collaborative evaluation of rehabilitation in stroke across europe

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



5 Mild




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)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


• 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)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

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


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


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


0

20

40

60

80

100

Admission Discharge 6 months

0

4

8

12


0

20

40

60

80

100


0

4

8

12


Barthel Index RMA-arm

Education

Equivalent income


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

collaborative evaluation of rehabilitation in stroke across europe

Documents