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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


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 patients’ outcome

PART I: CLINICAL ASPECTS

CERISE-project


Flow of the study
Flow of the study patients’ outcome

2 M

4 M

6 M

CVA

*

Inpatient period

Months post-stroke


Overview
Overview patients’ outcome

  • 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 patients’ outcome

  • 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 patients’ outcome

  • 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 patients’ outcome

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


Patients selection
Patients’ selection patients’ outcome

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 patients’ outcome

  • 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 patients’ outcome

532 stroke patients

BE

127

UK

135

CH

135

DE

135


Evaluations
Evaluations patients’ outcome

  • 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 patients’ outcome

  • 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


  • 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]


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-LT NS correction for multiple testing

  • RMA-A NS


Summary
Summary correction for multiple testing

  • 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 correction for multiple testing

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


Use of time1
Use of time correction for multiple testing

  • 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 correction for multiple testing

Generalized estimating equation model (GEE), controlling for:

  • dependency of the data

  • differences in patient groups (case-mix)

  • multiple comparison


* correction for multiple testing

*

*

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 correction for multiple testing

per professional group (in hours)


Summary1
Summary correction for multiple testing

  • 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 correction for multiple testing

  • 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 correction for multiple testing

  • 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 correction for multiple testing

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 correction for multiple testing

  • 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) correction for multiple testing

  • 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) correction for multiple testing

  • 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) correction for multiple testing


Use of time ot pt3
Use of time (OT & PT) correction for multiple testing

  • 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) correction for multiple testing

  • Results

    • 146 diaries PT: 95 OT: 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) correction for multiple testing


Use of time ot pt6
Use of time (OT & PT) correction for multiple testing

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 correction for multiple testing

  • 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 correction for multiple testing

more therapy time for patients

better motor and functional recovery

Overall conclusion

more formal management


Socio economic variables
Socio-economic variables correction for multiple testing

  • 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 correction for multiple testing

  • 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 correction for multiple testing

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 correction for multiple testing

Barthel Index

RMA-arm

Education

Equivalent

income


Socio economic variables4
Socio-economic variables correction for multiple testing


Socio economic variables5
Socio-economic variables correction for multiple testing


Socio economic variables6
Socio-economic variables correction for multiple testing

  • 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 correction for multiple testing

  • 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 correction for multiple testing

  • Recommendations for future research

    • Contextualisation of services in outcome comparison

    • Socioeconomic aspects in case-mix

    • Documentation of follow-up services


Anxiety and depression correction for multiple testing

  • 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 correction for multiple testing

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


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
Many people contributed: points: half of the patients with anxiety/depression at two months have recovered at six months

  • 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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