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Having More Daughters Independently Predicts Home Discharge in Stroke Patients Admitted to Inpatient Rehabilitation Ward
International Journal of Gerontology 11 (2017) 197e201
Contents lists available at ScienceDirect
International Journal of Gerontology journal homepage: www.ijge-online.com
Original Article
Having More Daughters Independently Predicts Home Discharge in Stroke Patients Admitted to Inpatient Rehabilitation Ward Shiau-Fu Hsieh a, b *, Kuo-Liong Chien b, c, Chu-Hao Weng d, Yi-Ping Chiang a a Department of Physical Medicine and Rehabilitation, MacKay Memorial Hospital, Taipei, Taiwan, b Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan, c Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan, d Department of Urology, MacKay Memorial Hospital, Taipei, Taiwan
a r t i c l e i n f o
s u m m a r y
Article history: Received 10 April 2017 Received in revised form 22 June 2017 Accepted 17 July 2017 Available online 23 August 2017
Background: The predictors for failure of home discharge after post-acute inpatient stroke rehabilitation need investigation. Methods: With this retrospective case-control study conducted in a stroke rehabilitation unit in one tertiary hospital, data of 297 eligible stroke patients regarding patient demographics, family information, disease and function were collected. The primary outcome was failure of home discharge. Results: One hundred and eighteen of 297 stroke patients (mean age 63 years, 37% women) failed to discharge home, including 109 admitted to rehabilitation hospitals and 9 to long-term care facilities. An inverse trend existed between numbers of daughters and the risk of failure of home discharge: having three or more daughters significantly lowers the risks for poor discharge destination (adjusted odds ratio, 0.23, 95% confidence interval, 0.07e0.72; test for trend, p ¼ 0.002). Conclusion: Having more daughters independently predicts home discharge after post-acute inpatient stroke rehabilitation. Copyright © 2017, Taiwan Society of Geriatric Emergency & Critical Care Medicine. Published by Elsevier Taiwan LLC. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/ licenses/by-nc-nd/4.0/).
Keywords: stroke, rehabilitation, discharge, social support, daughter
1. Introduction Discharge disposition is a health issue at the participation level and an important health outcome which increasingly gathers attention.1 For stroke patients, the first and crucial disposition happens after discharge from post-acute inpatient rehabilitation ward. Failure to return home may compromise the quality of lives of stroke patients and families.2 Understanding its predicting factors helps health professionals to provide counseling and helps policy makers in improving case referral and long term care systems. Previous studies identified social support and committed caregivers as important protecting factors for good functional and discharge outcomes.3 Among committed caregivers, spouses are best-recognized.4 While children might be similarly important on disabled parents' care, their influences are less understood. Daughters are proved to take more responsibility than sons in direct caregiving for disabled parents.5 Asian families tend to
* Corresponding author. Department of Physical Medicine and Rehabilitation, MacKay Memorial Hospital, Taipei, Taiwan. E-mail address: [email protected] (S.-F. Hsieh).
depend more on informal caregiver support than other ethnic groups and therefore are more suitable for studying such effects.6 We hypothesized that stroke patients with more daughters are less likely to suffer a poor discharge outcome after post-acute inpatient rehabilitation. Having daughters may be an independent protective factor.
2. Methods 2.1. Study design and participants In this retrospective case-control study, we collected data of consecutive patients of the rehabilitation ward in a tertiary hospital in Taipei, Taiwan between July 2011 and December 2013. Patients were included if they were in their first post-acute inpatient rehabilitation program of the latest stroke. The post-acute phase was defined as within 90 days from stroke onset. Patients with concomitant or history of traumatic brain injury, subarachnoid hemorrhage, brain tumor or other brain lesions were excluded. Meanwhile, patients were excluded if referral to medical or neurologic services happened during hospitalization.
http://dx.doi.org/10.1016/j.ijge.2017.07.005 1873-9598/Copyright © 2017, Taiwan Society of Geriatric Emergency & Critical Care Medicine. Published by Elsevier Taiwan LLC. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
198
S.-F. Hsieh et al.
2.2. Stroke diagnosis and rehabilitation program Neurologists and neurosurgeons confirmed patients' diagnosis, stroke classification and severity based on guidelines.7 An experienced rehabilitation team provided intensive inpatient post-acute stroke rehabilitation, including structured physical, occupational, speech/swallowing therapies at a frequency of 8e15 sessions per week. Extra practice was encouraged. Length of stay was restricted by the Taiwan National Health Insurance to be shorter than 30 days. Rehabilitation doctors individualized rehabilitation goals based patients' prognosis. Patients and families decided discharge disposition after counseling with rehabilitation doctors. 2.3. Outcome data and potential predictors Discharge disposition was coded into ‘failure of home discharge’ and ‘home discharge’. Failure of home discharge included discharge to other rehabilitation hospitals and to long-term care facilities. Four categories of potential predictors were collected,8 including: 1) patient factors: age, gender, length of stay, 2) disease factors: stroke type, stroke severity, with cognitive impairment or not, having aphasia or not, 3) functional status: functional ability on admission and at discharge, and 4) social and environmental factors: years of formal education, having a job or not, needing financial support or not, having stairs at home or not, living with families or not, being married or not, having children or not, number of children, number of daughters, and number of sons. Stroke severity was assessed with the National Institute of Health Stroke Severity (NIHSS) Score by neurologists and neurosurgeons at first evaluation.9 The Cog-4 Scale composited item 1b, 1c, 9, 11 of the NIHSS scale to represent cognitive function in acute stroke.10 Functional status was scored using the Barthel
index (BI) on admission and before discharge.11 Primary care nurses collected social factors data during admission interviews. We further categorized patients based on the number of their daughters and sons. 2.4. Statistical analysis Participants with missing data of primary outcome were excluded, while participants with missing data for other variables remained in the analysis. Descriptive analyses of the overall population and of patient groups according to numbers of daughters were presented. The Chi-squared test or the Student's t-test was selected as appropriate. Correlations between variables were checked. We used the CochraneArmitage test for trend for the trend between numbers of daughters/sons and rates of failure of home discharge. Simple logistic regression was performed with failure of home discharge as the dependent factor. In multiple logistic regressions, the model 1 adjusted for age and sex. In model 2, the association was adjusted for age, sex and function at discharge. In model 3, other important factors were added. P values <0.05 were considered to be statistically significant. With the significance level set at 0.05 and power at 0.90 and the effect size of 3.9 for patients with caregivers living together to return to home, we estimated the required sample size was 202.12 Analyses were performed with SAS version 9.1 (SAS Institute, Cary, NC). Institutional Review Board of the research hospital approved the study. 3. Results One hundred and eighteen of 297 patients (39.7%) failed to discharge home after post-acute inpatient rehabilitation, including 109 patients subsequently admitted to other hospitals, and 9 admitted to long-term care facilities (Fig. 1). The age of patients was 63.1 ± 13.4 years, and 37.4% of them were women. The median of
Fig. 1. Flowchart of patients.
