Assessing Stroke Patients for Rehabilitation During the Acute Hospitalization: Findings From the Get With The Guidelines–Stroke Program

Twenty Years of Get With The Guidelines-Stroke: Celebrating Past Successes, Lessons Learned, and Future Challenges

The Get With The Guidelines-Stroke program which, began 20 years ago, is one of the largest and most important nationally representative disease registries in the United States. Its importance to the stroke community can be gauged by its sustained growth and widespread dissemination of findings that demonstrate sustained increases in both the quality of care and patient outcomes over time. The objectives of this narrative review are to provide a brief history of Get With The Guidelines-Stroke, summarize its major successes and impact, and highlight lessons learned. Looking to the next 20 years, we discuss potential challenges and opportunities for the program.

Clinical and functional determinants of appropriate rehabilitation referrals after stroke: a single-center retrospective cohort study

BACKGROUND

Rehabilitation is currently the best available treatment for post-stroke disability. There is, however, great variability in the proportion of patients accessing rehabilitation across high-income countries suggesting that factors not explained by facilities availability or guidelines diversity may intervene in decision-making.

OBJECTIVES

To evaluate which factors are associated with appropriate post-stroke rehabilitation referrals in a tertiary stroke unit setting.

METHODS

Retrospective single-center cohort study including patients admitted to the Stroke Unit of the "Santa Maria della Misericordia" University Hospital, Udine (IT) from January 1st to December 31st, 2019. Information regarding stroke severity (National Institute of Health Stroke Scale), functional assessment (modified Rankin scale [mRS] and Barthel index [BI]), length of hospital stay, and rehabilitation pathway was collected. Outcome was defined as referral to the appropriate rehabilitation pathway. Appropriateness was assessed comparing patient clinical information at discharge against local criteria for intensive vs. extensive rehabilitation. A mixed-linear effect model was built to explore NIHSS, mRS, and BI variation over time. Multivariable logistic regression was used to estimate the adjusted-odds ratio (OR) and 95% confidence interval (CI 95%) of appropriate assignment to rehabilitation pathways.

RESULTS

288 patients were included in the study (age 73.1 years, males 57.9%) and in 75.7%, the rehabilitation pathway assignment was appropriate. NIHSS at discharge was lower compared to admission but no effect of rehabilitation assignment was evident, while mRS scores at discharge and at three months were 2.6 (CI 95% 2.2; 3.0) and 2.1 (CI 95% 1.8; 2.5) higher compared to admission (p < 0.0001). Rehabilitation assignment effect on mRS was time dependent, resulting in an additional - 0.6 (CI 95% - 1.0; - 0.2) lowering at discharge for those appropriately assigned (p = 0.003), with a trend for significance at three months (p = 0.08). BI score was higher at discharge (p < 0.0001), and appropriate assignment was associated with higher scores (p = 0.01). Multivariate analysis showed that the OR of appropriate rehabilitation pathway assignment were reduced by higher mRS (0.60 [CI 95% 0.48; 0.76], p < 0.0001) and increased by higher NIHSS (1.11 [CI 95% 1.04; 1.19], p = 0.001) scores at discharge. The latter finding might be explained by the rehabilitation assessment focus on post-stroke motor symptoms captured by NIHSS.

CONCLUSIONS

Higher mRS and lower NIHSS levels at discharge were independent predictors for inappropriate rehabilitation assignment after stroke in our cohort. These findings may reflect a therapeutic bias toward patients with higher post-stroke disability in a rehabilitation framework heavily tilted on post-stroke motor symptoms.

Assessment of rehabilitation following acute ischaemic stroke in China: a registry-based retrospective observational study

OBJECTIVES

This study aimed to describe the frequency, determinants and outcomes for assessment of patients who had an acute ischaemic stroke (AIS) for rehabilitation during hospitalisation in China.

DESIGN

A registry-based retrospective observational study.

