Collaborative evaluation of rehabilitation in stroke across europe
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Collaborative Evaluation of Rehabilitation in Stroke across Europe. Euro pean commission Fifth framework: Quality Of Life Key action 6.4: The ageing population and their disabilities Sekretariat für Bildung und Forschung.

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Collaborative Evaluation of Rehabilitation in Stroke across Europe

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Collaborative Evaluation of Rehabilitation in Stroke across Europe

European commission

Fifth framework: Quality Of Life

Key action 6.4: The ageing population and their disabilities

Sekretariat für Bildung und Forschung


Components of inpatient stroke rehabilitation crucial for patients’ outcome:not well known

Longitudinal studies comparing stroke care and recovery patterns across European countries

Collaborative Evaluation of Rehabilitation in Stroke across Europe


PART II: MANAGERIAL ASPECTS

PART I: CLINICAL ASPECTS

CERISE-project


Flow of the study

2 M

4 M

6 M

CVA

*

Inpatient period

Months post-stroke


Overview

  • Study 1: Motor and functional recovery after stroke

    • Stroke 2007;38:2101-2107

  • Study 2: Use of time by stroke patients

    • Stroke 2005;36:1977-1983

  • Study 3: Content of PT and OT

    • Stroke 2006;37:1483-1489

  • Study 4: Task characteristics of OT and PT

    • Disability and Rehabilitation 2006;28:1417-1424


Overview

  • Study 5: The effect of socio-economic status on recovery

    • J Neurol Neurosurg Psychiatry 2007;78:593-599

  • Study 6: Anxiety and depression after stroke

    • Disabil Rehabil, 2008 [In press]


Overview

  • Study 7: Comparative study on admission criteria to SRUs

    • J Rehabil Med 2006; 39:21-26

  • Study 8: Comparative study on follow-up services after inpatient stay

    • In preparation


Motor and functional recovery

Motor and functional recovery until 6 months after stroke between four European rehabilitation centres


Patients’ selection

532 consecutive stroke patients

4 rehabilitation centres

  • University Hospital Pellenberg (Belgium)

  • City Hospital and Queen’s Medical Centre (UK)

  • RehaClinic Zurzach (Switzerland)

  • Fachklinik Herzogenaurach (Germany)


Inclusion criteria

  • first ever stroke

  • age between 40 and 85 years

  • motor impairment on admission (RMA)

  • admitted < 6 weeks after stroke

  • pre-stroke Barthel Index >50

  • no other neurological disorders

  • informed consent


Methods

532 stroke patients

BE

127

UK

135

CH

135

DE

135


Evaluations

  • Demographic and prognostic data

    on admission to the centre

  • Motor and functional recovery

    • on admission, at 2, 4 and 6 months after stroke

      • Rivermead Motor Assessment (RMA)

      • Barthel ADL Index (BI)

    • at 2, 4 and 6 months after stroke

      • Nottingham Extended Activities of Daily Living (NEADL)


Statistical analysis

  • Comparison prognostic data: Chi², ANOVA, Kruskal Wallis tests

On admission:

  • age: older in UK & CH

  • gender: more men in DE

  • TSOA shorter in UK

  • urinary incontinence: more in BE & UK

  • swallowing problems: more in UK

  • dysarthria: more in BE

  • dysphasia: more in CH

  • initial BI: lower in BE & UK

  • initial RMA-GF: lower in BE & UK

correction for case mix


  • Comparison recovery patterns: random effects ordinal logistic model, controlling for:

    • differences between centres in patient groups (case-mix)

    • different TSOA

    • multiple comparison

       RMA-GF, BI and NEADL: division in classes

  • RMA-GF: five classes: [0-2], [3-5], [6-7], [8-9], [10-13]

  • BI: five classes: [0-20], [25-40], [45-60], [65-80], [85-100]

  • NEADL: six classes: [0-2], [3-5], [6-8], [9-11], [12-16], [17-22]


  • Odds ratio (OR): chance to stay in lower classes compared between 2 centres

  • OR at different time points (t1, t2)

OR (t2)

for centre 1 versus centre 2

= rate of change in odds ratio in time

OR (t1)

1) change of odd ratio in time

2) different change between centres

<1: patients in centre 1 have less chance to stay in lower classes vs patients in centre 2

>1: patients in centre 1 have more chance to stay in lower classes vs patients in centre 2


