"Home or Hospital for Stroke Rehabilitation? Results of a Randomized Controlled Trial: 
Cost Minimization Analysis at Six Months"

Craig Anderson, Ph.D., Sally Rubenach, MSocSc., Cliona Ni Mhurchu, Ph.D., Michael Clark, Ph.D., Carol Spencer, BAppSc (OT), & Adrian Winsor, FAFRM

Traditionally, acute hospital care and rehabilitation has been the treatment of choice for patients recovering from strokes. Advocates of home-based stroke rehabilitation, however, which strives to minimize time spent in a hospital facility, suggest that this approach is preferable because it focuses more on long-term outcomes, reduces the risks associated with inpatient care and saves in direct costs. Research has demonstrated that a home-based program of rehabilitation for stroke patients can significantly shorten length of stay in a hospital facility without compromising patient safety or functional outcomes. The present research sought to examine the cost-effectiveness of one such program, comparing it to the cost-effectiveness of traditional acute care in a hospital facility.

Subjects were 86 patients (mean age=75 years) who presented with strokes at either of two teaching hospitals in suburban Australia. These subjects were randomly assigned to one of two groups and were matched in terms of variables such as age and general physical health. Forty-two of these patients received early hospital discharge and home-based rehabilitation, while 44 patients were treated with conventional, acute-care rehabilitation in a hospital setting. Subjects in the home-based rehabilitation group spent an average of 15 days in the hospital; subjects receiving traditional acute care remained hospitalized for an average of 30 days.

Home-based rehabilitation was conducted by specialists in various disciplines (e.g. physical therapists, occupational therapists, speech therapists, social workers, etc.) and unique treatment programs were designed for each subject. Treatment sessions occurred in the subjects' homes and emphasis was placed on self-learning and adjustment to disability. Those subjects receiving traditional hospital-based acute care were treated by a similar team of practitioners while discharge-planning and follow-up care were conducted according to usual policies.

Cost-effectiveness was evaluated from the perspectives of both the health care system and the patients and their families. Six months later, no significant differences were found between subjects in the two groups in their use of community services or other health care resources. Although the cost of hospital care among subjects in the home-based rehabilitation group was greatly reduced, this savings was counterbalanced by the additional direct and indirect costs associated with home-based rehabilitation. The mean overall cost difference between the two intervention groups was not statistically significant. Among subjects in the home-based program, however, those with milder symptoms reported significantly lower costs than did home-based subjects whose symptoms were more severe.

In sum, the authors report that the cost of home-based rehabilitation was less than the cost of conventional hospital-based rehabilitation, principally because of the significant reduction in the initial length of stay in the hospital for subjects in the former group. They propose that such a treatment approach may emerge as a viable, less costly alternative to traditional hospital-based rehabilitation for patients recovering from strokes This finding was notably robust for subjects whose residual impairments were mild, suggesting that such home based rehabilitation may be particularly cost-effective for individuals whose symptoms fall into this category.

Article abstracted by Glen E. Heiss, Ph.D., Staff Psychologist at Jamaica Hospital Medical Center Department of Physical Medicine and Rehabilitation