Home Discharge of Stroke Patients
199
Table 1 Characteristics of patients: grouping based on number of daughters: none, one, two, and more than three. (n ¼ 297)
Male Ischemic stroke Aphasia Formal education, years Non <6 6-9 9-12 12 Having a job Requiring financial support Having stairs at home Living with others Being married Having children Failure of home discharge
None (n ¼ 82)
Two (n ¼ 54)
More than three (n ¼ 51)
%
N
%
N
%
N
%
N
%
186 201 75
62.6 68.8 25.3
60 41 20
73.2 50.0 24.4
71 77 31
64.6 70.6 28.2
31 45 9
57.4 84.9 17.0
24 38 15
47.1 76.0 29.4
36 107 44 57 52 88 49 127 268 208 257 118
12.2 36.2 14.9 19.3 17.6 29.9 16.7 43.8 90.2 70.4 86.5 39.7
2 16 12 24 28 40 15 45 69 39 42 39
2.4 19.5 14.6 29.3 34.2 48.8 19.0 57.7 84.2 47.6 51.2 47.6
18 32 15 26 18 29 18 49 102 86 110 47
16.5 29.4 13.8 23.9 16.5 27.1 16.5 45.4 92.7 78.9 100.0 42.7
8 28 8 4 6 12 11 17 52 44 54 21
14.8 51.9 14.8 7.4 11.1 22.2 20.4 31.5 96.3 81.5 100.0 38.9
8 31 9 3 0 7 5 16 45 39 51 11
15.7 60.8 17.7 5.9 0.0 13.7 9.8 32.7 88.2 76.5 100.0 21.6
(n ¼ 297)
Age, years Length of stay, days NIHSS score, points Cog-4 score, points BI score on admission, points BI score at discharge, points Difference of BI score, points Number of sons Number of daughters Number of children
One (n ¼ 110)
N
None (n ¼ 82)
One (n ¼ 110)
Two (n ¼ 54)
More than three (n ¼ 51)
Mean
SD
Mean
SD
Mean
SD
Mean
SD
Mean
SD
63.1 36.8 8.8 1.3 36.5 45.5 10.0 1.5 1.3 2.8
13.4 17.0 6.0 2.3 23.6 24.4 9.6 1.1 1.3 1.8
52.2 37.9 9.7 1.5 39.9 49.8 9.8 1.0 0.0 1.0
13.3 16.1 6.3 2.5 25.4 26.7 10.7 1.2 0.0 1.2
65.7 36.4 8.7 1.1 35.6 45.3 10.3 1.7 1.0 2.7
11.6 19.5 6.0 2.2 23.8 23.8 9.7 1.0 0.0 1.0
67.7 36.6 8.0 1.0 38.4 47.8 10.4 1.7 2.0 3.7
10.8 15.9 5.6 2.2 22.3 21.3 9.0 1.0 0.0 1.0
70.9 36.4 8.6 1.6 32.6 38.8 9.2 1.4 3.6 5.0
8.5 15.3 5.8 2.3 22.0 24.5 8.4 1.2 0.8 1.4
*Denotes a significant difference (p < 0.05) between groups of different numbers of daughters in the rate of demographics and other factors. BI: Barthel Index; NIHSS: National Institute of Health Stroke Severity.
Fig. 2. The rate of failure of home discharge decreases when patients have more daughters but is not related to patients' number of sons.
p
0.019* <0.001* 0.41 <0.001*
0.001* 0.37 0.007* 0.08 <0.001* <0.001* 0.023* p
<0.001* 0.94 0.69 0.70 0.40 0.18 0.93 <0.001* <0.001* <0.001*
200
S.-F. Hsieh et al.
length of stay of post-acute inpatient rehabilitation was 35 days (Table 1). Eighty-seven percent of patients had children (median 3, min 0, max 9; sons median 1, min 0, max 6; daughters median 1, min 0, max 7). The number of exclusions due to missing data for primary outcome was low compared with the total number of exclusion (8/192, 4.2%) and the total number of participants (8/489, 1.6%). The rates of participants missing data for other variables were also low (data not shown). A trend existed between having more daughters and a lower risk of failure of home discharge (test for trend, p ¼ 0.002) (Fig. 2). Such trend was not observed between number of sons and risk of failure of home discharge (p ¼ 0.06). Patients with more daughters were more likely to be older, female, married, and were more likely to have ischemic stroke, receive fewer years of formal education, have no job, live in homes without stairs, and have more sons and children (data not shown). Table 2 shows the unadjusted significant predictors for poor outcome, failure of home discharge. These factors include hemorrhagic stroke, aphasia, a younger age, higher stroke severity, poorer cognition, worse functional ability on admission and at discharge, having fewer daughter and having fewer children. Having three or more daughters reduced 77% of the risk for poor discharge outcome (OR 0.23, 95% CI 0.07e0.72, p ¼ 0.003), compared with those without daughters after adjusting for age, sex and function at discharge (Table 3).
