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  • Organization of physical medicine and rehabilitation in hospitals

Systematic review

Organization of physical medicine and rehabilitation in hospitals

Published Updated


About this publication

  • Year: 2008
  • By: The Knowledge Centre for the Health Services
  • ISSN (digital): 1890-1298
  • ISBN (digital): 978-82-8121-216-9

Key message

Objectives
Helse Nord asked the Norwegian Knowledge Centre for the Health Services to summarize the evidence on the most effective organisation of physical medicine and rehabilitation in hospitals.    

Method
This report is an overview over reviews, i.e. we have searched for, critically appraised, and summarised research from existing systematic reviews on the effectiveness of organizing physical medicine and rehabilitation in hospitals.

Results
We included thirty nine systematic reviews reporting results for six different groups of inpatients. Fifteen of these reviews were on the organisation of treatment and rehabilitation of patients with stroke. There is strong evidence that stroke patients who receive organised inpatient care in a stroke unit are more likely to be alive, independent and living at home one year after the stroke compared with patients who get other kinds of treatment and rehabilitation.  For stroke patients in hospitals, “early supported discharge” (ESD) that provides early assessment in hospital, co-ordinated discharge arrangements and post discharge support can accelerate their discharge home, and increase their chance of being independent.
 
Evaluation and management in geriatric departments of elderly patients admitted to hospitals due to chronic or acute functional failure show a positive effect on survival and return to home compared to ordinary care; i.e. in a medical department.
 
The latest systematic review on elderly patients with hip fracture shows that patients who received multidisciplinary rehabilitation were at lower risk of dying or being admitted to a nursing home, compared to those who received usual orthopaedic care.

Rehabilitation program for patients with MS do not change the level of impairment, but can improve their experience of activity and participation in daily activities.
 
Functional gains are associated with increased intensity of the rehabilitation program for patients with acquired brain injury (ABI), especially to patients with moderate to severe ABI.
 
The only systematic review we found on the effectiveness on spinal injury units (SIU) concluded that patients undergoing immediate referral to SIU’s may experience better outcome that patients whose referral is delayed or who are treated elsewhere.

Conclusion
With the exception of studies on rehabilitation of stroke patients and elderly patients admitted to hospitals with chronic or acute illnesses, only limited evidence is found to support one way of organizing rehabilitation services in hospitals compared to others. Further research is needed.

Summary

Background
According to national and regional plans to strengthen the rehabilitation services, Helse Nord asked the Norwegian Knowledge Centre for the Health Services to summarize the evidence on the effectiveness of organisation of physical medicine and rehabilitation in somatic hospitals; are some ways of organizing the rehabilitation services better for the patients than others?

Method
This report is an overview over reviews, i.e. we have searched for, critically appraised, and summarised research from existing systematic reviews based on studies on the effectiveness of different ways of organizing physical medicine and rehabilitation in hospitals. To identify relevant literature we carried out a comprehensive literature search in Cochrane Database of Systematic Reviews (CDSR), Database of Abstracts of Reviews of Effects (Dare), the HTA database in CRD Databases, ISI Web of Science, Medline and Pubmed. The first search was carried out in December 2007, with a supplementary search in April 2008.

The inclusion criteria comprised all kinds of patients in hospitals; i.e., we did not search for specific categories of patients. Outcomes of special interests were: death, dependency, requirement for long term care, patient quality of life, duration of stay, both in hospital and long term care. Systematic reviews on rehabilitation outside hospitals were excluded, as well as studies focusing on the content of rehabilitation programs.

In describing the results, we have emphasised the last published systematic reviews of good quality, and made a qualitative synthesis of the main results.

Results
The literature search identified 1209 titles which were assessed by two reviewers according to the inclusion criteria. 39 systematic reviews were included, critically appraised for methodological quality. The reviews are published in the period from 1993 to 2007, comprise various groups of patients and are of varying quality. We found more systematic reviews on organisation of treatment and rehabilitation of patients with stroke compared to rehabilitation of other groups of patients in hospitals.

Rehabilitation in hospitals of patients with stroke
We have included sixteen systematic reviews, of which one is an overview over reviews. Most studies on rehabilitation of patients with stroke focus on the effectiveness of organised stroke unit care compared to alternative services, for example medical or neurological wards. Organised stroke unit care is provided by multidisciplinary teams that exclusively manage stroke patients in a dedicated ward, with a mobile stroke team or within a mixed rehabilitation ward. Research in recent years has also focused on different types of organised stroke units.
 
