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A functional recovery profile for patients with stroke following post-acute rehabilitation care in Taiwan
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Original Article
A functional recovery profile for patients with stroke following post-acute rehabilitation care in Taiwan Sou-Hsin Chien a,b,c, Pi-Yu Sung a,c,d, Wen-Ling Liao d, Sen-Wei Tsai a,c,d,* a Department of Post-Acute Care Center, Taichung Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taichung City 427, Taiwan b Department of Plastic Surgery, Taichung Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taichung City 427, Taiwan c School of Medicine, Tzu Chi University, Hualien 970, Taiwan d Department of Physical Medicine and Rehabilitation, Taichung Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taichung City 427, Taiwan
Received 10 March 2019; received in revised form 10 April 2019; accepted 14 May 2019
KEYWORDS Post-acute care; Rehabilitation; Stroke; Modified ranking scale
Background: Functional impairment is frequently seen in patients with stroke. Although the progression of functional recovery after stroke has been proposed, the recovery profile after acute stroke is not well described. The objective of this study is to investigate functional recovery in stroke patients entering post-acute rehabilitation care. Methods: A retrospective cohort study collected the data of patients who entered the stroke Post-acute Care (PAC) programs. Ninety-five patients after stroke with a modified Ranking Scale (mRS) score of 3e4 who were referred to a post-acute care unit for intensive rehabilitation were recruited. The patients underwent functional, quality of life, and neuropsychological evaluation tests at admission and before discharge. The test scores before discharge were used as outcome variables and were compared with the test scores at admission to show functional recovery. Results: The average length of stay was 58.15 days. After an intensive rehabilitation intervention, significant improvements were observed in all test scores. Additionally, a significant removal rate for nasogastric tubes (p Z 0.000) and Foley catheters (p Z 0.003) was found at discharge. Conclusions: This study showed that the PAC rehabilitation unit was beneficial for patients with acute stroke who had functional impairments. The study results may call for further investigation to identify and develop better models for the delivery of rehabilitation in the stroke PAC unit.
* Corresponding author. Physical Medicine and Rehabilitation, Taichung Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Sec. 1, Fengxing Rd., Tanzi Dist., Taichung City 427, Taiwan. E-mail address: [email protected] (S.-W. Tsai). https://doi.org/10.1016/j.jfma.2019.05.013 0929-6646/Copyright ª 2019, Formosan Medical Association. 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/). Please cite this article as: Chien S-H et al., A functional recovery profile for patients with stroke following post-acute rehabilitation care in Taiwan, Journal of the Formosan Medical Association, https://doi.org/10.1016/j.jfma.2019.05.013
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S.-H. Chien et al. Copyright ª 2019, Formosan Medical Association. Published by Elsevier Taiwan LLC. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/bync-nd/4.0/).
Introduction Although advances in acute stroke treatment, such as thrombolytic and endovascular interventions, have increased post-stroke survival, stroke remains one of the most common causes of disability.1 Post-stroke disability is a major health burden worldwide.2,3 Moreover, variation exists in how stroke care services are provided in different regions and countries. The variations in post-stroke care are mostly dependent on the availability of financial and medical resources.4,5 In the United States, stroke post-acute care (PAC) can take place in the inpatient rehabilitation center, a skilled nursing facility, or in the patient’s home, and the spending is mostly provided by Medicare.6 According to previous reports, Medicare spending in the United States on PAC accounts for more than 15% of Medicare spending.4,7 In Europe, studies have surveyed the results of stroke through different registries, including the European Registers of Stroke (EROS) and Collaborative Evaluation of Rehabilitation in Stroke across Europe (CERISE). Although most poststroke patients receive institutional rehabilitation care, large variations exist in rehabilitation services and outcomes among different countries.8,9 In Taiwan, post-stroke rehabilitation in the past was primarily conducted in inpatient rehabilitation facilities for six months after discharge from acute settings. Thereafter, patients with functional limitation received outpatient rehabilitation. However, this inpatient rehabilitation program was not well structured, and the rehabilitation regimens were not well defined. Because spending for poststroke care has increased and a necessity has been identified to provide PAC with an aim of improving functional recovery and smooth transitions between inpatient settings and home,10 research and outcome data for post-stroke rehabilitation are necessary in Taiwan.11,12 In 2014, Taiwan National Health Insurance (TNHI) standardized and specified a highly intensive post-stroke inpatient rehabilitation program named Post-Acute Care Cerebrovascular Diseases (PAC-CVD).13 To be enrolled in this PAC-CVD program, patients with a modified Rankin Scale (mRS) score of 3e4 should be transferred to a highly intensive PAC rehabilitation facility certified by the TNHI within 30 post-stroke days. Some suggested functional scores should be recorded during this PAC care. This highly intensive PAC plan is defined as high frequency (3e5 times/ day) of an intensive rehabilitation program, including physical therapy, occupational therapy and speech therapy, provided in a multidiscipline rehabilitation team approach depending on the patient’s ability. The maximal duration of the PAC-CVD hospital length of stay is limited to 12 weeks. Functional recovery after stroke is essential for performing self-care and activities of daily living (ADLs). Despite evidence that stroke patients entering
multidisciplinary rehabilitation units have lower mortality, less disability, and improved outcomes,14 we have limited knowledge of the recovery patterns in these patients. Understanding the recovery profile across mobility, ADLs and quality of life (QoL) may improve our understanding of neurorehabilitation for post-stroke patients. In this observational study based on TNHI PAC administrative data from stroke patients in one single hospital, we analyzed the recorded data and observed the functional recovery profiles in patients following the PAC rehabilitation program. This study may contribute to the development of better models for the delivery of rehabilitation in the stroke PAC unit.