Table 3 Multivariate logistic regression for determinants for failure of home discharge in the study patients. Variable Model 1 Age, þ1 year Sex, male vs female Number of daughters, one vs none Number of daughters, two vs none Number of daughters, three or more vs none Model 2 Age, þ1 year Sex, male vs female Number of daughters, one vs none Number of daughters, two vs none Number of daughters, three or more vs none BI score at discharge, þ1 point Model 3 Age, þ1 year Sex, male vs female Number of daughters, one vs none Number of daughters, two vs none Number of daughters, three or more vs none BI score at discharge, þ1 point Type, ischemic vs hemorrhagic
Odds ratio
95% confidence interval
p
0.98 0.67 1.00 0.86 0.37
0.96 0.40 0.53 0.40 0.15
1.00 1.11 1.91 1.86 0.91
0.10 0.12 0.14 0.59 0.014*
0.97 0.86 0.91 1.20 0.23
0.95 0.45 0.40 0.46 0.07
1.00 1.65 2.08 3.14 0.72
0.029* 0.64 0.30 0.08 0.003*
0.97 0.98 0.84 0.92 1.33 0.24
0.95 0.95 0.43 0.40 0.50 0.08
0.98 1.00 1.61 2.10 3.54 0.77
0.001* 0.08 0.59 0.37 0.06 0.003*
0.97 0.68
0.95 0.33
0.98 1.37
0.001* 0.28
*Denotes a significant difference (p < 0.05) between groups of different numbers of daughters in the rate of demographics and other factors. BI: Barthel Index; NIHSS: National Institute of Health Stroke Severity.
4. Discussion Having three or more daughters independently protected stroke patients against poor discharge outcome after adjusting for age, sex and self-care function in post-acute stroke. We view this finding highly possible. Women in a modern industrialized society13 maintain strong family function while gaining financial autonomy. Evidences showed that married daughters often provide care for elderly parents and children simultaneously while some unmarried daughters may live with parents and become direct
Table 2 Univariate logistic regressions for failure of home discharge among the study patients. Variable
Odds ratio
Sex, male vs female Type, ischemic stroke vs hemorrhagic Aphasia, yes vs no Formal education 12 vs <12 years Having a job, yes vs no Requiring financial support, yes vs no Having stairs at home, yes vs no Living with others, yes vs no Being married, yes vs no Having children, yes vs no Age, þ1 year Length of stay, þ1 day NIHSS, þ1 point Cog-4, þ1 point BI score on admission, þ1 point BI score at discharge, þ1 point Difference of BI score, þ1 point Number of sons, þ1 person Number of daughters, þ1 person One daughter vs none Two daughters vs none Three daughters vs none Number of children, þ1 person
0.80 0.52 2.32 2.54 0.68 1.11 1.11 0.90 0.69 0.75 0.98 0.99 1.10 1.17 0.97 0.97 0.98 0.92 0.75 1.00 0.86 0.37 0.79
95% confidence interval 0.50 0.31 1.36 0.92 0.37 0.24 0.68 0.41 0.41 0.35 0.96 0.98 1.03 1.01 0.96 0.96 0.95 0.72 0.59 0.53 0.40 0.15 0.66
1.29 0.89 3.95 7.01 1.23 5.15 1.80 1.98 1.16 1.64 1.00 1.01 1.17 1.36 0.98 0.98 1.01 1.17 0.94 1.91 1.86 0.91 0.94
p 0.36 0.018* 0.002* 0.22 0.97 0.83 0.67 0.79 0.17 0.47 0.022* 0.21 0.003* 0.042* 0.001* 0.001* 0.18 0.47 0.012* 0.14 0.59 0.014* 0.009*
*Denotes a significant difference (p < 0.05) between groups of different numbers of daughters in the rate of demographics and other factors. BI: Barthel Index; NIHSS: National Institute of Health Stroke Severity.