STUDY DESIGN AND SETTINGS

Data regarding assessment or rehabilitation were extracted from the Chinese Stroke Center Alliance database from 1 August 2015 to 31 July 2019. Univariate and multivariate analyses were conducted to identify patient and hospital characteristics associated with rehabilitation assessment during acute hospitalisation as well as discharge outcomes.

STUDY COHORT

We included 837 897 patients who had a stroke in this study with patient characteristics, admission location, medical history, hospital characteristics and hospital designation.

PRIMARY AND SECONDARY OUTCOME MEASURES

Rehabilitation assessment and discharge outcomes.

RESULTS

Among 837 897 patients who had a stroke admitted to 1473 hospitals, 615 991 (73.5%) underwent rehabilitation assessment. There were significant variations in the rates of rehabilitation assessment across hospitals (IQR 61.3% vs 92.9%). According to multivariate analysis, guideline recommended care delivery was associated with a higher rehabilitation assessment rate, whereas high/low body mass index, ambulation (OR 0.88; 95% CI 0.87 to 0.90), history of stroke (OR 0.94; 95% CI 0.93 to 0.95), coronary heart disease (OR 0.84; 95% CI 0.82 to 0.85) and atrial fibrillation (OR 0.91; 95% CI 0.89 to 0.94) were associated with a lower rate. Additionally, rehabilitation assessment during hospitalisation was significantly associated with lower in-hospital mortality (OR 0.38; 95% CI 0.35 to 0.41) and a higher probability of discharge to a rehabilitation centre (OR 2.66; 95% CI 2.5 to 2.82).

CONCLUSIONS

Nearly one-quarter of patients who had an AIS do not undergo documented rehabilitation assessment and compliance across hospitals varies. Thus, it is necessary to improve adherence to rehabilitation assessment to improve the quality of medical care for patients who had an AIS.

Referral to Community-Based Rehabilitation Following Acute Stroke: Findings From the COMPASS Pragmatic Trial

BACKGROUND

Few studies on care transitions following acute stroke have evaluated whether referral to community-based rehabilitation occurred as part of discharge planning. Our objectives were to describe the extent to which patients discharged home were referred to community-based rehabilitation and identify the patient, hospital, and community-level predictors of referral.

METHODS

We examined data from 40 North Carolina hospitals that participated in the COMPASS (Comprehensive Post-Acute Stroke Services) cluster-randomized trial. Participants included adults discharged home following stroke or transient ischemic attack (N=10  702). In this observational analysis, COMPASS data were supplemented with hospital-level and county-level data from various sources. The primary outcome was referral to community-based rehabilitation (physical, occupational, or speech therapy) at discharge. Predictor variables included patient (demographic, stroke-related, medical history), hospital (structure, process), and community (therapist supply) measures. We used generalized linear mixed models with a hospital random effect and hierarchical backward model selection procedures to identify predictors of therapy referral.

RESULTS

Approximately, one-third (36%) of stroke survivors (mean age, 66.8 [SD, 14.0] years; 49% female, 72% White race) were referred to community-based rehabilitation. Rates of referral to physical, occupational, and speech therapists were 31%, 18%, and 10%, respectively. Referral rates by hospital ranged from 3% to 78% with a median of 35%. Patient-level predictors included higher stroke severity, presence of medical comorbidities, and older age. Female sex (odds ratio, 1.24 [95% CI, 1.12-1.38]), non-White race (2.20 [2.01-2.44]), and having Medicare insurance (1.12 [1.02-1.23]) were also predictors of referral. Referral was higher for patients living in counties with greater physical therapist supply. Much of the variation in referral across hospitals remained unexplained.

CONCLUSIONS

One-third of stroke survivors were referred to community-based rehabilitation. Patient-level factors predominated as predictors. Variation across hospitals was notable and presents an opportunity for further evaluation and possible targets for improved poststroke rehabilitative care.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT02588664.