Methods Subjects and settings This study was conducted in the PAC rehabilitation unit of Taichung Tzu Chi Hospital with the provision of inpatient multidisciplinary care, including physical therapy, occupational therapy, and speech therapy. Patients who were enrolled in this PAC plan were transferred to the Taichung Tzu Chi PAC rehabilitation unit from acute settings in either medical centers or regional hospitals within 30 days after the onset of cerebrovascular disease. According to the TNHI regulation, before entering the stroke PAC program, all patients should sign an informed consent form concerning the PAC plan and provide permission to use their anonymized medical data for research. From March 2014 to December 2017, all consecutive patients transferred to the Taichung Tzu Chi PAC unit who met the following inclusion criteria were recruited: (1) first-ever stroke as defined by the ICD-10 classification (I63, I61 or I60); (2) transferred to the PAC unit within 30 days after stroke onset; and (3) their functional score met the criterion of a mRS score of 3e4. The exclusion criteria were as follows: (1) the length of hospital stay in the PAC unit was less than 30 days because of very good recovery; (2) a recurrent stroke occurred in the PAC unit; and (3) incomplete medical clearance or records were not available during the PAC period. This study was approved by the ethics committee of Taichung Tzu Chi Hospital (No. REC 107-16). Outcome variables for functional recovery were assessed upon admission to the PAC unit and at 3, 6, 9, and 12 weeks or at discharge after admission to the PAC unit. The outcome variables measured in this study included the mRS, Barthel Activity Daily Living Index (BI), LawtoneBrody Instrumental Activity Daily Living scale (LB-IADL), Functional Oral Intake Scale (FOIS), EuroQol Five Dimensions Questionnaire 3-level (EQ-5D-3L), Berg Balance Scale (BBS), Mini Mental State Examination (MMSE); and Concise Chinese
Please cite this article as: Chien S-H et al., A functional recovery profile for patients with stroke following post-acute rehabilitation care in Taiwan, Journal of the Formosan Medical Association, https://doi.org/10.1016/j.jfma.2019.05.013
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A functional recovery profile for patients with stroke Aphasia Test (CCAT). The endpoints were as follows: (1) no functional improvement based on two consecutive evaluations and (2) the length of stay was 12 weeks after admission to the Taichung Tzu Chi PAC unit.
Data analysis Baseline and demographic characteristics are presented as the mean (standard deviation). Student’s t-test was used to compare the basic characteristics and outcome scores between admission and discharge. Pearson’s Chi-square test was used to compare changes in the levels of the patients’ numbers on the EQ-5D-3L at admission and discharge. The differences were considered statistically significant when p < 0.05. The analyses were performed using SPSS (version 13.0; SPSS Inc., Chicago, IL, USA).
Results Descriptive statistics of the patients The patients’ characteristics, including age, gender, stroke type, the use of a nasogastric tube, the use of a urinary catheter, and the length of stay in the PAC wards, are summarized in Table 1. A total of 95 patients (54 male patients and 41 female patients) who met the inclusion criteria were recruited (Inclusion and Exclusion Flow Diagram) (Fig. 1). Among these 95 subjects, the mean age was 66.01 15.36 years, the average period after stroke before admission to the PAC unit was 14.35 7.42 days, and the average length of stay in the PAC unit was 58.15 16.93 days. A total of 76 patients (80.0%) suffered from ischemic stroke, and 19 patients (20.0%) suffered from hemorrhagic stroke; additionally, 21 patients (22.11%) had a nasogastric tube and 10 patients (10.53%) needed a urinary catheter.
Functional recovery after the PAC program The clinical characteristics and the functional changes of the patients before and following the PAC plan are presented in Table 2. The mean mRS score was 3.8 0.45 at admission and improved to 2.96 0.91 at discharge
Table 1
Baseline data for the stroke patients.
Variables Gender Male, n (%) Female, n (%) Age, years, mean (SD) Days after stroke, days, mean (SD) Stroke type Ischemic, n (%) Hemorrhagic, n (%) Nasogastric tube used at admission, n (%) Foley catheter used at admission, n (%) Length of stay in the PAC, days, mean (SD)
Total (n Z 95) 54 (56.84) 41 (43.16) 66.01 (15.36) 14.35 (7.42) 76 (80) 19 (20) 21 (22.11) 10 (10.53) 58.15 (16.93)
Abbreviation: SD: standard deviation; PAC, post-acute care.
3 (p Z 0.000). In the activities of the daily living domain, the BI improved from 34.95 19.98 at admission to 69.16 23.11 (p Z 0.000) at discharge; the LB-IADL also improved from 1.36 1.35 to 2.71 1.83 (p Z 0.000). In the nutritional status domain, the FOIS improved from 5.34 2.25 to 6.66 0.93 (p Z 0.000). In the balance domain, the BBS improved from 20.5 18.44 before PAC training to 37.81 18.5 at discharge (p Z 0.000). In the mental status domain, the MMSE score improved from 20.35 8.9 initially to 23.92 7.73 at discharge (p Z 0.000). In the language domain, the CCAT score also improved from 9.6 2.82 to 10.43 2.25 (p Z 0.000). The rate of successful nasogastric tube removal was 66.7%, and the rate of urinary catheter removal was 90% at discharge. Table 3 shows the changes in the number and ratio of the EQ-5D-3L scores at admission and discharge. In the generic health status measurement dimension of the EQ-5D-3L, significant improvements were observed for all subcategories at discharge, including mobility (from 2.14 0.4 to 1.74 0.4, p Z 0.000), self-care (from 2.21 0.41 to 1.85 0.39, p Z 0.000), usual activity (from 2.19 0.38 to 1.87 0.36, p Z 0.000), pain/discomfort (from 1.47 0.5 to 1.22 0.42, p Z 0.000), and anxiety/depression (from 1.67 0.52 to 1.36 0.48, p Z 0.000). For the mobility, self-care, and usual activity subcategories, the numbers in level 3 were reduced significantly, whereas those in level 1 increased. In the pain/discomfort and anxiety/depression subcategories, the changes occurred predominantly with a shift in the numbers from level 2 to level 1.
