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
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• 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

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CERISE-project
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Flow of the study
6 M
2 M
4 M
CVA

Inpatient period
Months post-stroke
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Overview

• Study 1 Motor and functional recovery after
  stroke
• Stroke 2007382101-2107
• Study 2 Use of time by stroke patients
• Stroke 2005361977-1983
• Study 3 Content of PT and OT
• Stroke 2006371483-1489
• Study 4 Task characteristics of OT and PT
• Disability and Rehabilitation 2006281417-1424

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Overview

• Study 5 The effect of socio-economic status on
  recovery
• J Neurol Neurosurg Psychiatry 200778593-599
• Study 6 Anxiety and depression after stroke
• Disabil Rehabil, 2008 In press

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Overview

• Study 7 Comparative study on admission criteria
  to SRUs
• J Rehabil Med 2006 3921-26
• Study 8 Comparative study on follow-up services
  after inpatient stay
• In preparation

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Motor and functional recovery

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

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Patients selection

• 532 consecutive stroke patients

• 4 rehabilitation centres
• University Hospital Pellenberg (Belgium)
• City Hospital and Queens Medical Centre (UK)
• RehaClinic Zurzach (Switzerland)
• Fachklinik Herzogenaurach (Germany)

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Inclusion criteria

• first ever stroke
• age between 40 and 85 years
• motor impairment on admission (RMA)
• admitted lt 6 weeks after stroke
• pre-stroke Barthel Index gt50
• no other neurological disorders
• informed consent

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Methods
532 stroke patients
BE 127
UK 135
CH 135
DE 135
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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)

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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
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• 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

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• 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
lt1 patients in centre 1 have less chance to stay
in lower classes vs patients in centre 2 gt1
patients in centre 1 have more chance to stay in
lower classes vs patients in centre 2
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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
CH vs BE
UK vs BE
UK vs DE
CH vs UK
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• RMA-LT NS
• RMA-A NS

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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 gt85/100
• UK patients moderate on admission
• UK early discharge ? independence in ADL
• UK high input of nursing care

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Use of time

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

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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

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Use of time

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

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Absolute time in therapeutic activities Between
7.00 am and 5.00 pm
significant difference after correction for
case-mix
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Time available per patient per week per
professional group (in hours)
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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

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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
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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
  (ICC0.71-1.00)
• ? list was used to score the content of 15 PT-and
  15 OT tapes in each centre

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5 Mild
5 Mild


15 OT sessions

-

5 Moderate





5 Severe


30 therapy sessions
Centre



5 Mild




15 PT sessions

5 Moderate





5 Severe



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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

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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)

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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

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Use of time (OT PT)
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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

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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)

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Use of time (OT PT)
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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
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Summary

• German and Swiss centres rehabilitation
  programmes strictly timed ? Belgium and UK
  centres ad hoc organisation
• German PTs and OTs spent 66.1 and 63.3, resp.
  on direct patient care ? UK 46 and 33

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Overall conclusion
more formal management
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Socio-economic variables

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

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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

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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

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

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General conclusion

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

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General conclusion

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

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Anxiety and depression

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

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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 depression
• score 8 on HADS-A anxiety disorder
• score 8 on HADS-D depressive disorder

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Time course of prevalence of anxiety and
depression (complete cases n435)
Anxiety  (HADS-A 8) Depression (HADS-D 8)
Anxiety  Cochran-Q Q2.7 p0.26 Depression
Cochran-Q Q5.2 p0.07
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Composition of number of patients with anxiety
(HADS-Agt7) at two, four and six months after
stroke (total n435) and the associated severity
(median IQR)
Similar pattern for depression
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• 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

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Many people contributed

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

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

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

• 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

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• Use of time by stroke patients. A comparison of 4
  European rehabilitation centres. Stroke
  2005361977-1983.
• Stroke rehabilitation in Europe. What do
  physiotherapists and occupational therapists
  actually do? Stroke 2006341483-1489.
• Motor and functional recovery after stroke. A
  comparison of four European rehabilitation
  centres. Stroke 2007382101-2107
• Defining the content of individual PT and
  OTClinical Rehabilitation 200721450-459
• The effect of socioeconomic status on functional
  and motor recovery after stroke a European
  multicenter study. J Neurol Neurosurg Psychiatry
  200778593-599
• Use of time by physiotherapists and occupational
  therapists in a stroke rehabilitation unit a
  comparison between four European rehabilitation
  centres. Disabil Rehabil 2006281417-1424.
• Inpatient stroke rehabilitation a comparative
  study of admission-criteria to stroke
  rehabilitation units in four European centres. J
  Rehabil Med 20073921-26