Integrative Approaches in Acute Ischemic Stroke: From Symptom Recognition to Future Innovations

Among the high prevalence of cerebrovascular diseases nowadays, acute ischemic stroke stands out, representing a significant worldwide health issue with important socio-economic implications. Prompt diagnosis and intervention are important milestones for the management of this multifaceted pathology, making understanding the various stroke-onset symptoms crucial. A key role in acute ischemic stroke management is emphasizing the essential role of a multi-disciplinary team, therefore, increasing the efficiency of recognition and treatment. Neuroimaging and neuroradiology have evolved dramatically over the years, with multiple approaches that provide a higher understanding of the morphological aspects as well as timely recognition of cerebral artery occlusions for effective therapy planning. Regarding the treatment matter, the pharmacological approach, particularly fibrinolytic therapy, has its merits and challenges. Endovascular thrombectomy, a game-changer in stroke management, has witnessed significant advances, with technologies like stent retrievers and aspiration catheters playing pivotal roles. For select patients, combining pharmacological and endovascular strategies offers evidence-backed benefits. The aim of our comprehensive study on acute ischemic stroke is to efficiently compare the current therapies, recognize novel possibilities from the literature, and describe the state of the art in the interdisciplinary approach to acute ischemic stroke. As we aspire for holistic patient management, the emphasis is not just on medical intervention but also on physical therapy, mental health, and community engagement. The future holds promising innovations, with artificial intelligence poised to reshape stroke diagnostics and treatments. Bridging the gap between groundbreaking research and clinical practice remains a challenge, urging continuous collaboration and research.

Assessment of rehabilitation following subarachnoid haemorrhage in China: findings from the Chinese Stroke Center Alliance

BACKGROUND

Rehabilitation improves functional recovery in subarachnoid hemorrhage (SAH) patients, and assessing patients for rehabilitation is the first step in this process. However, little is known about clinical practice in China regarding the assessment and provision of rehabilitation for patients with SAH.

METHODS

To identify patients hospitalized with SAH and to analyze rehabilitation assessment rates, we used data for 11,234 SAH patients admitted to 861 hospitals from the China Stroke Center Alliance from August 2015 to July 2019. We examined factors for rehabilitation assessment and analyzed the relationship between rehabilitation assessment and outcomes in these patients.

RESULTS

Among 11,234 patients with SAH, 6,513 (58.0%) were assessed for rehabilitation. Assessed patients had an increased length of stay (mean ± SD days: 17.3 ± 12.5 versus 11.6 ± 10.5, P = 49.4), a higher Glasgow Coma Scale (GCS) score on admission (mean ± SD GCS score: 12.3 ± 3.8 versus 11.8 ± 4.4, P = 12.2), and were more likely to be admitted to the stroke unit (19.6% versus 13.8%, P = 15.6). In multivariable analysis, factors associated with an increased likelihood of a rehabilitation assessment (p < 0.05) included a longer length of stay (odds ratio [OR], 1.04; 95% confidence interval (CI), 1.04 to 1.05) and care such as dysphagia screening (OR, 1.88; 95% CI, 1.73 to 2.04), DVT prophylaxis (OR, 1.56; 95% CI, 1.41 to 1.72) and vessel evaluation (OR, 1.80; 95% CI, 1.63 to 1.98). For the multivariate analysis of outcomes, patients undergoing rehabilitation assessment had a longer length of stay (OR, 1.96; 95% CI, 1.81 to 2.12), a higher modified Rankin Scale (mRS) score at discharge (OR, 1.49; 95% CI, 1.36 to 1.64), and higher rates of discharge to a rehabilitation center (OR, 3.23; 95% CI, 1.81-5.75).

CONCLUSION

More than two-fifths of SAH patients were not assessed for rehabilitation. Rates vary considerably among hospital grades, and there is a need to improve adherence to recommended care for SAH patients.

A Comparison of Acute Ischemic Stroke Patients Discharged to Inpatient Rehabilitation vs a Skilled Nursing Facility: The Paul Coverdell National Acute Stroke Program

OBJECTIVE

To compare the sociodemographic, clinical, and hospital related factors associated with discharge of acute ischemic stroke (AIS) survivors to inpatient rehabilitation (IRF) and skilled nursing facility (SNF) rehabilitation services.

