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Collaborative Evaluation of Rehabilitation in Stroke across Europe

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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  1. 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

  2. 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

  3. PART II: MANAGERIAL ASPECTS PART I: CLINICAL ASPECTS CERISE-project

  4. Flow of the study 2 M 4 M 6 M CVA * Inpatient period Months post-stroke

  5. 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

  6. 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]

  7. 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

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

  9. 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)

  10. 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

  11. Methods 532 stroke patients BE 127 UK 135 CH 135 DE 135

  12. 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)

  13. 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

  14. 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]

  15. 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

  16. * 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

  17. RMA-LT NS • RMA-A NS

  18. 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

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

  20. 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

  21. Use of time Generalized estimating equation model (GEE), controlling for: • dependency of the data • differences in patient groups (case-mix) • multiple comparison

  22. * * * Absolute time in therapeutic activities Between 7.00 am and 5.00 pm * significant difference after correction for case-mix

  23. Time available per patient per week per professional group (in hours)

  24. 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

  25. 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

  26. 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

  27. 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

  28. 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

  29. 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)

  30. 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

  31. Use of time (OT & PT)

  32. 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

  33. Use of time (OT & PT) • Results • 146 diaries PT: 95 OT: 51 • N= 20 421 observed and labeled periods (Unit of analysis: “periods of 15 minutes”)

  34. Use of time (OT & PT)

  35. 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

  36. 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%

  37. more efficient use of human resources more therapy time for patients better motor and functional recovery Overall conclusion more formal management

  38. Socio-economic variables • Aim to examine the impact of the socio-economic status on motor and functional recovery during inpatient rehabilitation and after discharge

  39. 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

  40. 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

  41. Socio-economic variables Barthel Index RMA-arm Education Equivalent income

  42. Socio-economic variables

  43. Socio-economic variables

  44. 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

  45. General conclusion • Recommendations for health care policy • Non-clinical aspects to be incorporated in evaluation of rehabilitation programs • Socioeconomic aspects in stroke rehabilitation

  46. General conclusion • Recommendations for future research • Contextualisation of services in outcome comparison • Socioeconomic aspects in case-mix • Documentation of follow-up services

  47. Anxiety and depression • To determine the prevalence of post-stroke anxiety and depression • To explore the time course of post-stroke anxiety and depression

  48. 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

  49. 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

  50. 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

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