Systematic review
Effect of different ways of organising municipal rehabilitation services for people with neurological conditions
Systematic review
|Updated
A systematic review of the effect of different ways of organising rehabilitation services in municipalities for people with neurological conditions.
Key message
Today, there are differences between municipalities in how they organise their habilitation and rehabilitation services. We have systematically reviewed research about the effects of different ways of organising municipal habilitation and rehabilitation services to people with neurological conditions. The research documentation is based on ten RCTs. The documentation includes mainly studies with small sample sizes and some of the studies are not relevant with respect to current medical practice. Within neurology, we have only found relevant documentation on the diagnosis stroke.
Our main findings:
- Day-rehabilitation at a municipal health centre may be an equally good way to organise the service when it comes to improving function in activities of daily living and also to improve balance compared with providing the rehabilitation service in the patient’s home.
- Providing a larger amount of rehabilitation services may give a slight advantage compared to service provided less often (i.e. fewer meetings between patient and service providers per week) measured as higher scores on patient participation in society.
These findings are based on studies that have included stroke patients who are not in need of 24-hour health services.
This review shows that the organisation of rehabilitation services is “broad” and may include the dimensions service provider, funding and service delivery. The overview reveals major knowledge gaps, including the effect of ways to organise municipal rehabilitation services to target groups such as children and young people with neurological conditions, people with progressive conditions, people with severe cognitive-emotional problems and people in need of 24-hour health services. It is important to strengthen the field with good effect studies.
Summary
Background
Are some ways of organising municipal habilitation- and rehabilitation services more effective to people with neurological conditions than others? Today, there are differences between municipalities in how they organise their habilitation- and rehabilitation services. Moreover, Norwegian municipalities’ habilitation- and rehabilitation services are to a limited extent organised as one service unit. A successful habilitation and rehabilitation may provide significant health benefits.
Objective
The aim of this systematic review is to answer the following question:
What is the effect of different ways of organising municipal habilitation- and rehabilitation services with respect to people with neurological conditions? Impairment, disability, activity, participation, quality of life, satisfaction with health care, and hospital admissions are key outcome measures.
Method
We have prepared a systematic review in accordance with the Norwegian Knowledge Centre for the Health Services’ methods, about the effect of different ways of organising municipal habilitation- and rehabilitation services with respect to people with neurological conditions.
We performed a systematic search for literature in June 2015, without language restrictions or time limit, in Ovid MEDLINE (R); PubMed; Embase; ISI Web of Science; Cinahl; Cochrane Central Register of Controlled Trials (Central); Pedro; PsychInfo; AMED.
Two of us independently read titles and abstracts from the search and selected publications that we assessed in full text. We considered the relevance of full text versions based on the following criteria:
Population: People with acute or gradual reduced function due to neurological diseases and/or injuries (or if neurological conditions were a major component (> 70%) of the study population).
Intervention: Municipal habilitation- and rehabilitation services, i.e. organised outside hospitals in the primary health services or private rehabilitation services.
Comparison: Municipal habilitation- and rehabilitation services with the same content, but organised different from the intervention. Private rehabilitation services (or organised partly in hospital, if the service mainly is organised in the municipal health services). For example, habilitation and rehabilitation services in other localisation/setting. Other forms of organisation of multidisciplinary habilitation and rehabilitation services.
Outcomes: Disability, coping skills, self-care management, quality of life, independency, participation, quality adjusted life years, survival, time in need for rehabilitation services, readmissions.
Design: Randomised controlled trials, cluster randomised controlled trials with at least two clusters in both intervention and control groups, non-randomised controlled trials with at least two groups in both intervention and control groups, interrupted time series with at least three measuring points before and at least three measuring points after the intervention was introduced.
Language: Publications in English, Scandinavian, German and French were included. Other languages would have been considered for translation.
Exclusion: Comparisons of the content of the service (e.g. exercises).
In case of disagreement about inclusion, we consulted a third reviewer for clarification. Two people independently assessed the risk of bias for each study using a checklist. One person extracted data and graded each outcome using the GRADE method, and a second reviewer verified the data extraction and the GRADE assessments.
Results
Today's research documentation is based on ten RCTs. The documentation includes mainly studies with small sample sizes and some of the studies are not relevant with respect to current medical practice. Within the field of neurology, we have only documentation pertaining to people with stroke. Interventions in included studies are the setting for rehabilitation services, the use of resources in terms of amount of rehabilitation service, and the use of unskilled speech service providers instead of a speech therapist for aphasia. The studied outcomes are patient outcomes that primarily focus on disability, handicap, activity and participation.
Our main findings:
- Rehabilitation in day hospitals is probably an equally good way to organise the service to achieve improvement in ADL (activities of daily living) and in balance for patients recently discharged from hospital after stroke – compared with providing the same service in the patient’s home.
- Higher amount of weekly rehabilitation services may give a slight advantage compared to lower amount of provided services (fewer face-to-face meetings between patient and service providers per week) – measured as higher scores on patient participation.
Discussion
Our research question was not whether rehabilitation services are effective, but whether some way of organising services are more effective. While conducting this systematic review, we experienced the following challenges: i) due to lack of information in several publications, it was difficult to decide whether the study intervention took place in the specialist- or in the primary health care service; ii) to decide whether the services could be defined as rehabilitation versus nursing care; ii) and to distinguish what effects are due to organisation of rehabilitation services versus the effect of for example physical exercise.
The results are based on small individual studies. Only three studies have included more than 100 people. For most of the outcomes of interest, there is a knowledge gap. Thus, indicating the importance of strengthening the research with high quality evaluations of effect when organisational interventions are initiated.
This systematic review shows which organizational rehabilitation services in primary care that have been evaluated in controlled studies, within the field of neurology. This review shows that the organization of rehabilitation services is “broad” and may include the dimensions service provider, funding and service delivery. The review reveals major knowledge gaps, including the effect of ways to organise municipal rehabilitation services to target groups such as children and young people with neurological conditions, people with progressive conditions, people with severe cognitive-emotional problems and people in need of 24-hour services. It is important to strengthen the field with good effect studies.
Conclusion
Within the field of neurology, the effect of organising municipal rehabilitation services has been studied for people with stroke, but not for people with other neurological diagnoses. Interventions in the studies include the setting for rehabilitation services and the use of Resources.
Studies on the effect of the setting in which the service was provided, in the patient's home versus the health center, were close to our research question. The documentation from studies on the effects of day hospital rehabilitation versus rehabilitation in the patient's homes indicates that the two organisational forms are comparable when it comes to improvement in ADL and balance for people recently discharged from hospital after stroke. The results are more uncertain for other outcomes, and there is a lack of documentation of results on QALYs, survival, time needed for rehabilitation, coordinated services, readmissions and COSTs.
Higher amount of weekly rehabilitation services possibly provides a slight advantage compared to a less amount of rehabilitation service (fewer meetings between patient and service providers weekly), documented as higher scores on patient participation in society. For other outcomes such as physical disability, reduced function and activity, there was no difference in efficacy between the two measures.