Discussion This observational study provides striking evidence of significant improvement in functional recovery after stroke following PAC rehabilitation services. Differences in health care systems, countries and regions can impact stroke rehabilitation programs and outcomes. One of the major outcome measurements is functional disability, which usually is calculated by evaluating ADL functions.15 Another widely adapted measurement in clinical trials to evaluate post-stroke outcomes is the mRS.16 Lai et al. found that 62% of patients had at least a shift of one grade in the mRS from baseline after stroke.17 The results in this study were coincident with those of Lai’s report and showed an improvement of approximately one grade in the mRS from 3.8 0.45 at admission to 2.96 0.91 at discharge. The BI is a common ADL outcome measurement scale in stroke trials. The BI was originally established to assess the ADLs of the elderly population and has been widely used in stroke patients for outcome assessment.18 A previous study suggested that a 20-point threshold in the BI would certainly indicate an important change.19 Scores below 40 on the BI are well accepted to represent complete dependence on others, whereas scores on the BI of greater than 60 represent a status transition from complete dependence to assisted independence. Finally, a BI score greater than 85 represents independence or minor assistance with activities of daily living.20 The BI was also suggested to be a strong predictor of post-stroke healthcare costs. Previous studies have shown that health care costs are much higher in post-stroke patients with functional
Please cite this article as: Chien S-H et al., A functional recovery profile for patients with stroke following post-acute rehabilitation care in Taiwan, Journal of the Formosan Medical Association, https://doi.org/10.1016/j.jfma.2019.05.013
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Figure 1
Table 2
Inclusion and exclusion flow diagram.
Effect of PAC on functional performance and quality of life in patients with stroke.
Variables
N
Admission
Discharge
p-value
mRS BI LB-IADL FOIS BBS MMSE CCAT Nasogastric tube used, n (%) Foley catheter used, n (%)
95 95 95 95 95 95 95
3.8 0.45 34.95 19.98 1.36 1.35 5.34 2.25 20.5 18.44 20.35 8.9 9.6 2.82 21 (22.11) 10 (10.53)
2.96 0.91 69.16 23.11 2.71 1.83 6.66 0.93 37.81 18.5 23.92 7.73 10.43 2.25 7 (7.773) 1 (1.05)
0.000* 0.000* 0.000* 0.000* 0.000* 0.000* 0.000* 0.000* 0.003*
Notes: *p < 0.05. Data presented as the mean SD unless otherwise indicated. Abbreviations: mRS, modified Ranking Scale; BI, Barthel Activity Daily Living index; LB-IADL, LawtoneBrody Instrumental Activity Daily Living scale; FOIS, Functional Oral Intake Scale; EQ-5D, EuroQol Five Dimensions questionnaire; BBS, Berg Balance Scale; MMSE, Mini Mental State Examination; CCAT, Concise Chinese Aphasia Test.
dependency and more disability.21 In this study, the results regarding changes in the BI showed an improvement from a BI mean score of 34.95 at admission to 69.16 at discharge. Our study result is coincident with a previous report by Lai et al. that an improvement in the BI mean score of about 36 at discharge in PAC plan.12 This more than 20-point change was not only clinically significant but also showed that this PAC plan transitioned the ADL function from complete dependence to assisted independence. This result also implied that the future health care costs for these post-stroke patients would be reduced after PAC care. Stroke patients have a high risk of falling. Falls are common consequences of post-stroke limb weakness.22 Researchers have identified some specific risk factors for falls in people after stroke; the cases of a fall after stroke
are usually a combination of these factors, such as increased age, foot dragging, uneven standing sway, greater posture sway, and reduced force generation when standing.23 Among these factors, balance function is one of the most important.24 Hyndman et al. reported that a poor balance function was an important factor that predicted falls in stroke patients living in the community. Therefore, rehabilitation training has focused on balance improvement for fall prevention in stroke. One commonly used assessment tool in rehabilitation settings is the BBS. The BBS was initially developed for use in assessing balance and risk for falls in elderly individuals. Studies also showed that it could be used in patients with stroke.25,26 Subjects with BBS scores of less than 20 are usually suggested to have balance impairment, scores from 21 to 40 represent subjects with acceptable balance, and BBS scores
Please cite this article as: Chien S-H et al., A functional recovery profile for patients with stroke following post-acute rehabilitation care in Taiwan, Journal of the Formosan Medical Association, https://doi.org/10.1016/j.jfma.2019.05.013
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A functional recovery profile for patients with stroke
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Table 3 Effect of PAC on the improvement of EQ-5D-3L scores, and number and ratio of the score of EQ-5D-3L in patients with stroke at admission and discharge. EQ-5D-3L dimensions EQ-5D:mobility EQ-5D:self-care EQ-5D:usual activities EQ-5D:pain/ discomfort EQ-5D:anxiety/ depression
Admission mean SD Level 1
Level 2
Discharge Level 3
mean SD Level 1
Level 2
p Level 3
2.14 0.4 2 (2.11%) 78 (82.11%) 15 (15.79%) 1.74 0.4 26 (27.37%) 68 (71.58%) 1 (1.05%) 0.000a 0.000* 2.21 0.41 0 (0%) 75 (78.95%) 20 (21.05%) 1.85 0.39 15 (15.79%) 79 (83.16%) 1 (1.05%) 0.000a 0.000* 2.19 0.38 0 (0%) 79 (83.16%) 16 (16.84%) 1.87 0.36 13 (13.68%) 81 (85.26%) 1 (1.05%) 0.000a 0.000* 1.47 0.5
50 45 (47.37%) 0 (0%) (52.63%) 1.67 0.51 33 60 (63.16%) 2 (2.11%) (34.74%)
1.22 0.42 74 (77.89%) 21 (22.11%) 0 (0%)
0.000a 0.000*
1.36 0.48 60 (63.83%) 34 (36.17%) 0 (0%)
0.000a 0.000*
*p < 0.05. Pearson’s Chi-square test was used to compare changes in the ratio of the patient’s numbers from the EQ-5D-3L at admission and discharge; ap < 0.05. Student’s t-test was used to compare the EQ-5D-3L mean scores between admission and discharge.