* p<0.05: significant difference between centres after correction for multiple testing

* p<0.05: significant difference between centres without correction for multiple testing

Pair wise comparisons of the rate of change of odds ratio over time (95% confidence limits) between centers for RMA-GF, and BI and NEADL

BE vs DE

CH vs DE

UK vs DE

UK vs BE

CH vs BE

CH vs UK


  • RMA-LTNS

  • RMA-ANS


Summary

  • Motor and functional recovery better in German and Swiss centers versus UK centre respectively: more therapy

  • Exception recovery Barthel Index: better in UK vs German centre

    • 25% of German patients score >85/100

    • UK patients: moderate on admission

    • UK: early discharge  independence in ADL

    • UK: high input of nursing care


Use of time

Use of time by stroke patients during inpatient rehabilitation between four European rehabilitation centres


Use of time

  • 60 stroke patients in each centre

  • observations at 10-minute intervals: activity, location and interaction

  • observations from 7.00am till 10.00pm

  • equally distributed over the 5 week days


Use of time

Generalized estimating equation model (GEE), controlling for:

  • dependency of the data

  • differences in patient groups (case-mix)

  • multiple comparison


*

*

*

Absolute time in therapeutic activities

Between 7.00 am and 5.00 pm

* significant difference after correction for case-mix


Time available per patient per week

per professional group (in hours)


Summary

  • Study 1: motor and functional recovery is respectively better in German and Swiss centres compared to UK centre, but BI improved more in UK compared to DE

  • Study 2: significantly less therapy time in UK centre compared to other centres


Content of OT and PT

  • to compare the content of PT and OT

  • to compare the content of individual PT and OT sessions for stroke patients between centres

develop a reliable scoring list


Methods

  • scoring list of 12 therapeutic categories

    • ambulatory activities- lying activities

    • selective movements- ADL

    • mobilisation- leisure activities

    • sitting activities- domestic activities

    • standing activities- sensory training

    • transfers- miscellaneous

  • inter-rater reliability: fair to high (ICC=0.71-1.00)

     list was used to score the content of 15 PT-and 15 OT tapes in each centre


1 cognitive disorder

1 language disorder

1 neglect

2 not specifically defined

1 cognitive disorder

1 language disorder

1 neglect

2 not specifically defined

1 cognitive disorder

1 language disorder

1 neglect

2 not specifically defined

1 cognitive disorder

1 language disorder

1 neglect

2 not specifically defined

1 cognitive disorder

1 language disorder

1 neglect

2 not specifically defined

1 cognitive disorder

1 language disorder

1 neglect

2 not specifically defined

5 Mild

5 Mild

15 OT sessions

-

5 Moderate

5 Severe

30 therapy

sessions

Centre

5 Mild

15 PT sessions

5 Moderate

5 Severe


Summary

  • PT and OT are distinct professions with clear demarcation of roles

  • Content of each therapeutic discipline was consistent between centres

  • Differences in stroke rehabilitation outcome could not be attributed to differences in content of PT and OT


Use of time (OT & PT)

  • Aim

    • compare time allocated to

      • therapeutic activities (TA)

      • non therapeutic activities (NTA)

    • compare time OT and PT

      • in-between different units (SRU)


Use of time (OT & PT)

  • Method

    • Diary

      • recording activities in 15 minutes time slots two weeks

    • Labelled

      • activity

      • number of patients

      • number of stroke patients

      • involvement of other people

      • location

      • frequency of each activity


Use of time (OT & PT)


Use of time (OT & PT)

  • Multivariate analyses

    • activities on stroke patients (N= 13 349)

    • negative binomial regression model

  • Two comparisons

    • OT vs PT

    • between centres


Use of time (OT & PT)

  • Results

    • 146 diariesPT: 95OT: 51

    • N= 20 421 observed and labeled periods

      (Unit of analysis: “periods of 15 minutes”)


Use of time (OT & PT)


Use of time (OT & PT)

TA vs N-TA

PRA vs N-PRA

significant differences on TA vs NTA for OT

PRA: Patient co-ordination tasks + TA  no differences between centres


Summary

  • German and Swiss centres: rehabilitation programmes strictly timed  Belgium and UK centres: ‘ad hoc’ organisation