caregivers. In this background, adult daughters may have larger influences than sons to coordinate, support and fund home discharge of their disabled parents. Daughters were common caregivers for diseased parents besides patients' spouses, daughters-in-law. Daughters are more likely to take caregiving responsibility than sons, and are frequent suffers for care-related stress and depression.14e16 A similar study from Koyama researching the Japanese population reported that children had limited impacts on stroke patients' home discharge while spouses mattered.17 We suspect this finding may result from differences in the selected geographic areas and from differences in the family structures of the selected populations, which requires further researches to clarify. Our study reported the second highest rate of failure of home discharge among studies, 36.7%, with a relatively short length of stay and comparable rehabilitation quality. Other studies reported poor discharge outcome rates between 18 and 55%.18,19 Another important finding is 92% of these patients were transferred to other acute rehabilitation hospitals, representing an abnormally high readmission rate. Our observation is, for stroke patients, Taiwan's National Health Insurance limits inpatient rehabilitation to shorter than one month but the system doesn't restrict patients from attending more than one inpatient program until 6 months from stroke onset. Patients tend to rotate among rehabilitation wards rather than plan for home discharge within this time frame. Acute inpatient rehabilitation programs provide medical care, rehabilitation training, and barrier-free environment and therefore are easy choices for patients and families compared with home discharge or long term care facilities. In our study, being married was not statistically significant despite of a protecting trend. Previous studies showed being married was protective for home discharge,20 and that a large portion of primary caregivers was patients' wives.21 We believed here this effect was less obvious in our study due to a stronger influence from daughters which was strongly related to being married (data not shown). Our study confirmed that functional ability is important against poor discharge outcome.19 Younger age is related to a small
Home Discharge of Stroke Patients
increase in risk while previous studies showed opposite associations.20 One explanation is that in young patients set high rehabilitation goals so tend to seek further inpatient programs while the elderly in Taiwan expect less independence than their counterparts in western countries. Study limitations included that outcome data was retrospectively retrieved. But the proportion of misclassification was estimated to be small. Second, demographic data of patients' family members were not collected. Their caregiver roles will be addressed in our future research. Third, some potential confounders were not analyzed in our study due to absence or insufficient quality of data, including visuospatial impairment,3 sitting balance,20 comorbidities,18 quality of life22 but we addressed other important factors such as gender,3 etiology of stroke,3 communication ability,20 cognitive function,4 and environmental factors.3 Our novel finding requires attention because as disabled and geriatric populations increase in every society, new strategies to facilitate their home discharge are important to cut unnecessary costs while maintaining high-quality inpatient rehabilitation services. The implications from our findings are that resources should be allocated to caregivers especially daughters after patients' hospitalization to facilitate good discharge outcome. For patients without daughters, alternative home caregiving services should be introduced early. Conflict of interest None. References 1. WHO I. International Classification of Functioning. Disability and Health. Geneva, Switzerland: World Health Organization; 2001. 2. Meijer R, van Limbeek J, Peusens G, et al. The stroke unit discharge guideline, a prognostic framework for the discharge outcome from the hospital stroke unit. A prospective cohort study. Clin Rehabil. 2005;19:770e778. 3. Meijer R, Ihnenfeldt DS, van Limbeek J, et al. Prognostic factors in the subacute phase after stroke for the future residence after six months to one year. A systematic review of the literature. Clin Rehabil. 2003;17:512e520. 4. Meijer R, Ihnenfeldt D, van Limbeek J, et al. Prognostic social factors in the subacute phase after a stroke for the discharge destination from the hospital stroke-unit. A systematic review of the literature. Disabil Rehabil. 2004;26: 191e197.
201 5. Bhattacharjee M, Vairale J, Gawali K, et al. Factors affecting burden on caregivers of stroke survivors: population-based study in Mumbai (India). Ann Indian Acad Neurol. 2012;15:113e119. 6. Pinquart M, Sorensen S. Ethnic differences in stressors, resources, and psychological outcomes of family caregiving: a meta-analysis. Gerontologist. 2005;45:90e106. 7. Adams Jr HP, del Zoppo G, Alberts MJ, et al. Guidelines for the early management of adults with ischemic stroke: a guideline from the American Heart Association/American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council, and the Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups: the American Academy of Neurology affirms the value of this guideline as an educational tool for neurologists. Circulation. 2007;115:e478e534. 8. Meijer R, Ihnenfeldt D, Vermeulen M, et al. The use of a modified Delphi procedure for the determination of 26 prognostic factors in the sub-acute stage of stroke. Int J Rehabil Res. 2003;26:265e270. 9. Brott T, Adams Jr HP, Olinger CP, et al. Measurements of acute cerebral infarction: a clinical examination scale. Stroke. 1989;20:864e870. 10. Cumming TB, Blomstrand C, Bernhardt J, et al. The NIH stroke scale can establish cognitive function after stroke. Cerebrovasc Dis. 2010;30:7e14. 11. Mahoney FI, Barthel DW. Functional evaluation: the Barthel index. Md State Med J. 1965;14:61e65. 12. Demidenko E. Sample size determination for logistic regression revisited. Stat Med. 2007;26:3385e3397. 13. Juratovac E, Zauszniewski JA. Full-time employed and a family caregiver: a profile of women's workload, effort, and health. Women's Health Issues. 2014;24:e187ee196. 14. Do YK, Norton EC, Stearns SC, et al. Informal care and caregiver's health. Health Econ. 2015;24:224e237. 15. Harris PB, Long SO. Daughter-in-law's burden: an exploratory study of caregiving in Japan. J Cross Cult Gerontol. 1993;8:97e118. 16. Kim JS. Daughters-in-law in Korean caregiving families. J Adv Nurs. 2001;36: 399e408. 17. Koyama T, Sako Y, Konta M, et al. Poststroke discharge destination: functional independence and sociodemographic factors in urban Japan. J Stroke Cerebrovasc Dis. 2011;20:202e207. 18. Pinedo S, Erazo P, Tejada P, et al. Rehabilitation efficiency and destination on discharge after stroke. Eur J Phys Rehabil Med. 2014;50:323e333. 19. Sandstrom R, Mokler PJ, Hoppe KM. Discharge destination and motor function outcome in severe stroke as measured by the functional independence measure/function-related group classification system. Arch Phys Med Rehabil. 1998;79:762e765. 20. Frank M, Conzelmann M, Engelter S. Prediction of discharge destination after neurological rehabilitation in stroke patients. Eur Neurol. 2010;63:227e233. 21. Bugge C, Alexander H, Hagen S. Stroke patients' informal caregivers. Patient, caregiver, and service factors that affect caregiver strain. Stroke. 1999;30: 1517e1523. 22. Graessel E, Schmidt R, Schupp W. Stroke patients after neurological inpatient rehabilitation: a prospective study to determine whether functional status or health-related quality of life predict living at home 2.5 years after discharge. Int J Rehabil Res. 2014;37:212e219.
