Background and Purpose— There is limited evidence to guide rehabilitation to meet the longer term needs of stroke survivors. The clinical effectiveness and cost-effectiveness of an extended stroke rehabilitation service (EXTRAS) provided following early supported discharge were determined. Methods— EXTRAS was a pragmatic parallel-group observer-blind randomized controlled trial involving 19 UK centers. Patients with stroke were individually randomized to receive EXTRAS or usual care at discharge from early supported discharge. Five EXTRAS reviews were provided by an early supported discharge team member between one and 18 months, usually by telephone. Reviews consisted of a semi-structured interview assessing progress, rehabilitation needs, and service provision, with goal setting and action planning. The primary outcome was performance in extended activities of daily living (Nottingham EADL Scale) at 24 months post-randomization. The Nottingham EADL Scale is scored 0 to 66, with higher scores indicating better performance in these activities. Cost-effectiveness was estimated using resource utilization costs and Quality Adjusted Life Years. Analyses were intention to treat. Results— Between January 9, 2013 and October 26, 2015, 573 participants were randomized (EXTRAS, n=285; usual care, n=288). Mean 24 month Nottingham EADL Scale scores were EXTRAS (n=219) 40.0 (SD 18.1) and usual care (n=231) 37.2 (SD 18.5) giving an adjusted mean difference of 1.8 (95% CI, –0.7 to 4.2). 1155/1338 (86%) of expected EXTRAS reviews were undertaken. Over 24 months, the mean cost of resource utilization was lower in the intervention group: –£311 (–$450 [95% CI, −£3292 to £2787; −$4764 to $4033]). EXTRAS provided more Quality Adjusted Life Years (0.07 [95% CI, 0.01 to 0.12]). At current conventional thresholds of willingness to pay (£20 000 [$28 940] per Quality Adjusted Life Years), there was a 90% chance that EXTRAS could be considered cost-effective. Conclusions— EXTRAS did not significantly improve stroke survivors’ performance in extended activities of daily living. However, given the impact on costs and Quality Adjusted Life Years, EXTRAS may be an affordable addition to improve stroke care. Clinical Trial Registration— URL: www.isrctn.com . Unique identifier: ISRCTN45203373.

High sugar foods and beverages consumed frequently are associated with increased dental caries and periodontal disease. Based on parental survey responses, the diets of children with Down's syndrome, autistic spectrum disorder (ASD) and cri du chat syndrome and comparison groups of siblings were considered from an oral health perspective. In each group children who were frequent consumers of one high sugar food or beverage were likely to be high consumers of others, whilst other children were low consumers of high sugar foods and beverages. Children in middle and late childhood tended to consume more cariogenic foods and beverages than preschool children. For most children frequency of meal and snack consumption would allow little opportunity for remineralization of teeth.

ObjectivesThe key objectives of this study were to quantify extent of prescribing, reasons for deprescribing, common therapeutic groups of medicines deprescribed and adverse events.MethodsA retrospective analysis was carried out on a quality improvement project where 422 care home residents in 20 care homes received a medicines optimisation review with a pharmacist and other members of the healthcare team (general medical practitioner, care home nurse). Data on number, type and cost of medicines were collected. Statistical analysis was performed to test for differences between pharmacist-only review and the pharmacist plus general practitioner (GP), and to identify any correlation between the original number of medicines and the number of medicines stopped.ResultsOf the 422 patients reviewed, 298 (70.6%) had at least one medicine stopped with 704 medicines being stopped. This represented 19.5% of the medicines originally prescribed (3602 medicines). There was no statistically significant difference between pharmacist only and pharmacist plus GP in terms of stopping medicines. The main groups of medicines stopped were laxatives, skin products and bone protection. There was weak correlation between the original number of medicines prescribed and the number stopped.ConclusionsThis study has shown that medicines optimisation reviews can lead to a reduction in polypharmacy for care home residents through a deprescribing process. Patients' medicine regimens were simplified and optimised while making financial significant savings for the National Health Service.

Background There is limited evidence about the effectiveness of rehabilitation in meeting the longer-term needs of stroke patients and their carers. Objective To determine the clinical effectiveness and cost-effectiveness of an extended stroke rehabilitation service (EXTRAS). Design 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. Setting Nineteen NHS study centres. Participants Patients with a new stroke who received early supported discharge and their informal carers. Interventions 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. Results 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. Conclusions 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. Trial registration Current Controlled Trials ISRCTN45203373. Funding This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 24. See the NIHR Journals Library website for further project information.