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

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


Collaborative evaluation of rehabilitation in stroke across europe

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


Cerise project

PART II: MANAGERIAL ASPECTS

PART I: CLINICAL ASPECTS

CERISE-project


Flow of the study

Flow of the study

2 M

4 M

6 M

CVA

*

Inpatient period

Months post-stroke


Overview

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


Overview1

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]


Overview2

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


Collaborative evaluation of rehabilitation in stroke across europe

Motor and functional recovery

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


Patients selection

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

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

Methods

532 stroke patients

BE

127

UK

135

CH

135

DE

135


Evaluations

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

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


Collaborative evaluation of rehabilitation in stroke across europe

  • 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]


Collaborative evaluation of rehabilitation in stroke across europe

  • 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


Collaborative evaluation of rehabilitation in stroke across europe

* 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


Collaborative evaluation of rehabilitation in stroke across europe

  • RMA-LTNS

  • RMA-ANS


Summary

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

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


Use of time1

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 time2

Use of time

Generalized estimating equation model (GEE), controlling for:

  • dependency of the data

  • differences in patient groups (case-mix)

  • multiple comparison


Collaborative evaluation of rehabilitation in stroke across europe

*

*

*

Absolute time in therapeutic activities

Between 7.00 am and 5.00 pm

* significant difference after correction for case-mix


Collaborative evaluation of rehabilitation in stroke across europe

Time available per patient per week

per professional group (in hours)


Summary1

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


Collaborative evaluation of rehabilitation in stroke across europe

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


Collaborative evaluation of rehabilitation in stroke across europe

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


Collaborative evaluation of rehabilitation in stroke across europe

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


Collaborative evaluation of rehabilitation in stroke across europe

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

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 pt1

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 pt2

Use of time (OT & PT)


Use of time ot pt3

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 pt4

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 pt5

Use of time (OT & PT)


Use of time ot pt6

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


Summary2

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%


Overall conclusion

more efficient use of human resources

more therapy time for patients

better motor and functional recovery

Overall conclusion

more formal management


Socio economic variables

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 variables1

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 variables2

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 variables3

Socio-economic variables

Barthel Index

RMA-arm

Education

Equivalent

income


Socio economic variables4

Socio-economic variables


Socio economic variables5

Socio-economic variables


Socio economic variables6

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

General conclusion

  • Recommendations for health care policy

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

    • Socioeconomic aspects in stroke rehabilitation


General conclusion1

General conclusion

  • Recommendations for future research

    • Contextualisation of services in outcome comparison

    • Socioeconomic aspects in case-mix

    • Documentation of follow-up services


Collaborative evaluation of rehabilitation in stroke across europe

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

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

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


Collaborative evaluation of rehabilitation in stroke across europe

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


Collaborative evaluation of rehabilitation in stroke across europe

  • 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

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


Collaborative evaluation of rehabilitation in stroke across europe

  • 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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