Collaborative Evaluation of Rehabilitation in Stroke across Europe
European commissionFifth framework: Quality Of LifeKey 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
PART I: CLINICAL ASPECTS
Flow of the study
6 M
Months post-stroke
CVA 2 M 4 M
* Inpatient period
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 until 6 months after
stroke between four European rehabilitation centres
Motor and functional recovery
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)
Patients’ selection
– 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
Inclusion criteria
Methods
532 stroke patients
BE
127
UK
135
CH
135
DE
135
• Demographic and prognostic dataon 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)
Evaluations
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)
1) change of odd ratio in time
2) different change between centres
OR (t1)OR (t2) for centre 1 versus centre 2
= rate of change in odds ratio in time
<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
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
0
1
2
3
4
5RMA-GF
BI
NEADL
CH vs BE CH vs UKUK vs BEBE vs DE UK vs DE CH vs DE
* p<0.05: significant difference between centres after correction for multiple testing
* p<0.05: significant difference between centres without correction for multiple testing
• RMA-LT NS
• RMA-A NS
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 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
Use of time
0
20
40
60
80
100
120
140
160
total therapy physio-therapy
occupationaltherapy
speechtherapy
neuro.training nursing care medical care sports autonomexercise
other therapy
time
(min
.)
PellenbergNottinghamZurzachHerzogenaurach
Absolute time in therapeutic activities Between 7.00 am and 5.00 pm
*
*
* significant difference after correction for case-mix
*
BE UK CH DE
physiotherapy 3.94 7.35 10.54 4.90
occupational therapy 2.24 4.06 5.69 2.56
speech therapy 1.30 1.35 1.52 1.10
neuropsychology 0.57 0.49 1.71 1.70
medical care 2.33 3.31 2.28 3.07
nursing care 20.76 52.98 19.00 13.80
other therapy 0.77 0.00 2.24 3.14
TOTAL 31.91 69.54 42.98 30.27
Time available per patient per weekper professional group (in hours)
bedsNr hrs/week x workingstaff FTE ofNr
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 listdevelop 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
30 therapy sessions
-
15 PT sessions
5 Mild
5 Moderate
5 Severe
Centre
1 cognitive disorder1 language disorder1 neglect2 not specifically defined
1 cognitive disorder1 language disorder1 neglect2 not specifically defined
1 cognitive disorder1 language disorder1 neglect2 not specifically defined
5 Mild
1 cognitive disorder1 language disorder1 neglect2 not specifically defined
1 cognitive disorder1 language disorder1 neglect2 not specifically defined
1 cognitive disorder1 language disorder1 neglect2 not specifically defined
5 Mild
5 Moderate
5 Severe
15 OT sessions
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
• 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)Mobility training ADL training Neuro Psychol
trainingOther training
100 Mobilisation + positioning 108 ADL-activities 106 Sensory/perceptual training 114 Miscellaneous techniques
101 Sitting + sitting balance 109 Domestic activities 107 Cognitive training 115 Other
102 Standing + standing balance 110 Aids + Equipment
103 Relearning selective movements 112 Home visit
104 Transfers 113 Leisure + work related activities
105 Walking
116 Wheelchair training
117 Fitness training
111 Assessment
Patient-linked co-ordination
Unit-linked co-ordination
Other
120 Patient administration 121 Center/Unit administration 129 Break
124 Discussion about patient(s) 122 Training/demonstration 130 Other
127 Ward round 123 Supervision
128 Team conference 125 Discussion about team
131 Giving advice 126 Discussion about unit/center
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
• Results 146 diaries
PT: 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)SRU-GB SRU-CH SRU-DE SRU-BE
PT OT PT OT PT OT PT OT
observations, n 2476 1284 3883 2033 4548 2157 2545 1495
therapeutic activities,% 45.9 32.9 53.7 45.2 66.1 63.3 61.7 50.2
non-therapeutic activities,% 54.1 67.1 46.3 54.8 33.9 36.7 38.2 49.8
therapeutic activities
individual/group therapy,%
one-to-one sessions 98.8 84.3 91.2 92.3 92.2 80.0 75.3 85.6
one-to-many sessions 1.2 15.7 8.8 7.7 7.8 20.0 24.7 14.4
location,%
rehabilitation room 39.7 8.4 54.5 71.8 52.3 78.5 38.7 55.4
office room 0.0 0.0 0.0 1.3 0.2 0.0 3.3 0.0
ward 20.7 54.3 18.1 21.8 13.1 19.5 43.5 37.3
other 39.6 37.3 27.4 5.0 34.4 2.1 14.4 7.4
53,7 66,1 61,845,9 69,0 67,7 82,8 71,5
38,233,954,1 17,2 28,532,331,046,3
65,4 69,7 76,2 63,332,9 45,2 63,3 50,2
36,723,830,334,649,836,754,867,1
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
SRU- GB SRU-CH
SRU- DE SRU- BE SRU- GB SRU-CH
SRU- DE SRU- BE SRU- GB SRU-CH
SRU- DE SRU- BE SRU- GB SRU-CH
SRU- DE SRU- BE
Perc
enta
ge o
f tim
e
non-TATAnon-PRAPRA
p=.03*p=.25* p=.21*p=.50*
TA versus non-TA
PT OT
PRA versus non-PRA
PT OT
Use of time (OT & PT)
significant differences on TA vs NTA for OTPRA: Patient co-ordination tasks + TA no differences between centres
TA vs N-TA PRA vs N-PRA