above 41 usually represent good balance. In this study, an improvement was observed in the BBS mean scores from 20.5 at admission to 37.8 at discharge. Our study results are in agreement with those of other studies that observed changes in the BBS scales over time in patients with stroke.27 This significant training effect transitioned the balance function in most post-stroke patients from poor balance to acceptable balance. Whether this training effect can be transferred to a fall-down prevention effect still needs further investigation. Studies have shown that disability caused by stroke has a great impact on quality of life (QoL) in both the stroke patients themselves and their caregivers.28 The EQ-5D-3L is a widely used self-reported instrument to describe the health state and perceived problems in five dimensions (mobility, self-care, usual activities, pain, and anxiety and depression), each with 3 levels (no problems, some problems, and extreme problems).29 In this study, based on the EQ-5D-3L descriptive scales (Table 3), we showed that initially some patients exhibited extreme (levels 2 and 3) problems in the mobility, self-care and performing usual activities subcategories, whereas most of the patients had less than moderate problems (levels 1 and 2) at admission in the pain/discomfort and anxiety/depression subcategories. This improvement was consistent with the accompanying improvement in the mRS and BI at discharge. In the pain/ discomfort and anxiety/depression subcategories, the changes occurred predominantly with a shift in case numbers from level 2 to level 1 (p Z 0.000). In the mobility, self-care, and usual activity subcategories, the major changes from admission to discharge were reduced case numbers in level 3 and increased case numbers in level 1. The study of Graessel et al. showed that higher stroke survivor EQ-5D scores at discharge were predictors of staying at home after discharge.30 Although we did not follow the returning home rate, our study results might imply an increased rate of returning home after receiving our PAC plan. Further investigation and follow up are necessary to clarify this issue. Few studies have been designed to evaluate the removal rate of urinary catheters in patients after stroke. In Frost et al.’s study about the removal of urinary catheters in acute stroke patients, 175 of 432 patients had an IUC removal event, and a 26% failure rate was noted.31 These
authors found that the factors associated with failed urinary catheter removal included hemorrhagic stroke, a lower level of physical function, and the hospital length of stay. In our study, 10 patients had urinary catheters when transferred to our PAC ward. At discharge, only 1 patient still needed a urinary catheter; thus, the successful removal rate was 90%. In this TNHI PAC program, an mRS score of 3e4 and potential to gain improvement were the essential enrollment criteria, which might explain our high removal rate. Further observation is necessary to clarify this post-stroke urinary catheter issue. Swallowing problems are a common symptom following an acute stroke, but the occurrence frequency varies considerably.32 Typically, a nasogastric tube is used to prevent or reduce complications, such as pneumonia, malnutrition, and dehydration.33 However, nasogastric tubes are not well tolerated by patients and may be frequently dislodged. In this study, at admission 21 patients (22.1%) had a nasogastric tube when transferred to our PAC ward. At discharge, 7 patient still needed a nasogastric tube for feeding due to dysphagia; thus, the successful removal rate was 66.7%. Arnold et al. showed that patients with dysphagia had a lower chance of being discharged home.34 Removal of indwelling tubes, such as a nasogastric tube or urinary catheter, may increase the rate of early discharge and returning home. This study has some limitations. Although the characteristics and clinical outcomes of the patients were assessed regularly and routinely based on the TNHI PAC rules, the retrospective study design was a drawback. Another limitation was that our enrolled patients were all from central Taiwan and from a single PAC rehabilitation unit; thus, the results may have geographic variations and may not represent the whole current situation in Taiwan.
Conclusion In summary, this study showed that the PAC rehabilitation unit was beneficial for patients with first-ever acute stroke who had functional impairments in terms of not only improvement in ADL function but also improvement in quality of life and balance function. This PAC program also had a high success rate for removal of urinary catheters and
Please cite this article as: Chien S-H et al., A functional recovery profile for patients with stroke following post-acute rehabilitation care in Taiwan, Journal of the Formosan Medical Association, https://doi.org/10.1016/j.jfma.2019.05.013
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6 nasogastric tubes. The study results may call for further investigations to identify and develop better models for delivery of rehabilitation in the stroke PAC unit.
Conflict of interest The authors have no conflicts of interest relevant to this article.
Acknowledgements This research (grant No. TTCRD105-03) was supported from Taichung Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation.
Appendix A. Supplementary data Supplementary data to this article can be found online at https://doi.org/10.1016/j.jfma.2019.05.013.
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S.-H. Chien et al. 13. Hsieh CY, Tsao WC, Lin RT, Chao AC. Three years of the nationwide post-acute stroke care program in taiwan. J Chin Med Assoc 2018;81:87e8. 14. Kramer AM, Kowalsky JC, Lin M, Grigsby J, Hughes R, Steiner JF. Outcome and utilization differences for older persons with stroke in hmo and fee-for-service systems. J Am Geriatr Soc 2000;48:726e34. 15. Duncan PW, Jorgensen HS, Wade DT. Outcome measures in acute stroke trials: a systematic review and some recommendations to improve practice. Stroke 2000;31:1429e38. 16. Banks JL, Marotta CA. Outcomes validity and reliability of the modified rankin scale: implications for stroke clinical trials: a literature review and synthesis. Stroke 2007;38:1091e6. 17. Lai SM, Duncan PW. Stroke recovery profile and the modified rankin assessment. Neuroepidemiology 2001;20:26e30. 18. Mahoney FI, Barthel DW. Functional evaluation: the barthel index. Md State Med J 1965;14:61e5. 19. Collin C, Wade DT, Davies S, Horne V. The barthel adl index: a reliability study. Int Disabil Stud 1988;10:61e3. 20. Sinoff G, Ore L. The barthel activities of daily living index: selfreporting versus actual performance in the old-old (> or Z 75 years). J Am Geriatr Soc 1997;45:832e6. 21. Caro JJ, Huybrechts KF, Kelley HE. Predicting treatment costs after acute ischemic stroke on the basis of patient characteristics at presentation and early dysfunction. Stroke 2001;32:100e6. 22. Batchelor FA, Mackintosh SF, Said CM, Hill KD. Falls after stroke. Int J Stroke 2012;7:482e90. 23. Cheng PT, Chen CL, Wang CM, Hong WH. Leg muscle activation patterns of sit-to-stand movement in stroke patients. Am J Phys Med Rehabil 2004;83:10e6. 24. Harris JE, Eng JJ, Marigold DS, Tokuno CD, Louis CL. Relationship of balance and mobility to fall incidence in people with chronic stroke. Phys Ther 2005;85:150e8. 25. Blum L, Korner-Bitensky N. Usefulness of the berg balance scale in stroke rehabilitation: a systematic review. Phys Ther 2008;88:559e66. 26. Wang YH, Yang YR, Pan PJ, Wang RY. Modeling factors predictive of functional improvement following acute stroke. J Chin Med Assoc 2014;77:469e76. 27. English CK, Hillier SL, Stiller K, Warden-Flood A. The sensitivity of three commonly used outcome measures to detect change amongst patients receiving inpatient rehabilitation following stroke. Clin Rehabil 2006;20:52e5. 28. Lou S, Carstensen K, Jorgensen CR, Nielsen CP. Stroke patients’ and informal carers’ experiences with life after stroke: an overview of qualitative systematic reviews. Disabil Rehabil 2017;39:301e13. 29. Andrew NE, Busingye D, Lannin NA, Kilkenny MF, Cadilhac DA. The quality of discharge care planning in acute stroke care: influencing factors and association with postdischarge outcomes. J Stroke Cerebrovasc Dis 2018;27:583e90. 30. 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;37:212e9. 31. Frost FS, Fan Y, Harrison A, Modlin T, Samuel S, Thompson N, et al. Failed removal of indwelling urinary catheters in patients with acute stroke: incidence and risk factors. PM R 2018;10:160e7. 32. Mann G, Hankey GJ, Cameron D. Swallowing disorders following acute stroke: prevalence and diagnostic accuracy. Cerebrovasc Dis 2000;10:380e6. 33. Virvidaki IE, Nasios G, Kosmidou M, Giannopoulos S, Milionis H. Swallowing and aspiration risk: a critical review of non instrumental bedside screening tests. J Clin Neurol 2018;14:265e74. 34. Arnold M, Liesirova K, Broeg-Morvay A, Meisterernst J, Schlager M, Mono ML, et al. Dysphagia in acute stroke: incidence, burden and impact on clinical outcome. PLoS One 2016;11:e0148424.
