Title: What is the impact of large scale implementation of stroke Early Supported Discharge?
Funder: Department of Health and Social Care

Abstract: Stroke Early Supported Discharge (ESD) is a multidisciplinary team intervention that clinical trials have shown reduces length of hospital stay and reduces risk of dependency. The ESD intervention comprised facilitated discharge from hospital and delivery of stroke specialist rehabilitation in patients’ homes. There has been widespread implementation of ESD across England, following recommendations in UK national policy documents and clinical guidelines. However, the type of ESD service patients receive on the ground is variable and in some regions ESD is still not offered at all. This research study will investigate the impact of implementing ESD at scale in real world conditions. Are the benefits suggested by randomised controlled trials, still realised in practice? A realist evaluation approach will be adopted to investigate the influence of contextual factors on the relationship between core evidence based components of ESD and what outcomes are achieved. Work package 1 will involve analysis of historical prospective national stroke audit data from hospital and community providers across the East Midlands, West Midlands, East of England and Northern England. Effectiveness of ESD will be measured with national evidence based metrics as defined by the national stroke audit, and that reflect outcome measures used in the original ESD trials. Quasi-experimental cross-sectional and before-and-after designs with regression analysis and multi-level modelling will be used. Data analysis will investigate whether the degree to which an ESD service has adopted an evidence based model is related to better patient care (measured by ESD responsiveness and rehabilitation delivered), patient dependency (Modified Rankin scale) and reduction in length of hospital stay. Contextual factors at site, team and patient level will feature as variables in the analysis to investigate whether urban and rural sites differ and to account for potential confounding variables. Cost implications of ESD models will be investigated using a cost-consequence analysis. Work package 2 will use qualitative methods to further examine how contextual factors influence the implementation and effectiveness of ESD in practice. Case study sites offering contrasting results for anticipated reasons will be included. Six sites featured in work package 1 will be selected based on the level to which evidence based ESD has been implemented and the influence of rurality on ESD effectiveness. Semi-structured one-to one interviews with NHS commissioning and senior provider staff, group ESD team interviews and documentary analysis will be conducted. Interviews with stroke patients will also be conducted in two sites to investigate what matters most to them. Stakeholder perspectives on reasons for ESD implementation and model selection, what makes an ESD service effective and cost implications of ESD models will be explored using framework analysis. This research investigates whether current large scale implementation of ESD is achieving the outcomes clinical trial evidence suggested it would; if this is the case, findings will help facilitate further implementation of ESD nationally and internationally. This study adopts a mixed-methods approach to contribute to current theoretical understanding of the implementation of complex interventions. Findings will inform debate about optimal methodological approaches to evaluation of healthcare delivery.

Lay abstract: Early Supported Discharge (ESD) is the discharge of a stroke patient from hospital to their own home, co-ordinated by a team of therapists, nurses and a doctor. Specialist stroke rehabilitation is then provided in the patient’s own home. Clinical trials have shown that patients who received ESD spent less time in hospital and recovered better, than patients who did not. A variety of ESD services have now been set up across England. This research study will investigate whether these services offer the same benefits to patients as those identified in clinical trials. The aim is to compare different types of ESD service across the East Midlands, West Midlands, East of England and Northern England to try and understand if some are better than others. Work package 1 will use national stroke audit data that has been routinely collected by hospital and community services across the East Midlands, West Midlands, East of England and Northern England regions. It will look at how much rehabilitation is provided by ESD teams at each site and how soon after leaving hospital this occurs, and also whether experiencing ESD affects how patients recover. It will also compare the length of hospital stay before and after the introduction of the ESD service in each region, and in areas without ESD, to see if there are any differences. Data analysis will take into account how closely ESD services relate to the types of teams clinical trial evidence said would be effective and how much ESD teams are likely to cost. It will also make sure that differences in the type of stroke patients accessing ESD services and also differences in the geographical area teams are operating in, are accounted for. Work package 2 will involve interviewing NHS staff to gain a deeper understanding of how ESD services are operating in practice and what they believe influences the effectiveness of the service. Stroke survivors will also be asked about the ESD service they used, what they hoped to gain from experiencing this type of service and what matters to them most. This will permit wider investigation of which types of ESD work well, and what factors contribute to both the setting up, and the sustainability, of an effective service. Research findings will drive improvements in stroke services across England and internationally, leading to provision of more efficient, evidence based care and better patient recovery. This research proposal has been discussed with the Nottingham Stroke Research Partnership group, a stroke survivor group who provide guidance on research studies in Nottingham. The group were supportive of the research proposal and a member of the group will sit on the study steering committee. Stroke survivors from this group and across the regions in which the research will be conducted, will be consulted as the study progresses, to discuss study materials and interpretation of study findings. This programme of research will generate a number of academic publications in journals such as Stroke, Clinical Rehabilitation and Implementation Science. Research findings will be presented at the UK Stroke Forum, Health Services Research Network Conference, European Stroke Conferences and World NeuroRehabilitation Congress. Findings will also be presented at the biannual Nottingham Stroke Lay conference, the Stroke Association Assembly and at national NHS events, through collaboration with the Academic Health Science Networks and Strategic Clinical Networks.

Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: STROKE