Having a stroke is a debilitating and costly event. Once a patient has been stabilized, rehabilitation to return as much function as possible is initiated through both physical and occupational therapy. As you would expect, this care and treatment continue for many months after hospital discharge. This week a study in Lancet entitled Family-led rehabilitation after stroke in India (ATTEND): a randomised controlled trial sheds light on that post-discharge care. Unlike the US, India does not have the resources to provide any significant level of rehabilitative care after hospitalization. About 1250 post-stroke patients were randomized to receive no additional care or had a family member instructed in rehabilitation exercises to continue at home. Here is what they found:
- Mortality in the groups was essentially the same, 12-14% 
- No difference in rehospitalization in the groups, 13-14%
- No difference in residual dependence, 33-35%
They concluded that “Although task shifting is an attractive solution for health-care sustainability, our results do not support investment in new stroke rehabilitation services that shift tasks to family caregivers, unless new evidence emerges.”
Post-discharge rehabilitation is expensive, with the expenses varying regionally and where the patient is initially placed. Simply discharged to home with health aides costs Medicare $13,000 per patient in the first year after stroke. The cost when the patient is discharged in rehabilitation or a nursing home is greater. So there is a temptation to shift the burden of care (and cost) to the family. I think that family involvement is important, but for some of us, no family can help, even with the best of intentions. This study is a pretty strong signal, merely instructing the family in some rehabilitation exercise is no better than no care at all. As CMS turns a more critical eye to its post-discharge costs and crafts alternative treatment, this is an important fact to remember.
 This is a high figure, the mortality at one year in the US is in the range of 3-4%