DESIGN

Retrospective descriptive study from the Paul Coverdell National Acute Stroke Program (PCNASP) participating hospitals during 2016 to 2019.

SETTING

9 Participating states from PCNASP in United States.

PARTICIPANTS

130,988 patients with AIS from 569 hospitals (N=337,857).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

Discharge to IRF and SNF.

RESULTS

Patients discharged to a SNF had longer length of hospital stay, more comorbidities, and higher modified Rankin scores compared with patients discharged to an IRF. Nine characteristics were associated with being less likely to be discharged to an IRF than an SNF: older age (85+ years old, adjusted odds ratio [AOR]=0.20 [confidence interval [CI]=0.18-0.21]), identifying as non-Hispanic Black (AOR=0.85 [CI=0.81-0.89]), identifying as Hispanic (AOR=0.80 [CI=0.74-0.87]), having Medicaid or Medicare (AOR=0.73 [CI=0.70-0.77]), being able to ambulate with assistance from another person (AOR=0.93 [CI=0.89-0.97]), being unable to ambulate (AOR=0.73 [CI=0.62-0.87]) and having comorbidities, prior stroke (AOR=0.69 [CI=0.66-0.73]), diabetes (AOR=0.85 [CI=0.82-0.88]), and myocardial infraction or coronary artery disease (AOR=0.94 [CI=0.90-0.97]). Four characteristics were associated with being more likely to be discharged to an IRF than an SNF: being a man (AOR=1.20 [CI=1.16-1.24]), and having a slight disability (Rankin Score 2) (AOR=1.41 [CI=1.29-1.54]), being at larger hospitals (200-399 beds: AOR=1.31 [CI=1.23-1.40]; 400+ beds: AOR=1.29 [CI=1.20-1.38]), and being at a hospital with stroke unit (AOR=1.12 [CI=1.07-1.17]).

CONCLUSION

This study found differences in demographic, clinical, and hospital characteristics of AIS patients discharged for rehabilitation to an IRF vs SNF. The characteristics of patients receiving rehabilitation services may be helpful for researchers and hospitals making policies related to stroke discharge and practices that optimize patient outcomes. Populations experiencing inequities in access to rehabilitation services should be identified, and those who qualify for rehabilitation in IRF should receive this care in preference to rehabilitation in SNF.

Rehabilitation Therapy Doses Are Low After Stroke and Predicted by Clinical Factors

BACKGROUND

Stroke is a leading cause of long-term disability. Greater rehabilitation therapy after stroke is known to improve functional outcomes. This study examined therapy doses during the first year of stroke recovery and identified factors that predict rehabilitation therapy dose.

METHODS

Adults with new radiologically confirmed stroke were enrolled 2 to 10 days after stroke onset at 28 acute care hospitals across the United States. Following an initial assessment during acute hospitalization, the number of physical therapy, occupational therapy, and speech therapy sessions were determined at visits occurring 3, 6, and 12 months following stroke. Negative binomial regression examined whether clinical and demographic factors were associated with therapy counts. False discovery rate was used to correct for multiple comparisons.

RESULTS

Of 763 patients enrolled during acute stroke admission, 510 were available for follow-up. Therapy counts were low overall, with most therapy delivered within the first 3 months; 35.0% of patients received no physical therapy; 48.8%, no occupational therapy, and 61.7%, no speech therapy. Discharge destination was significantly related to cumulative therapy; the percentage of patients discharged to an inpatient rehabilitation facility varied across sites, from 0% to 71%. Most demographic factors did not predict therapy dose, although Hispanic patients received a lower cumulative amount of physical therapy and occupational therapy. Acutely, the severity of clinical factors (grip strength and National Institutes of Health Stroke Scale score, as well as National Institutes of Health Stroke Scale subscores for aphasia and neglect) predicted higher subsequent therapy doses. Measures of impairment and function (Fugl-Meyer, modified Rankin Scale, and Stroke Impact Scale Activities of Daily Living) assessed 3 months after stroke also predicted subsequent cumulative therapy doses.