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Original Article
A functional recovery profile for patients with stroke following post-acute rehabilitation care in Taiwan Sou-Hsin Chien a,b,c, Pi-Yu Sung a,c,d, Wen-Ling Liao d, Sen-Wei Tsai a,c,d,* a Department of Post-Acute Care Center, Taichung Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taichung City 427, Taiwan b Department of Plastic Surgery, Taichung Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taichung City 427, Taiwan c School of Medicine, Tzu Chi University, Hualien 970, Taiwan d Department of Physical Medicine and Rehabilitation, Taichung Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taichung City 427, Taiwan
Received 10 March 2019; received in revised form 10 April 2019; accepted 14 May 2019
KEYWORDS Post-acute care; Rehabilitation; Stroke; Modified ranking scale
Background: Functional impairment is frequently seen in patients with stroke. Although the progression of functional recovery after stroke has been proposed, the recovery profile after acute stroke is not well described. The objective of this study is to investigate functional recovery in stroke patients entering post-acute rehabilitation care. Methods: A retrospective cohort study collected the data of patients who entered the stroke Post-acute Care (PAC) programs. Ninety-five patients after stroke with a modified Ranking Scale (mRS) score of 3e4 who were referred to a post-acute care unit for intensive rehabilitation were recruited. The patients underwent functional, quality of life, and neuropsychological evaluation tests at admission and before discharge. The test scores before discharge were used as outcome variables and were compared with the test scores at admission to show functional recovery. Results: The average length of stay was 58.15 days. After an intensive rehabilitation intervention, significant improvements were observed in all test scores. Additionally, a significant removal rate for nasogastric tubes (p Z 0.000) and Foley catheters (p Z 0.003) was found at discharge. Conclusions: This study showed that the PAC rehabilitation unit was beneficial for patients with acute stroke who had functional impairments. The study results may call for further investigation to identify and develop better models for the delivery of rehabilitation in the stroke PAC unit.
* Corresponding author. Physical Medicine and Rehabilitation, Taichung Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Sec. 1, Fengxing Rd., Tanzi Dist., Taichung City 427, Taiwan. E-mail address: [email protected] (S.-W. Tsai). https://doi.org/10.1016/j.jfma.2019.05.013 0929-6646/Copyright ª 2019, Formosan Medical Association. 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/). Please cite this article as: Chien S-H et al., A functional recovery profile for patients with stroke following post-acute rehabilitation care in Taiwan, Journal of the Formosan Medical Association, https://doi.org/10.1016/j.jfma.2019.05.013
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S.-H. Chien et al. Copyright ª 2019, Formosan Medical Association. Published by Elsevier Taiwan LLC. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/bync-nd/4.0/).
Introduction Although advances in acute stroke treatment, such as thrombolytic and endovascular interventions, have increased post-stroke survival, stroke remains one of the most common causes of disability.1 Post-stroke disability is a major health burden worldwide.2,3 Moreover, variation exists in how stroke care services are provided in different regions and countries. The variations in post-stroke care are mostly dependent on the availability of financial and medical resources.4,5 In the United States, stroke post-acute care (PAC) can take place in the inpatient rehabilitation center, a skilled nursing facility, or in the patient’s home, and the spending is mostly provided by Medicare.6 According to previous reports, Medicare spending in the United States on PAC accounts for more than 15% of Medicare spending.4,7 In Europe, studies have surveyed the results of stroke through different registries, including the European Registers of Stroke (EROS) and Collaborative Evaluation of Rehabilitation in Stroke across Europe (CERISE). Although most poststroke patients receive institutional rehabilitation care, large variations exist in rehabilitation services and outcomes among different countries.8,9 In Taiwan, post-stroke rehabilitation in the past was primarily conducted in inpatient rehabilitation facilities for six months after discharge from acute settings. Thereafter, patients with functional limitation received outpatient rehabilitation. However, this inpatient rehabilitation program was not well structured, and the rehabilitation regimens were not well defined. Because spending for poststroke care has increased and a necessity has been identified to provide PAC with an aim of improving functional recovery and smooth transitions between inpatient settings and home,10 research and outcome data for post-stroke rehabilitation are necessary in Taiwan.11,12 In 2014, Taiwan National Health Insurance (TNHI) standardized and specified a highly intensive post-stroke inpatient rehabilitation program named Post-Acute Care Cerebrovascular Diseases (PAC-CVD).13 To be enrolled in this PAC-CVD program, patients with a modified Rankin Scale (mRS) score of 3e4 should be transferred to a highly intensive PAC rehabilitation facility certified by the TNHI within 30 post-stroke days. Some suggested functional scores should be recorded during this PAC care. This highly intensive PAC plan is defined as high frequency (3e5 times/ day) of an intensive rehabilitation program, including physical therapy, occupational therapy and speech therapy, provided in a multidiscipline rehabilitation team approach depending on the patient’s ability. The maximal duration of the PAC-CVD hospital length of stay is limited to 12 weeks. Functional recovery after stroke is essential for performing self-care and activities of daily living (ADLs). Despite evidence that stroke patients entering
multidisciplinary rehabilitation units have lower mortality, less disability, and improved outcomes,14 we have limited knowledge of the recovery patterns in these patients. Understanding the recovery profile across mobility, ADLs and quality of life (QoL) may improve our understanding of neurorehabilitation for post-stroke patients. In this observational study based on TNHI PAC administrative data from stroke patients in one single hospital, we analyzed the recorded data and observed the functional recovery profiles in patients following the PAC rehabilitation program. This study may contribute to the development of better models for the delivery of rehabilitation in the stroke PAC unit.
