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Long-Term Outcomes after Acute Stroke Treatment. Larry B. Goldstein, M.D. Professor of Medicine (Neurology) Center for Cerebrovascular Disease Center for Clinical Health Policy Research Duke University and Durham VA Medical Center. Disclosures None relevant. Quality of life.

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Long-Term Outcomes after Acute Stroke Treatment

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Long-Term Outcomes after Acute Stroke Treatment

Larry B. Goldstein, M.D.

Professor of Medicine (Neurology)

Center for Cerebrovascular Disease

Center for Clinical Health Policy Research

Duke University

and

Durham VA Medical Center

Disclosures

None relevant


Quality of life

Quality of life

Participation

Dimension

Handicap

Activities

Dimension

Disability

Body

Dimension

Impair-

ment

Levels of Outcome MeasurementWorld Health Organization


Level of Measurement

Disease

Body

Dimension

Activities

Dimension

Participation

Dimension

Severity

Comorbidity

Severity

Comorbidity

Severity

Comorbidity

Motivation

Depression

Social Sup.

Motivation

Depression

Social Sup.

Education

Occupation

Access


Which Scales?

  • Reliable

  • Valid

  • Sensitive to change

  • Logistically feasible


Reliability (Precision)

  • Degree of agreement between or among observers

    • Inter-observer agreement

  • Degree of agreement between observations

    • Intra-observer agreement (test-retest)


Validity (Accuracy)

  • Content validity

    • Does the scale includes all relevant dimensions of what is being measured?

  • Criterion validity

    • Concurrent validity - Does the scale produce the same result as a “gold standard?”

    • Predictive validity - Does scale predict future health status?

  • Construct validity

    • Discriminant validity - Do the results differ from measures of a different type of deficit?

    • Convergent validity - Is the scale responsive to change?


Quality of life

Participation

Dimension

Activities

Dimension

Body

Dimension

Stroke ScalesLevels of Outcome Measurement

NIH Stroke Scale

Canadian Stroke Scale

European Stroke Scale

Scandinavian Stroke Scale


Stroke Impairment ScalesReliability and Validity


Quality of life

Participation

Dimension

Activities

Dimension

Barthel Index

Katz

Kenny

Functional Independence Measure

IADL

Body

Dimension

NIH Stroke Scale

Canadian Stroke Scale

European Stroke Scale

Scandinavian Stroke Scale

Stroke ScalesLevels of Outcome Measurement


Stroke ADL Scales


Instrumental ADLApplication to Stroke

  • No consensus for a clear definition of IADL

  • Measure ability to live independently in the home

  • Bridge delineation between disability and handicap

  • Core activities

    • Domestic chores

    • Household management

    • Outdoor activities

    • Transportation

Chong Stroke 1995; 26: 1119


IADL Scales for StrokeEvidence for Reliability and Validity

Chong Stroke 1995; 26: 1119


Quality of life

Participation

Dimension

Activities

Dimension

Body

Dimension

NIH Stroke Scale

Canadian Stroke Scale

European Stroke Scale

Scandinavian Stroke Scale

Stroke ScalesLevels of Outcome Measurement

Rankin Index

Glasgow Outcomes Scale

Barthel Index

Katz

Kenny

Functional Independence Measure

IADL


Modified Rankin Score


Quality of life

Participation

Dimension

Activities

Dimension

Body

Dimension

NIH Stroke Scale

Canadian Stroke Scale

European Stroke Scale

Scandinavian Stroke Scale

Stroke ScalesLevels of Outcome Measurement

SF-36

Sickness Impact Profile

Stroke Impact Scale

Rankin Index

Glasgow Outcomes Scale

Barthel Index

Katz

Kenny

Functional Independence Measure

IADL


Quality Adjusted Life YearsQALYS

  • Outcome of clinical trial

  • Assign QOL weights

  • Calculate QALY

    • Assumes QOL rating independent of time in that state

    • Implies 2 QALYs is twice as good as 1 QALY

    • 1 person gaining 10 QALYs = 10 persons gaining 1 QALY

  • Estimate of costs for that state used for cost-effectiveness analysis


Quality of life

Participation

Dimension

Activities

Dimension

Body

Dimension

NIH Stroke Scale

Canadian Stroke Scale

European Stroke Scale

Scandinavian Stroke Scale

Stroke ScalesLevels of Outcome Measurement

SF-36

Sickness Impact Profile

Stroke Impact Scale

Rankin Index

Glasgow Outcomes Scale

Barthel Index

Katz

Kenny

Functional Independence Measure

IADL


Effect of Comorbid Conditions

Goldstein et al Stroke 2004; 35: 1941


Competing EventsCumulative Recurrence Rates

30% of Strokes are

recurrent events

Petty et al. Neurology 1998; 50: 208


Causes of Death After Stroke

Hankey et al. Stroke 2000; 31: 2080


Motor Recovery After StrokeDurham County Stroke Study

Duncan et al. Stroke 1992; 23: 1084


Long-Term Outcomes after Stroke

Disease

Body

Dimension

Activities

Dimension

Participation

Dimension

Severity

Comorbidity

Severity

Comorbidity

Severity

Comorbidity

Motivation

Depression

Social Sup.

Motivation

Depression

Social Sup.

Education

Occupation

Access

TIME


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