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 formal management
more efficient use of human resources
more therapy time for patients
better motor and functional recovery
Socio-economic variables
• Aimto 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
)14(*3.0)14(*5.0)(1_
yrspersonsyrspersonspatientincomehousehold
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
0
20
40
60
80
100
Admission Discharge 6 months
0
4
8
12
Admission Discharge 6 months
0
20
40
60
80
100
Admission Discharge 6 months
0
4
8
12
Admission Discharge 6 months
Barthel Index RMA-arm
Education
Equivalent income
Socio-economic variables
Contrast OR 95% CI p-value I npatient stroke rehabilitation
Barthel I ndex education low vs high 0.53 0.32-0.87 0.011 income low vs moderate 1.34 0.74-2.42 0.335 income low vs high 1.85 0.87-3.92 0.108 income moderate vs high 1.38 0.74-2.58 0.307
RMA-GF education low vs high 0.58 0.32-1.03 0.063 income low vs moderate 0.98 0.50-1.92 0.955 income low vs high 0.83 0.32-2.18 0.709 income moderate vs high 0.85 0.37-1.95 0.700
RMA-LT education low vs high 0.73 0.45-1.18 0.207 income low vs moderate 1.01 0.57-1.82 0.954 income low vs high 1.20 0.58-2.51 0.610 income moderate vs high 1.19 0.64-2.20 0.582
RMA-AR education low vs high 0.54 0.31-0.94 0.030 income low vs moderate 0.71 0.36-1.40 0.321 income low vs high 0.89 0.39-2.02 0.781 income moderate vs high 1.26 0.63-2.50 0.511
Socio-economic variables Contrast OR 95% CI p-value Between discharge and 6 months post-stroke
Barthel I ndex education low vs high 0.81 0.49-1.34 0.412 income low vs moderate 0.63 0.34-1.17 0.146 income low vs high 0.55 0.25-1.19 0.127 income moderate vs high 0.86 0.45-1.66 0.662
RMA-GF education low vs high 0.88 0.43-1.80 0.733 income low vs moderate 0.39 0.17-0.89 0.025 income low vs high 0.20 0.06-0.66 0.008 income moderate vs high 0.52 0.18-1.48 0.222
RMA-LT education low vs high 0.68 0.37-1.26 0.223 income low vs moderate 0.52 0.26-1.04 0.065 income low vs high 0.22 0.09-0.55 0.001 income moderate vs high 0.42 0.19-0.93 0.031
RMA-AR education low vs high 0.90 0.43-1.88 0.775 income low vs moderate 0.81 0.33-1.99 0.643 income low vs high 0.30 0.10-0.87 0.027
income moderate vs high 0.37 0.15-0.90 0.029
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 Scale at 2, 4, and 6 months after stroke: 14 questions
HADS-A: measures symptoms of anxiety
HADS-D: measures symptoms of depressionscore ≥ 8 on HADS-A: anxiety disorderscore ≥ 8 on HADS-D: depressive disorder
Time course of prevalence of anxiety and depression
(complete cases: n=435)
0
10
20
30
40
50
2 4 6
time after stroke (months)
perc
enta
ge o
f pat
ient
sAnxiety (HADS-A>7)
Depression (HADS-D>7)
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
n=4110 [9-12]
n=41 11 [9-13]
n=41 11 [9-13]
n=2111 [9-13]
n=21 10 [8-12]
n=369 [9-10] n=20
9,5 [8-12,5]
n=20 9,5 [7-12]
n=179 [8-9]
n=22 8 [8-10]
n=912 [9-15] n=9
8 [8-9]
0
20
40
60
80
100
120
140
2mths 4mths 6mths
time after stroke (months)
num
ber
of p
atie
nts
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:
German team: W. Schupp, N. Brinkmann & J. Jurkat
Swiss team: W. Jenni, B. Schuback & C. Kaske
British team: N. Lincoln,B. Smith & L. Connell
Belgian team: L. De Wit, K. Putman, I.Baert, H. Feys, W. De Weerdt F. Louckx, M. LeysE. 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. Use of time by stroke patients. A comparison of 4 European rehabilitation centres. Stroke Stroke 2005;36:1977-1983.2005;36:1977-1983.
Stroke rehabilitation in Europe. What do physiotherapists and occupational therapists Stroke rehabilitation in Europe. What do physiotherapists and occupational therapists actually do? actually do? Stroke Stroke 2006;34:1483-1489.2006;34:1483-1489.
Motor and functional recovery after stroke. A comparison of four European Motor and functional recovery after stroke. A comparison of four European rehabilitation centres. rehabilitation centres. Stroke 2007;38:2101-2107Stroke 2007;38:2101-2107
Defining the content of individual PT and OT…Defining the content of individual PT and OT…Clinical Rehabilitation 2007;21:450-459Clinical Rehabilitation 2007;21:450-459
The effect of socioeconomic status on functional and motor recovery after stroke: a The effect of socioeconomic status on functional and motor recovery after stroke: a European multicenter study. European multicenter study. J Neurol Neurosurg Psychiatry 2007;78:593-599J Neurol Neurosurg Psychiatry 2007;78:593-599
Use of time by physiotherapists and occupational therapists in a stroke rehabilitation Use of time by physiotherapists and occupational therapists in a stroke rehabilitation unit: a comparison between four European rehabilitation centres.unit: a comparison between four European rehabilitation centres. Disabil Rehabil Disabil Rehabil 2006;28:1417-1424.2006;28:1417-1424.
Inpatient stroke rehabilitation: a comparative study of admission-criteria to stroke Inpatient stroke rehabilitation: a comparative study of admission-criteria to stroke rehabilitation units in four European centres.rehabilitation units in four European centres. J Rehabil Med 2007;39:21-26 J Rehabil Med 2007;39:21-26