CONCLUSIONS

Rehabilitative therapy doses during the first year poststroke are low in the United States. This is the first US-wide study to demonstrate that behavioral deficits predict therapy dose, with patients having more severe deficits receiving higher doses. Findings suggest directions for identifying groups at risk of receiving disproportionately low rehabilitation doses.

Assessment of rehabilitation following intracerebral hemorrhage in China: findings from the Chinese stroke center alliance

OBJECTIVES

Evidence shows that rehabilitation is the most effective strategy to reduce the disability rate of patients with stroke. However, there is limited understanding about the factors associated with rehabilitation assessment among patients with intracerebral hemorrhage (ICH) in China. We aimed to investigate the factors associated with rehabilitation assessment in patients with ICH and the relationship between rehabilitation assessment and hospitalization outcomes.

METHODS

Data from 85,664 patients with ICH admitted to 1,312 hospitals between 1 August 2015 and 31 July 2019 were analyzed. A multivariable logistic regression model accounting for in-hospital clustering was used to identify patient and hospital factors associated with rehabilitation assessment during acute hospitalization.

RESULTS

A total of 62,228 (72.6%) patients with ICH underwent rehabilitation assessments. In multivariable analyses, factors associated with an increased likelihood of undergoing a rehabilitation assessment (P < .05) included a higher Glasgow Coma Scale score on admission, a history of hypertension, a history of peripheral vascular disease, dysphagia screening, carotid vessel imaging, and a longer length of hospital stay. Conversely, patients admitted to the intensive care unit and tertiary-grade hospitals were less likely to undergo rehabilitation assessments during hospitalization for ICH.

DISCUSSION

This study showed that the rate of rehabilitation assessment was 74.2%, which is low. Rehabilitation assessment was associated with longer hospital stays and lower mortality. Therefore, patients with acute cerebral haemorrhage should undergo comprehensive and professional rehabilitation assessment.

Management of communication disability in the first 90 days after stroke: a scoping review

INTRODUCTION

People with communication disability after stroke need interventions to optimise healthcare communication and rehabilitation outcomes. Current evidence syntheses do not adequately inform the management of communication disability during the first 90 days post-stroke.

PURPOSE

To explore the scope of literature for the management of communication disability in the first 90 days after stroke.

MATERIALS AND METHODS

A scoping review was conducted using a systematic keyword search of six databases. A descriptive synthesis was generated using communication-related domains related to the biopsychosocial framework of the International Classification of Functioning, Disability, and Health (ICF).

RESULTS

A total of 129 studies met eligibility criteria. Aphasia was the most frequently addressed communication disability after stroke (76/129 studies) with a paucity of evidence investigating other acquired neurogenic communication impairments. Management predominantly focused on communication-related: body functions and structures (62 studies) (e.g., linguistic-behavioural therapies), followed by environmental factors (39 studies) (e.g., communication partner training/support); activities and participation (15 studies) (e.g., augmentative and alternative communication); and personal factors (13 studies) (e.g., assessment of depression after aphasia).

CONCLUSION

A coordinated, integrated approach to developing and testing acute and subacute interventions for all communication disabilities across all communication-related domains is required.IMPLICATIONS FOR REHABILITATIONInterdisciplinary stroke clinicians need to manage communication disabilities in the first 90 days after stroke to optimise healthcare communication and rehabilitation outcomes.There is some evidence to guide clinicians in aphasia management but less in other disabilities of speech and cognitive functioning.Most interventions to inform clinical practice address communication-related body functions and structures (e.g., linguistic and speech therapies). Clinicians need to address all domains and more evidence is needed to address environmental factors (e.g., communication support); activities and participation (e.g., person-centred goal setting); and personal factors (e.g., psychological care).