Contents lists available at ScienceDirect
International Journal of Gerontology journal homepage: www.ijge-online.com
Original Article
Having More Daughters Independently Predicts Home Discharge in Stroke Patients Admitted to Inpatient Rehabilitation Ward Shiau-Fu Hsieh a, b *, Kuo-Liong Chien b, c, Chu-Hao Weng d, Yi-Ping Chiang a a Department of Physical Medicine and Rehabilitation, MacKay Memorial Hospital, Taipei, Taiwan, b Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan, c Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan, d Department of Urology, MacKay Memorial Hospital, Taipei, Taiwan
a r t i c l e i n f o
s u m m a r y
Article history: Received 10 April 2017 Received in revised form 22 June 2017 Accepted 17 July 2017 Available online 23 August 2017
Background: The predictors for failure of home discharge after post-acute inpatient stroke rehabilitation need investigation. Methods: With this retrospective case-control study conducted in a stroke rehabilitation unit in one tertiary hospital, data of 297 eligible stroke patients regarding patient demographics, family information, disease and function were collected. The primary outcome was failure of home discharge. Results: One hundred and eighteen of 297 stroke patients (mean age 63 years, 37% women) failed to discharge home, including 109 admitted to rehabilitation hospitals and 9 to long-term care facilities. An inverse trend existed between numbers of daughters and the risk of failure of home discharge: having three or more daughters significantly lowers the risks for poor discharge destination (adjusted odds ratio, 0.23, 95% confidence interval, 0.07e0.72; test for trend, p ¼ 0.002). Conclusion: Having more daughters independently predicts home discharge after post-acute inpatient stroke rehabilitation. Copyright © 2017, Taiwan Society of Geriatric Emergency & Critical Care Medicine. Published by Elsevier Taiwan LLC. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/ licenses/by-nc-nd/4.0/).
Keywords: stroke, rehabilitation, discharge, social support, daughter
1. Introduction Discharge disposition is a health issue at the participation level and an important health outcome which increasingly gathers attention.1 For stroke patients, the first and crucial disposition happens after discharge from post-acute inpatient rehabilitation ward. Failure to return home may compromise the quality of lives of stroke patients and families.2 Understanding its predicting factors helps health professionals to provide counseling and helps policy makers in improving case referral and long term care systems. Previous studies identified social support and committed caregivers as important protecting factors for good functional and discharge outcomes.3 Among committed caregivers, spouses are best-recognized.4 While children might be similarly important on disabled parents' care, their influences are less understood. Daughters are proved to take more responsibility than sons in direct caregiving for disabled parents.5 Asian families tend to
* Corresponding author. Department of Physical Medicine and Rehabilitation, MacKay Memorial Hospital, Taipei, Taiwan. E-mail address: [email protected] (S.-F. Hsieh).
depend more on informal caregiver support than other ethnic groups and therefore are more suitable for studying such effects.6 We hypothesized that stroke patients with more daughters are less likely to suffer a poor discharge outcome after post-acute inpatient rehabilitation. Having daughters may be an independent protective factor.
2. Methods 2.1. Study design and participants In this retrospective case-control study, we collected data of consecutive patients of the rehabilitation ward in a tertiary hospital in Taipei, Taiwan between July 2011 and December 2013. Patients were included if they were in their first post-acute inpatient rehabilitation program of the latest stroke. The post-acute phase was defined as within 90 days from stroke onset. Patients with concomitant or history of traumatic brain injury, subarachnoid hemorrhage, brain tumor or other brain lesions were excluded. Meanwhile, patients were excluded if referral to medical or neurologic services happened during hospitalization.
http://dx.doi.org/10.1016/j.ijge.2017.07.005 1873-9598/Copyright © 2017, Taiwan Society of Geriatric Emergency & Critical Care Medicine. Published by Elsevier Taiwan LLC. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
198
S.-F. Hsieh et al.
2.2. Stroke diagnosis and rehabilitation program Neurologists and neurosurgeons confirmed patients' diagnosis, stroke classification and severity based on guidelines.7 An experienced rehabilitation team provided intensive inpatient post-acute stroke rehabilitation, including structured physical, occupational, speech/swallowing therapies at a frequency of 8e15 sessions per week. Extra practice was encouraged. Length of stay was restricted by the Taiwan National Health Insurance to be shorter than 30 days. Rehabilitation doctors individualized rehabilitation goals based patients' prognosis. Patients and families decided discharge disposition after counseling with rehabilitation doctors. 2.3. Outcome data and potential predictors Discharge disposition was coded into ‘failure of home discharge’ and ‘home discharge’. Failure of home discharge included discharge to other rehabilitation hospitals and to long-term care facilities. Four categories of potential predictors were collected,8 including: 1) patient factors: age, gender, length of stay, 2) disease factors: stroke type, stroke severity, with cognitive impairment or not, having aphasia or not, 3) functional status: functional ability on admission and at discharge, and 4) social and environmental factors: years of formal education, having a job or not, needing financial support or not, having stairs at home or not, living with families or not, being married or not, having children or not, number of children, number of daughters, and number of sons. Stroke severity was assessed with the National Institute of Health Stroke Severity (NIHSS) Score by neurologists and neurosurgeons at first evaluation.9 The Cog-4 Scale composited item 1b, 1c, 9, 11 of the NIHSS scale to represent cognitive function in acute stroke.10 Functional status was scored using the Barthel
index (BI) on admission and before discharge.11 Primary care nurses collected social factors data during admission interviews. We further categorized patients based on the number of their daughters and sons. 2.4. Statistical analysis Participants with missing data of primary outcome were excluded, while participants with missing data for other variables remained in the analysis. Descriptive analyses of the overall population and of patient groups according to numbers of daughters were presented. The Chi-squared test or the Student's t-test was selected as appropriate. Correlations between variables were checked. We used the CochraneArmitage test for trend for the trend between numbers of daughters/sons and rates of failure of home discharge. Simple logistic regression was performed with failure of home discharge as the dependent factor. In multiple logistic regressions, the model 1 adjusted for age and sex. In model 2, the association was adjusted for age, sex and function at discharge. In model 3, other important factors were added. P values <0.05 were considered to be statistically significant. With the significance level set at 0.05 and power at 0.90 and the effect size of 3.9 for patients with caregivers living together to return to home, we estimated the required sample size was 202.12 Analyses were performed with SAS version 9.1 (SAS Institute, Cary, NC). Institutional Review Board of the research hospital approved the study. 3. Results One hundred and eighteen of 297 patients (39.7%) failed to discharge home after post-acute inpatient rehabilitation, including 109 patients subsequently admitted to other hospitals, and 9 admitted to long-term care facilities (Fig. 1). The age of patients was 63.1 ± 13.4 years, and 37.4% of them were women. The median of
Fig. 1. Flowchart of patients.