Methods Subjects and settings This study was conducted in the PAC rehabilitation unit of Taichung Tzu Chi Hospital with the provision of inpatient multidisciplinary care, including physical therapy, occupational therapy, and speech therapy. Patients who were enrolled in this PAC plan were transferred to the Taichung Tzu Chi PAC rehabilitation unit from acute settings in either medical centers or regional hospitals within 30 days after the onset of cerebrovascular disease. According to the TNHI regulation, before entering the stroke PAC program, all patients should sign an informed consent form concerning the PAC plan and provide permission to use their anonymized medical data for research. From March 2014 to December 2017, all consecutive patients transferred to the Taichung Tzu Chi PAC unit who met the following inclusion criteria were recruited: (1) first-ever stroke as defined by the ICD-10 classification (I63, I61 or I60); (2) transferred to the PAC unit within 30 days after stroke onset; and (3) their functional score met the criterion of a mRS score of 3e4. The exclusion criteria were as follows: (1) the length of hospital stay in the PAC unit was less than 30 days because of very good recovery; (2) a recurrent stroke occurred in the PAC unit; and (3) incomplete medical clearance or records were not available during the PAC period. This study was approved by the ethics committee of Taichung Tzu Chi Hospital (No. REC 107-16). Outcome variables for functional recovery were assessed upon admission to the PAC unit and at 3, 6, 9, and 12 weeks or at discharge after admission to the PAC unit. The outcome variables measured in this study included the mRS, Barthel Activity Daily Living Index (BI), LawtoneBrody Instrumental Activity Daily Living scale (LB-IADL), Functional Oral Intake Scale (FOIS), EuroQol Five Dimensions Questionnaire 3-level (EQ-5D-3L), Berg Balance Scale (BBS), Mini Mental State Examination (MMSE); and Concise Chinese
Please cite this article as: Chien S-H et al., A functional recovery profile for patients with stroke following post-acute rehabilitation care in Taiwan, Journal of the Formosan Medical Association, https://doi.org/10.1016/j.jfma.2019.05.013
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A functional recovery profile for patients with stroke Aphasia Test (CCAT). The endpoints were as follows: (1) no functional improvement based on two consecutive evaluations and (2) the length of stay was 12 weeks after admission to the Taichung Tzu Chi PAC unit.
Data analysis Baseline and demographic characteristics are presented as the mean (standard deviation). Student’s t-test was used to compare the basic characteristics and outcome scores between admission and discharge. Pearson’s Chi-square test was used to compare changes in the levels of the patients’ numbers on the EQ-5D-3L at admission and discharge. The differences were considered statistically significant when p < 0.05. The analyses were performed using SPSS (version 13.0; SPSS Inc., Chicago, IL, USA).
Results Descriptive statistics of the patients The patients’ characteristics, including age, gender, stroke type, the use of a nasogastric tube, the use of a urinary catheter, and the length of stay in the PAC wards, are summarized in Table 1. A total of 95 patients (54 male patients and 41 female patients) who met the inclusion criteria were recruited (Inclusion and Exclusion Flow Diagram) (Fig. 1). Among these 95 subjects, the mean age was 66.01 15.36 years, the average period after stroke before admission to the PAC unit was 14.35 7.42 days, and the average length of stay in the PAC unit was 58.15 16.93 days. A total of 76 patients (80.0%) suffered from ischemic stroke, and 19 patients (20.0%) suffered from hemorrhagic stroke; additionally, 21 patients (22.11%) had a nasogastric tube and 10 patients (10.53%) needed a urinary catheter.
Functional recovery after the PAC program The clinical characteristics and the functional changes of the patients before and following the PAC plan are presented in Table 2. The mean mRS score was 3.8 0.45 at admission and improved to 2.96 0.91 at discharge
Table 1
Baseline data for the stroke patients.
Variables Gender Male, n (%) Female, n (%) Age, years, mean (SD) Days after stroke, days, mean (SD) Stroke type Ischemic, n (%) Hemorrhagic, n (%) Nasogastric tube used at admission, n (%) Foley catheter used at admission, n (%) Length of stay in the PAC, days, mean (SD)
Total (n Z 95) 54 (56.84) 41 (43.16) 66.01 (15.36) 14.35 (7.42) 76 (80) 19 (20) 21 (22.11) 10 (10.53) 58.15 (16.93)
Abbreviation: SD: standard deviation; PAC, post-acute care.