  • German PT’s and OT’s spent 66.1% and 63.3%, resp. on direct patient care  UK: 46% and 33%


more efficient use of human resources

more therapy time for patients

better motor and functional recovery

Overall conclusion

more formal management


Socio-economic variables

  • Aim

    to examine the impact of the socio-economic status on motor and functional recovery during inpatient rehabilitation and after discharge


Socio-economic variables

  • Method

  • Educational level

    • the international standard classification of education (ISCED 97, WHO)

      • low= below or equal to lower secondary level

      • high= upper secondary level or higher

  • Equivalent income

    • the modified OECD scale

      • three categories for equivalent income (low, moderate or high) based on the respective median national equivalent income for the 4 countries


Socio-economic variables

Analyses

  • Descriptive statistics:

    • patients’ characteristics on admission to the stroke rehabilitation unit

  • Functional and motor outcome compared between SES groups

  • Association between SES and motor and functional recovery

    • multivariate ordinal logistic regression models

    • two time-periods

      • the period of inpatient rehabilitation

      • the period between discharge and 6 months post-stroke


Socio-economic variables

Barthel Index

RMA-arm

Education

Equivalent

income


Socio-economic variables


Socio-economic variables


Socio-economic variables

  • Conclusion

    • Education as the ‘cultural’ dimension of SES seems to be of particular importance during the inpatient rehabilitation period

    • Equivalent income as the ‘material’ indicator of SES seems to be of particular importance between discharge and 6 months post-stroke


General conclusion

  • Recommendations for health care policy

    • Non-clinical aspects to be incorporated in evaluation of rehabilitation programs

    • Socioeconomic aspects in stroke rehabilitation


General conclusion

  • Recommendations for future research

    • Contextualisation of services in outcome comparison

    • Socioeconomic aspects in case-mix

    • Documentation of follow-up services


Anxiety and depression

  • To determine the prevalence of post-stroke anxiety and depression

  • To explore the time course of post-stroke anxiety and depression


Anxiety and depression

Hospital Anxiety and Depression Scaleat 2, 4, and 6 months after stroke: 14 questions

HADS-A: measures symptoms of anxiety

HADS-D: measures symptoms of depression

score ≥ 8 on HADS-A: anxiety disorder

score ≥ 8 on HADS-D: depressive disorder


Time course of prevalence of anxiety and depression (complete cases: n=435)

Anxiety 

(HADS-A ≥ 8)

Depression

(HADS-D ≥ 8)

Anxiety : Cochran-Q: Q=2.7; p=0.26

Depression: Cochran-Q: Q=5.2; p=0.07


Composition of number of patients with anxiety (HADS-A>7) at two, four and six months after stroke (total n=435) and the associated severity (median [IQR])

Similar pattern for depression


  • Other patients are anxious/depressed at different time points: half of the patients with anxiety/depression at two months have recovered at six months

  • Patients who remain anxious/depressed throughout the sub acute period suffer from more severe affective disorders that do not have the tendency to get milder


Many people contributed:

  • British team: N. Lincoln,B. Smith & L. Connell

  • German team: W. Schupp, N. Brinkmann & J. Jurkat

  • Swiss team: W. Jenni, B. Schuback & C. Kaske

  • Belgian team:

    L. De Wit, K. Putman, I.Baert, H. Feys, W. De Weerdt

    F. Louckx, M. Leys

    E. Dejaeger, H. Beyens,

    E. Lesaffre, A Komarek, K. Bogaerts, A-M De Meyer


  • Use of time by stroke patients. A comparison of 4 European rehabilitation centres. Stroke 2005;36:1977-1983.

  • Stroke rehabilitation in Europe. What do physiotherapists and occupational therapists actually do? Stroke 2006;34:1483-1489.

  • Motor and functional recovery after stroke. A comparison of four European rehabilitation centres. Stroke 2007;38:2101-2107

  • Defining the content of individual PT and OT…Clinical Rehabilitation 2007;21:450-459

  • The effect of socioeconomic status on functional and motor recovery after stroke: a European multicenter study. J Neurol Neurosurg Psychiatry 2007;78:593-599

  • Use of time by physiotherapists and occupational therapists in a stroke rehabilitation unit: a comparison between four European rehabilitation centres. Disabil Rehabil 2006;28:1417-1424.

  • Inpatient stroke rehabilitation: a comparative study of admission-criteria to stroke rehabilitation units in four European centres. J Rehabil Med 2007;39:21-26


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