Home Discharge of Stroke Patients
199
Table 1 Characteristics of patients: grouping based on number of daughters: none, one, two, and more than three. (n ¼ 297)
Male Ischemic stroke Aphasia Formal education, years Non <6 6-9 9-12 12 Having a job Requiring financial support Having stairs at home Living with others Being married Having children Failure of home discharge
None (n ¼ 82)
Two (n ¼ 54)
More than three (n ¼ 51)
%
N
%
N
%
N
%
N
%
186 201 75
62.6 68.8 25.3
60 41 20
73.2 50.0 24.4
71 77 31
64.6 70.6 28.2
31 45 9
57.4 84.9 17.0
24 38 15
47.1 76.0 29.4
36 107 44 57 52 88 49 127 268 208 257 118
12.2 36.2 14.9 19.3 17.6 29.9 16.7 43.8 90.2 70.4 86.5 39.7
2 16 12 24 28 40 15 45 69 39 42 39
2.4 19.5 14.6 29.3 34.2 48.8 19.0 57.7 84.2 47.6 51.2 47.6
18 32 15 26 18 29 18 49 102 86 110 47
16.5 29.4 13.8 23.9 16.5 27.1 16.5 45.4 92.7 78.9 100.0 42.7
8 28 8 4 6 12 11 17 52 44 54 21
14.8 51.9 14.8 7.4 11.1 22.2 20.4 31.5 96.3 81.5 100.0 38.9
8 31 9 3 0 7 5 16 45 39 51 11
15.7 60.8 17.7 5.9 0.0 13.7 9.8 32.7 88.2 76.5 100.0 21.6
(n ¼ 297)
Age, years Length of stay, days NIHSS score, points Cog-4 score, points BI score on admission, points BI score at discharge, points Difference of BI score, points Number of sons Number of daughters Number of children
One (n ¼ 110)
N
None (n ¼ 82)
One (n ¼ 110)
Two (n ¼ 54)
More than three (n ¼ 51)
Mean
SD
Mean
SD
Mean
SD
Mean
SD
Mean
SD
63.1 36.8 8.8 1.3 36.5 45.5 10.0 1.5 1.3 2.8
13.4 17.0 6.0 2.3 23.6 24.4 9.6 1.1 1.3 1.8
52.2 37.9 9.7 1.5 39.9 49.8 9.8 1.0 0.0 1.0
13.3 16.1 6.3 2.5 25.4 26.7 10.7 1.2 0.0 1.2
65.7 36.4 8.7 1.1 35.6 45.3 10.3 1.7 1.0 2.7
11.6 19.5 6.0 2.2 23.8 23.8 9.7 1.0 0.0 1.0
67.7 36.6 8.0 1.0 38.4 47.8 10.4 1.7 2.0 3.7
10.8 15.9 5.6 2.2 22.3 21.3 9.0 1.0 0.0 1.0
70.9 36.4 8.6 1.6 32.6 38.8 9.2 1.4 3.6 5.0
8.5 15.3 5.8 2.3 22.0 24.5 8.4 1.2 0.8 1.4
*Denotes a significant difference (p < 0.05) between groups of different numbers of daughters in the rate of demographics and other factors. BI: Barthel Index; NIHSS: National Institute of Health Stroke Severity.
Fig. 2. The rate of failure of home discharge decreases when patients have more daughters but is not related to patients' number of sons.
p
0.019* <0.001* 0.41 <0.001*
0.001* 0.37 0.007* 0.08 <0.001* <0.001* 0.023* p
<0.001* 0.94 0.69 0.70 0.40 0.18 0.93 <0.001* <0.001* <0.001*
200
S.-F. Hsieh et al.
length of stay of post-acute inpatient rehabilitation was 35 days (Table 1). Eighty-seven percent of patients had children (median 3, min 0, max 9; sons median 1, min 0, max 6; daughters median 1, min 0, max 7). The number of exclusions due to missing data for primary outcome was low compared with the total number of exclusion (8/192, 4.2%) and the total number of participants (8/489, 1.6%). The rates of participants missing data for other variables were also low (data not shown). A trend existed between having more daughters and a lower risk of failure of home discharge (test for trend, p ¼ 0.002) (Fig. 2). Such trend was not observed between number of sons and risk of failure of home discharge (p ¼ 0.06). Patients with more daughters were more likely to be older, female, married, and were more likely to have ischemic stroke, receive fewer years of formal education, have no job, live in homes without stairs, and have more sons and children (data not shown). Table 2 shows the unadjusted significant predictors for poor outcome, failure of home discharge. These factors include hemorrhagic stroke, aphasia, a younger age, higher stroke severity, poorer cognition, worse functional ability on admission and at discharge, having fewer daughter and having fewer children. Having three or more daughters reduced 77% of the risk for poor discharge outcome (OR 0.23, 95% CI 0.07e0.72, p ¼ 0.003), compared with those without daughters after adjusting for age, sex and function at discharge (Table 3).