3 (p Z 0.000). In the activities of the daily living domain, the BI improved from 34.95 19.98 at admission to 69.16 23.11 (p Z 0.000) at discharge; the LB-IADL also improved from 1.36 1.35 to 2.71 1.83 (p Z 0.000). In the nutritional status domain, the FOIS improved from 5.34 2.25 to 6.66 0.93 (p Z 0.000). In the balance domain, the BBS improved from 20.5 18.44 before PAC training to 37.81 18.5 at discharge (p Z 0.000). In the mental status domain, the MMSE score improved from 20.35 8.9 initially to 23.92 7.73 at discharge (p Z 0.000). In the language domain, the CCAT score also improved from 9.6 2.82 to 10.43 2.25 (p Z 0.000). The rate of successful nasogastric tube removal was 66.7%, and the rate of urinary catheter removal was 90% at discharge. Table 3 shows the changes in the number and ratio of the EQ-5D-3L scores at admission and discharge. In the generic health status measurement dimension of the EQ-5D-3L, significant improvements were observed for all subcategories at discharge, including mobility (from 2.14 0.4 to 1.74 0.4, p Z 0.000), self-care (from 2.21 0.41 to 1.85 0.39, p Z 0.000), usual activity (from 2.19 0.38 to 1.87 0.36, p Z 0.000), pain/discomfort (from 1.47 0.5 to 1.22 0.42, p Z 0.000), and anxiety/depression (from 1.67 0.52 to 1.36 0.48, p Z 0.000). For the mobility, self-care, and usual activity subcategories, the numbers in level 3 were reduced significantly, whereas those in level 1 increased. In the pain/discomfort and anxiety/depression subcategories, the changes occurred predominantly with a shift in the numbers from level 2 to level 1.
Discussion This observational study provides striking evidence of significant improvement in functional recovery after stroke following PAC rehabilitation services. Differences in health care systems, countries and regions can impact stroke rehabilitation programs and outcomes. One of the major outcome measurements is functional disability, which usually is calculated by evaluating ADL functions.15 Another widely adapted measurement in clinical trials to evaluate post-stroke outcomes is the mRS.16 Lai et al. found that 62% of patients had at least a shift of one grade in the mRS from baseline after stroke.17 The results in this study were coincident with those of Lai’s report and showed an improvement of approximately one grade in the mRS from 3.8 0.45 at admission to 2.96 0.91 at discharge. The BI is a common ADL outcome measurement scale in stroke trials. The BI was originally established to assess the ADLs of the elderly population and has been widely used in stroke patients for outcome assessment.18 A previous study suggested that a 20-point threshold in the BI would certainly indicate an important change.19 Scores below 40 on the BI are well accepted to represent complete dependence on others, whereas scores on the BI of greater than 60 represent a status transition from complete dependence to assisted independence. Finally, a BI score greater than 85 represents independence or minor assistance with activities of daily living.20 The BI was also suggested to be a strong predictor of post-stroke healthcare costs. Previous studies have shown that health care costs are much higher in post-stroke patients with functional
Please cite this article as: Chien S-H et al., A functional recovery profile for patients with stroke following post-acute rehabilitation care in Taiwan, Journal of the Formosan Medical Association, https://doi.org/10.1016/j.jfma.2019.05.013
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Figure 1
Table 2
Inclusion and exclusion flow diagram.
Effect of PAC on functional performance and quality of life in patients with stroke.
Variables
N
Admission
Discharge
p-value
mRS BI LB-IADL FOIS BBS MMSE CCAT Nasogastric tube used, n (%) Foley catheter used, n (%)
95 95 95 95 95 95 95
3.8 0.45 34.95 19.98 1.36 1.35 5.34 2.25 20.5 18.44 20.35 8.9 9.6 2.82 21 (22.11) 10 (10.53)
2.96 0.91 69.16 23.11 2.71 1.83 6.66 0.93 37.81 18.5 23.92 7.73 10.43 2.25 7 (7.773) 1 (1.05)
0.000* 0.000* 0.000* 0.000* 0.000* 0.000* 0.000* 0.000* 0.003*
Notes: *p < 0.05. Data presented as the mean SD unless otherwise indicated. Abbreviations: mRS, modified Ranking Scale; BI, Barthel Activity Daily Living index; LB-IADL, LawtoneBrody Instrumental Activity Daily Living scale; FOIS, Functional Oral Intake Scale; EQ-5D, EuroQol Five Dimensions questionnaire; BBS, Berg Balance Scale; MMSE, Mini Mental State Examination; CCAT, Concise Chinese Aphasia Test.
dependency and more disability.21 In this study, the results regarding changes in the BI showed an improvement from a BI mean score of 34.95 at admission to 69.16 at discharge. Our study result is coincident with a previous report by Lai et al. that an improvement in the BI mean score of about 36 at discharge in PAC plan.12 This more than 20-point change was not only clinically significant but also showed that this PAC plan transitioned the ADL function from complete dependence to assisted independence. This result also implied that the future health care costs for these post-stroke patients would be reduced after PAC care. Stroke patients have a high risk of falling. Falls are common consequences of post-stroke limb weakness.22 Researchers have identified some specific risk factors for falls in people after stroke; the cases of a fall after stroke
are usually a combination of these factors, such as increased age, foot dragging, uneven standing sway, greater posture sway, and reduced force generation when standing.23 Among these factors, balance function is one of the most important.24 Hyndman et al. reported that a poor balance function was an important factor that predicted falls in stroke patients living in the community. Therefore, rehabilitation training has focused on balance improvement for fall prevention in stroke. One commonly used assessment tool in rehabilitation settings is the BBS. The BBS was initially developed for use in assessing balance and risk for falls in elderly individuals. Studies also showed that it could be used in patients with stroke.25,26 Subjects with BBS scores of less than 20 are usually suggested to have balance impairment, scores from 21 to 40 represent subjects with acceptable balance, and BBS scores
Please cite this article as: Chien S-H et al., A functional recovery profile for patients with stroke following post-acute rehabilitation care in Taiwan, Journal of the Formosan Medical Association, https://doi.org/10.1016/j.jfma.2019.05.013
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A functional recovery profile for patients with stroke
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Table 3 Effect of PAC on the improvement of EQ-5D-3L scores, and number and ratio of the score of EQ-5D-3L in patients with stroke at admission and discharge. EQ-5D-3L dimensions EQ-5D:mobility EQ-5D:self-care EQ-5D:usual activities EQ-5D:pain/ discomfort EQ-5D:anxiety/ depression
Admission mean SD Level 1
Level 2
Discharge Level 3
mean SD Level 1
Level 2
p Level 3
2.14 0.4 2 (2.11%) 78 (82.11%) 15 (15.79%) 1.74 0.4 26 (27.37%) 68 (71.58%) 1 (1.05%) 0.000a 0.000* 2.21 0.41 0 (0%) 75 (78.95%) 20 (21.05%) 1.85 0.39 15 (15.79%) 79 (83.16%) 1 (1.05%) 0.000a 0.000* 2.19 0.38 0 (0%) 79 (83.16%) 16 (16.84%) 1.87 0.36 13 (13.68%) 81 (85.26%) 1 (1.05%) 0.000a 0.000* 1.47 0.5
50 45 (47.37%) 0 (0%) (52.63%) 1.67 0.51 33 60 (63.16%) 2 (2.11%) (34.74%)
1.22 0.42 74 (77.89%) 21 (22.11%) 0 (0%)
0.000a 0.000*
1.36 0.48 60 (63.83%) 34 (36.17%) 0 (0%)
0.000a 0.000*
*p < 0.05. Pearson’s Chi-square test was used to compare changes in the ratio of the patient’s numbers from the EQ-5D-3L at admission and discharge; ap < 0.05. Student’s t-test was used to compare the EQ-5D-3L mean scores between admission and discharge.
