An extended stroke rehabilitation service for people who have had a stroke: the EXTRAS RCT

Shaw, Lisa, Bhattarai, Nawaraj, Cant, Robin, Drummond, Avril, Ford, Gary A, Forster, Anne, Francis, Richard, Hills, Katie, Howel, Denise, Laverty, Anne Marie, McKevitt, Christopher, McMeekin, Peter, Price, Christopher, Stamp, Elaine, Stevens, Eleanor, Vale, Luke and Rodgers, Helen (2020) An extended stroke rehabilitation service for people who have had a stroke: the EXTRAS RCT. Health Technology Assessment, 24 (24). pp. 1-202. ISSN 1366-5278

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There is limited evidence about the effectiveness of rehabilitation in meeting the longer-term needs of stroke patients and their carers.

To determine the clinical effectiveness and cost-effectiveness of an extended stroke rehabilitation service (EXTRAS).

A pragmatic, observer-blind, parallel-group, multicentre randomised controlled trial with embedded health economic and process evaluations. Participants were randomised (1 : 1) to receive EXTRAS or usual care.

Nineteen NHS study centres.

Patients with a new stroke who received early supported discharge and their informal carers.

Five EXTRAS reviews provided by an early supported discharge team member between 1 and 18 months post early supported discharge, usually over the telephone. Reviewers assessed rehabilitation needs, with goal-setting and action-planning. Control treatment was usual care post early supported discharge.

Main outcome measures
The primary outcome was performance in extended activities of daily living (Nottingham Extended Activities of Daily Living Scale) at 24 months post randomisation. Secondary outcomes at 12 and 24 months included patient mood (Hospital Anxiety and Depression Scale), health status (Oxford Handicap Scale), experience of services and adverse events. For carers, secondary outcomes included carers’ strain (Caregiver Strain Index) and experience of services. Cost-effectiveness was estimated using resource utilisation costs (adaptation of the Client Service Receipt Inventory) and quality-adjusted life-years.

A total of 573 patients (EXTRAS, n = 285; usual care, n = 288) with 194 carers (EXTRAS, n = 103; usual care, n = 91) were randomised. Mean 24-month Nottingham Extended Activities of Daily Living Scale scores were 40.0 (standard deviation 18.1) for EXTRAS (n = 219) and 37.2 (standard deviation 18.5) for usual care (n = 231), giving an adjusted mean difference of 1.8 (95% confidence interval –0.7 to 4.2). The mean intervention group Hospital Anxiety and Depression Scale scores were not significantly different at 12 and 24 months. The intervention did not improve patient health status or carer strain. EXTRAS patients and carers reported greater satisfaction with some aspects of care. The mean cost of resource utilisation was lower in the intervention group: –£311 (95% confidence interval –£3292 to £2787), with a 68% chance of EXTRAS being cost-saving. EXTRAS was associated with 0.07 (95% confidence interval 0.01 to 0.12) additional quality-adjusted life-years. At current conventional thresholds of willingness to pay for a quality-adjusted life-year, there is a 90% chance that EXTRAS is cost-effective.

EXTRAS did not improve stroke survivors’ performance in extended activities of daily living but did improve their overall satisfaction with services. Given the impact on costs and quality-adjusted life-years, there is a high chance that EXTRAS could be considered cost-effective.

Future work
Further research is required to identify whether or not community-based interventions can improve performance of extended activities of daily living, and to understand the improvements in health-related quality of life and costs seen by provision of intermittent longer-term specialist review.

Item Type: Article
Additional Information: © Queen’s Printer and Controller of HMSO 2020. This work was produced by Shaw et al. under the terms of a commissioning contract issued by the Secretary of State for Health and Social Care. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK.
Subjects: A300 Clinical Medicine
A900 Others in Medicine and Dentistry
B100 Anatomy, Physiology and Pathology
B700 Nursing
B900 Others in Subjects allied to Medicine
Department: Faculties > Health and Life Sciences > Nursing, Midwifery and Health
Depositing User: Rachel Branson
Date Deposited: 16 Nov 2020 15:18
Last Modified: 31 Jul 2021 13:34

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