Table 3 Multivariate logistic regression for determinants for failure of home discharge in the study patients. Variable Model 1 Age, þ1 year Sex, male vs female Number of daughters, one vs none Number of daughters, two vs none Number of daughters, three or more vs none Model 2 Age, þ1 year Sex, male vs female Number of daughters, one vs none Number of daughters, two vs none Number of daughters, three or more vs none BI score at discharge, þ1 point Model 3 Age, þ1 year Sex, male vs female Number of daughters, one vs none Number of daughters, two vs none Number of daughters, three or more vs none BI score at discharge, þ1 point Type, ischemic vs hemorrhagic
Odds ratio
95% confidence interval
p
0.98 0.67 1.00 0.86 0.37
0.96 0.40 0.53 0.40 0.15
1.00 1.11 1.91 1.86 0.91
0.10 0.12 0.14 0.59 0.014*
0.97 0.86 0.91 1.20 0.23
0.95 0.45 0.40 0.46 0.07
1.00 1.65 2.08 3.14 0.72
0.029* 0.64 0.30 0.08 0.003*
0.97 0.98 0.84 0.92 1.33 0.24
0.95 0.95 0.43 0.40 0.50 0.08
0.98 1.00 1.61 2.10 3.54 0.77
0.001* 0.08 0.59 0.37 0.06 0.003*
0.97 0.68
0.95 0.33
0.98 1.37
0.001* 0.28
*Denotes a significant difference (p < 0.05) between groups of different numbers of daughters in the rate of demographics and other factors. BI: Barthel Index; NIHSS: National Institute of Health Stroke Severity.
4. Discussion Having three or more daughters independently protected stroke patients against poor discharge outcome after adjusting for age, sex and self-care function in post-acute stroke. We view this finding highly possible. Women in a modern industrialized society13 maintain strong family function while gaining financial autonomy. Evidences showed that married daughters often provide care for elderly parents and children simultaneously while some unmarried daughters may live with parents and become direct
Table 2 Univariate logistic regressions for failure of home discharge among the study patients. Variable
Odds ratio
Sex, male vs female Type, ischemic stroke vs hemorrhagic Aphasia, yes vs no Formal education 12 vs <12 years Having a job, yes vs no Requiring financial support, yes vs no Having stairs at home, yes vs no Living with others, yes vs no Being married, yes vs no Having children, yes vs no Age, þ1 year Length of stay, þ1 day NIHSS, þ1 point Cog-4, þ1 point BI score on admission, þ1 point BI score at discharge, þ1 point Difference of BI score, þ1 point Number of sons, þ1 person Number of daughters, þ1 person One daughter vs none Two daughters vs none Three daughters vs none Number of children, þ1 person
0.80 0.52 2.32 2.54 0.68 1.11 1.11 0.90 0.69 0.75 0.98 0.99 1.10 1.17 0.97 0.97 0.98 0.92 0.75 1.00 0.86 0.37 0.79
95% confidence interval 0.50 0.31 1.36 0.92 0.37 0.24 0.68 0.41 0.41 0.35 0.96 0.98 1.03 1.01 0.96 0.96 0.95 0.72 0.59 0.53 0.40 0.15 0.66
1.29 0.89 3.95 7.01 1.23 5.15 1.80 1.98 1.16 1.64 1.00 1.01 1.17 1.36 0.98 0.98 1.01 1.17 0.94 1.91 1.86 0.91 0.94
p 0.36 0.018* 0.002* 0.22 0.97 0.83 0.67 0.79 0.17 0.47 0.022* 0.21 0.003* 0.042* 0.001* 0.001* 0.18 0.47 0.012* 0.14 0.59 0.014* 0.009*
*Denotes a significant difference (p < 0.05) between groups of different numbers of daughters in the rate of demographics and other factors. BI: Barthel Index; NIHSS: National Institute of Health Stroke Severity.