above 41 usually represent good balance. In this study, an improvement was observed in the BBS mean scores from 20.5 at admission to 37.8 at discharge. Our study results are in agreement with those of other studies that observed changes in the BBS scales over time in patients with stroke.27 This significant training effect transitioned the balance function in most post-stroke patients from poor balance to acceptable balance. Whether this training effect can be transferred to a fall-down prevention effect still needs further investigation. Studies have shown that disability caused by stroke has a great impact on quality of life (QoL) in both the stroke patients themselves and their caregivers.28 The EQ-5D-3L is a widely used self-reported instrument to describe the health state and perceived problems in five dimensions (mobility, self-care, usual activities, pain, and anxiety and depression), each with 3 levels (no problems, some problems, and extreme problems).29 In this study, based on the EQ-5D-3L descriptive scales (Table 3), we showed that initially some patients exhibited extreme (levels 2 and 3) problems in the mobility, self-care and performing usual activities subcategories, whereas most of the patients had less than moderate problems (levels 1 and 2) at admission in the pain/discomfort and anxiety/depression subcategories. This improvement was consistent with the accompanying improvement in the mRS and BI at discharge. In the pain/ discomfort and anxiety/depression subcategories, the changes occurred predominantly with a shift in case numbers from level 2 to level 1 (p Z 0.000). In the mobility, self-care, and usual activity subcategories, the major changes from admission to discharge were reduced case numbers in level 3 and increased case numbers in level 1. The study of Graessel et al. showed that higher stroke survivor EQ-5D scores at discharge were predictors of staying at home after discharge.30 Although we did not follow the returning home rate, our study results might imply an increased rate of returning home after receiving our PAC plan. Further investigation and follow up are necessary to clarify this issue. Few studies have been designed to evaluate the removal rate of urinary catheters in patients after stroke. In Frost et al.’s study about the removal of urinary catheters in acute stroke patients, 175 of 432 patients had an IUC removal event, and a 26% failure rate was noted.31 These
authors found that the factors associated with failed urinary catheter removal included hemorrhagic stroke, a lower level of physical function, and the hospital length of stay. In our study, 10 patients had urinary catheters when transferred to our PAC ward. At discharge, only 1 patient still needed a urinary catheter; thus, the successful removal rate was 90%. In this TNHI PAC program, an mRS score of 3e4 and potential to gain improvement were the essential enrollment criteria, which might explain our high removal rate. Further observation is necessary to clarify this post-stroke urinary catheter issue. Swallowing problems are a common symptom following an acute stroke, but the occurrence frequency varies considerably.32 Typically, a nasogastric tube is used to prevent or reduce complications, such as pneumonia, malnutrition, and dehydration.33 However, nasogastric tubes are not well tolerated by patients and may be frequently dislodged. In this study, at admission 21 patients (22.1%) had a nasogastric tube when transferred to our PAC ward. At discharge, 7 patient still needed a nasogastric tube for feeding due to dysphagia; thus, the successful removal rate was 66.7%. Arnold et al. showed that patients with dysphagia had a lower chance of being discharged home.34 Removal of indwelling tubes, such as a nasogastric tube or urinary catheter, may increase the rate of early discharge and returning home. This study has some limitations. Although the characteristics and clinical outcomes of the patients were assessed regularly and routinely based on the TNHI PAC rules, the retrospective study design was a drawback. Another limitation was that our enrolled patients were all from central Taiwan and from a single PAC rehabilitation unit; thus, the results may have geographic variations and may not represent the whole current situation in Taiwan.
Conclusion In summary, this study showed that the PAC rehabilitation unit was beneficial for patients with first-ever acute stroke who had functional impairments in terms of not only improvement in ADL function but also improvement in quality of life and balance function. This PAC program also had a high success rate for removal of urinary catheters and
Please cite this article as: Chien S-H et al., A functional recovery profile for patients with stroke following post-acute rehabilitation care in Taiwan, Journal of the Formosan Medical Association, https://doi.org/10.1016/j.jfma.2019.05.013
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6 nasogastric tubes. The study results may call for further investigations to identify and develop better models for delivery of rehabilitation in the stroke PAC unit.
Conflict of interest The authors have no conflicts of interest relevant to this article.
Acknowledgements This research (grant No. TTCRD105-03) was supported from Taichung Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation.
Appendix A. Supplementary data Supplementary data to this article can be found online at https://doi.org/10.1016/j.jfma.2019.05.013.
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Please cite this article as: Chien S-H et al., A functional recovery profile for patients with stroke following post-acute rehabilitation care in Taiwan, Journal of the Formosan Medical Association, https://doi.org/10.1016/j.jfma.2019.05.013