. Community versus hospital rehabilitation - Early discharge

Figure 6Mortality

Figure 7Adverse events

Figure 8Quality of life (SF-36)

Table 10Quality of life (St. George’s Respiratory Questionnaire)

Table 11Quality of life (Life Satisfaction)

Figure 9Quality of life (SF-12)- PCS

Figure 10Quality of life (SF-12)- MCS

Figure 11Patient satisfaction

Figure 12Patient Satisfaction

Table 12Carer Satisfaction

Figure 13Carer Satisfaction

Figure 14Carer Satisfaction (Caregiver Strain Index)

Figure 15Length of stay (in-hospital)

Figure 16Length of stay in hospital and programme

Figure 17Admissions

Figure 18GP presentations

Figure 19Quality of life (MacNew-Global)

Appendix D. Clinical evidence tables

Cochrane reviews

Randomised controlled trials

Appendix E. Economic evidence tables

A. Stroke rehabilitation

B. Geriatric rehabilitation

c. Cardiac rehabilitation

Appendix F. GRADE tables

Appendix G. Excluded clinical studies

Appendix H. Excluded economic studies

Publication Details

Copyright

Publisher

NLM Citation

Table 1PICO characteristics of review question

Table 2Summary of studies included in the review: Admission avoidance

Table 3Summary of studies included in the review: Early discharge

Table 4Clinical evidence summary: Community rehabilitation versus hospital rehabilitation after acute medical emergencies

Table 5Clinical evidence summary: Community rehabilitation versus hospital rehabilitation after acute medical emergencies

Table 6Economic evidence profile: Community based stroke rehabilitation versus inpatient rehabilitation

Table 7Economic evidence profile: Community based geriatric rehabilitation versus inpatient rehabilitation

Table 8Economic evidence profile: Community based cardiac rehabilitation versus outpatient rehabilitation

Table 9Review protocol: community rehabilitation

Figure 1Flow chart of clinical article selection for the review of Community rehabilitation

Figure 2Mortality

Figure 3Length of treatment

Figure 4Quality of life –SF 36- Physical component summary

Figure 5Quality of life –SF 36- Mental component summary

Figure 6Mortality

Figure 7Adverse events

Figure 8Quality of life (SF-36)

Table 10Quality of life (St. George’s Respiratory Questionnaire)

Table 11Quality of life (Life Satisfaction)

Figure 9Quality of life (SF-12)- PCS

Figure 10Quality of life (SF-12)- MCS

Figure 11Patient satisfaction