caregivers. In this background, adult daughters may have larger influences than sons to coordinate, support and fund home discharge of their disabled parents. Daughters were common caregivers for diseased parents besides patients' spouses, daughters-in-law. Daughters are more likely to take caregiving responsibility than sons, and are frequent suffers for care-related stress and depression.14e16 A similar study from Koyama researching the Japanese population reported that children had limited impacts on stroke patients' home discharge while spouses mattered.17 We suspect this finding may result from differences in the selected geographic areas and from differences in the family structures of the selected populations, which requires further researches to clarify. Our study reported the second highest rate of failure of home discharge among studies, 36.7%, with a relatively short length of stay and comparable rehabilitation quality. Other studies reported poor discharge outcome rates between 18 and 55%.18,19 Another important finding is 92% of these patients were transferred to other acute rehabilitation hospitals, representing an abnormally high readmission rate. Our observation is, for stroke patients, Taiwan's National Health Insurance limits inpatient rehabilitation to shorter than one month but the system doesn't restrict patients from attending more than one inpatient program until 6 months from stroke onset. Patients tend to rotate among rehabilitation wards rather than plan for home discharge within this time frame. Acute inpatient rehabilitation programs provide medical care, rehabilitation training, and barrier-free environment and therefore are easy choices for patients and families compared with home discharge or long term care facilities. In our study, being married was not statistically significant despite of a protecting trend. Previous studies showed being married was protective for home discharge,20 and that a large portion of primary caregivers was patients' wives.21 We believed here this effect was less obvious in our study due to a stronger influence from daughters which was strongly related to being married (data not shown). Our study confirmed that functional ability is important against poor discharge outcome.19 Younger age is related to a small
Home Discharge of Stroke Patients
increase in risk while previous studies showed opposite associations.20 One explanation is that in young patients set high rehabilitation goals so tend to seek further inpatient programs while the elderly in Taiwan expect less independence than their counterparts in western countries. Study limitations included that outcome data was retrospectively retrieved. But the proportion of misclassification was estimated to be small. Second, demographic data of patients' family members were not collected. Their caregiver roles will be addressed in our future research. Third, some potential confounders were not analyzed in our study due to absence or insufficient quality of data, including visuospatial impairment,3 sitting balance,20 comorbidities,18 quality of life22 but we addressed other important factors such as gender,3 etiology of stroke,3 communication ability,20 cognitive function,4 and environmental factors.3 Our novel finding requires attention because as disabled and geriatric populations increase in every society, new strategies to facilitate their home discharge are important to cut unnecessary costs while maintaining high-quality inpatient rehabilitation services. The implications from our findings are that resources should be allocated to caregivers especially daughters after patients' hospitalization to facilitate good discharge outcome. For patients without daughters, alternative home caregiving services should be introduced early. Conflict of interest None. References 1. WHO I. International Classification of Functioning. Disability and Health. Geneva, Switzerland: World Health Organization; 2001. 2. Meijer R, van Limbeek J, Peusens G, et al. The stroke unit discharge guideline, a prognostic framework for the discharge outcome from the hospital stroke unit. A prospective cohort study. Clin Rehabil. 2005;19:770e778. 3. Meijer R, Ihnenfeldt DS, van Limbeek J, et al. Prognostic factors in the subacute phase after stroke for the future residence after six months to one year. A systematic review of the literature. Clin Rehabil. 2003;17:512e520. 4. Meijer R, Ihnenfeldt D, van Limbeek J, et al. Prognostic social factors in the subacute phase after a stroke for the discharge destination from the hospital stroke-unit. A systematic review of the literature. Disabil Rehabil. 2004;26: 191e197.
201 5. Bhattacharjee M, Vairale J, Gawali K, et al. Factors affecting burden on caregivers of stroke survivors: population-based study in Mumbai (India). Ann Indian Acad Neurol. 2012;15:113e119. 6. Pinquart M, Sorensen S. Ethnic differences in stressors, resources, and psychological outcomes of family caregiving: a meta-analysis. Gerontologist. 2005;45:90e106. 7. Adams Jr HP, del Zoppo G, Alberts MJ, et al. Guidelines for the early management of adults with ischemic stroke: a guideline from the American Heart Association/American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council, and the Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups: the American Academy of Neurology affirms the value of this guideline as an educational tool for neurologists. Circulation. 2007;115:e478e534. 8. Meijer R, Ihnenfeldt D, Vermeulen M, et al. The use of a modified Delphi procedure for the determination of 26 prognostic factors in the sub-acute stage of stroke. Int J Rehabil Res. 2003;26:265e270. 9. Brott T, Adams Jr HP, Olinger CP, et al. Measurements of acute cerebral infarction: a clinical examination scale. Stroke. 1989;20:864e870. 10. Cumming TB, Blomstrand C, Bernhardt J, et al. The NIH stroke scale can establish cognitive function after stroke. Cerebrovasc Dis. 2010;30:7e14. 11. Mahoney FI, Barthel DW. Functional evaluation: the Barthel index. Md State Med J. 1965;14:61e65. 12. Demidenko E. Sample size determination for logistic regression revisited. Stat Med. 2007;26:3385e3397. 13. Juratovac E, Zauszniewski JA. Full-time employed and a family caregiver: a profile of women's workload, effort, and health. Women's Health Issues. 2014;24:e187ee196. 14. Do YK, Norton EC, Stearns SC, et al. Informal care and caregiver's health. Health Econ. 2015;24:224e237. 15. Harris PB, Long SO. Daughter-in-law's burden: an exploratory study of caregiving in Japan. J Cross Cult Gerontol. 1993;8:97e118. 16. Kim JS. Daughters-in-law in Korean caregiving families. J Adv Nurs. 2001;36: 399e408. 17. Koyama T, Sako Y, Konta M, et al. Poststroke discharge destination: functional independence and sociodemographic factors in urban Japan. J Stroke Cerebrovasc Dis. 2011;20:202e207. 18. Pinedo S, Erazo P, Tejada P, et al. Rehabilitation efficiency and destination on discharge after stroke. Eur J Phys Rehabil Med. 2014;50:323e333. 19. Sandstrom R, Mokler PJ, Hoppe KM. Discharge destination and motor function outcome in severe stroke as measured by the functional independence measure/function-related group classification system. Arch Phys Med Rehabil. 1998;79:762e765. 20. Frank M, Conzelmann M, Engelter S. Prediction of discharge destination after neurological rehabilitation in stroke patients. Eur Neurol. 2010;63:227e233. 21. Bugge C, Alexander H, Hagen S. Stroke patients' informal caregivers. Patient, caregiver, and service factors that affect caregiver strain. Stroke. 1999;30: 1517e1523. 22. Graessel E, Schmidt R, Schupp W. Stroke patients after neurological inpatient rehabilitation: a prospective study to determine whether functional status or health-related quality of life predict living at home 2.5 years after discharge. Int J Rehabil Res. 2014;37:212e219.