There is strong evidence to say that stroke patients who receive organised inpatient care in a stroke unit are more likely to survive their stroke, return home and be independent in looking after themselves, compared with those patients who get other kinds of treatment and rehabilitation. A variety of different stroke units have been developed. The best results appear to come from those which are based in a dedicated ward, also compared to a mobile stroke team.

Early supported discharge
Seven systematic reviews are included. Early supported discharge (ESD) is a specific way of organising the discharge of patients from hospitals after the treatment in hospital is finished. The concept is based on the hypothesis that a quick return to home will increase level of independence. Early supported discharge provides early assessment in hospital, planned and coordinated discharge arrangements and post discharge support. ESD is provided by a multidisciplinary team, emphasising the cooperation with different levels of healthcare. Most studies on ESD are on stroke patients, but some studies also comprise other groups of patients. Stroke patients who receive these kinds of services can return home earlier, and are more likely to remain at home in the long term, and to regain independency in daily activities. The greatest benefits were seen in patients with mild to moderate disabilities.

Rehabilitation of elderly patients
We have included seven systematic reviews and one “overview over reviews”. Most reviews included studies of general multidisciplinary geriatric evaluation and management of elderly patients admitted to hospitals due to acute functional failure, compared to routine care, e.g. in a medical department. The results have been categorised in two groups: 1) Geriatric evaluation and management in specialised units/departments in the hospital, and 2) Geriatric consultation services by a team or an individual towards departments in the hospital. Studies of evaluation and management in specialised units showed a positive effect on survival and return to own home versus death or institutionalisation. The results were less convincing when considering mortality alone. For other important outcomes, such as level of functioning, need for hospitalisation, and length of stay, the findings were inconsistent. For geriatric consultation teams towards other hospital departments, no convincing effects were demonstrated.

Rehabilitation of elderly patients with hip fracture
Three systematic reviews are included. The reviews examine the effects of co-ordinated multi disciplinary inpatient rehabilitation, compared with usual care (orthopaedic care) in older people who had sustained a hip fracture. Data for mortality did not demonstrate any difference between multidisciplinary rehabilitation and usual orthopaedic care. However, the last published review shows that, multidisciplinary rehabilitation reduces the risk of “poor outcome”, combining death and admission to nursing home, following hip fracture.

Rehabilitation of patients with multiple scleroses
We found only one systematic review, based on eight studies. However, only three of these focused on rehabilitation programs in hospitals. There was strong evidence that despite no change in the level of impairment, inpatient multidisciplinary rehabilitation can produce shortterm gains at the level of activity and participation for patients with MS.

Rehabilitation of adults with acquired brain injury (ABI)
We have included two systematic reviews based on studies on adults in working age (16-65 years) with acquired brain injury. For patients with moderate to severe ABI who already are in rehabilitation, there is evidence that more intensive programmes are associated with earlier functional gains.

Rehabilitation of patients with spinal cord injury
We found one systematic review on effectiveness of hospital based spinal cord injury services, of which one question was on the consequences of immediate versus delayed or no referral to spinal injury unit (SIU). The authors conclude that patients undergoing immediate referral to SIUs may experience better outcomes than patients whose referral is delayed, or who are treated elsewhere. Owing to the questionable comparability of groups in the majority of studies, the evidence to support this conclusion is weak

Conclusions
We have found several systematic reviews on the effectiveness of organisation of rehabilitation in hospitals for different groups of patients, of which organised stroke unit care are most examined. There is strong evidence to say that organised inpatient care in stroke units produce more benefits to patients than other forms of care.  Moreover, early supported discharge can increase their chance of being independent and accelerate their discharge home. And geriatric evaluation and management in specialised units in the hospital seem to have positive effects on elderly patients possibilities of being independent in their own homes.

For patients with MS, spinal cord injury or acquired brain injury only limited evidence is found to support one way of organizing rehabilitation services in hospitals compared to others.

For other groups of patients we have not found any systematic reviews. Thus, this overview over reviews is not exhaustive. Further research is needed.