Stroke rehabilitation and recovery

Stroke is the UK's leading cause of disability. Stroke rehabilitation can maximise recovery and improve quality of life. This article discusses some post-stroke impairments, including hemiplegia, dysphagia, communication impairments and neglect, and how rehabilitation can address these. Developing techniques of adaptation or compensation is vital, since the extent of stroke recovery is dependent on successful neuroplasticity, with healthy neurons adapting to compensate for damaged ones.

Management characteristics and prognosis after stroke in China: findings from a large nationwide stroke registry

BACKGROUND AND PURPOSE

There is limited nationwide evidence about the standard management characteristics of stroke types and prognosis in China. This study aimed to assess clinical characteristics, in-hospital and after-discharge management characteristics and prognosis for stroke types in China.

METHODS

A nationwide registry recruited 14 244 imaging-confirmed first-ever incident strokes from 132 hospitals across 31 provinces of China during 2007-2008, recording presenting characteristics, diagnostic procedures and in-hospital treatment. After hospital discharge, patients were followed up for 6 months. Conventional statistical methods were used to examine the patterns of management and prognosis.

RESULTS

Overall, 68.7%, 26.9% and 4.4% were ischaemic stroke (IS), intracerebral haemorrhage (ICH), and subarachnoid haemorrhage (SAH), respectively. Only 20% were managed in a dedicated stroke unit. Among IS, 1.3% received thrombolysis within 3 hours after symptom onset, whereas the proportions of receiving in-hospital antiplatelet therapy, neuroprotective agents and traditional Chinese medicines (TCM) were 88.4%, 69.7% and 70.6%, respectively. For ICH, 63.3% and 36.3% received neuroprotective agents and TCM in hospital, respectively. At discharge, 70.7% and 38.0% of the patients with IS were given antiplatelet and statin therapies, respectively, decreasing to 64.8% and 23.9%, respectively, at 6 months. In-hospital mortality was 3.2%, 9.3% and 10.1% for IS, ICH and SAH, respectively, with a further 8.6%, 18.2% and 22.0%, respectively, died by 6 month. Meanwhile, in-hospital recurrence rate was 2.6%, 1.9% and 7.2% for IS, ICH and SAH, respectively, with a further 8.0%, 5.1% and 7.5%, respectively, recurred by 6 month.

CONCLUSIONS

In China, the mortality rate of stroke is lower than that reported from west populations, though most strokes are not managed in specialised stroke unit. There is widespread use of some unproven therapies but limited proven treatments, especially after discharge, leading to unnecessary recurrent risks.

Impact of Multidisciplinary Stroke Post-Acute Care on Cost and Functional Status: A Prospective Study Based on Propensity Score Matching

Few papers discuss how the economic burden of patients with stroke receiving rehabilitation courses is related to post-acute care (PAC) programs. This is the first study to explore the economic burden of stroke patients receiving PAC rehabilitation and to evaluate the impact of multidisciplinary PAC programs on cost and functional status simultaneously. A total of 910 patients with stroke between March 2014 and October 2018 were separated into a PAC group (at two medical centers) and a non-PAC group (at three regional hospitals and one district hospital) by using propensity score matching (1:1). A cost-illness approach was employed to identify the cost categories for analysis in this study according to various perspectives. Total direct medical cost in the per-diem-based PAC cohort was statistically lower than that in the fee-for-service-based non-PAC cohort (p < 0.001) and annual per-patient economic burden of stroke patients receiving PAC rehabilitation is approximately US $354.3 million (in 2019, NT $30.5 = US $1). Additionally, the PAC cohort had statistical improvement in functional status vis-à-vis the non-PAC cohort and total score of each functional status before rehabilitation and was also statistically significant with its total score after one-year rehabilitation training (p < 0.001). Early stroke rehabilitation is important for restoring health, confidence, and safe-care abilities in these patients. Compared to the current stroke rehabilitation system, PAC rehabilitation shortened the waiting time for transfer to the rehabilitation ward and it was indicated as an efficient policy for treatment of stroke in saving medical cost and improving functional status.

Selection of discharge destination for patients with moderate-to-severe traumatic brain injury

OBJECTIVES

To investigate criteria acute care interdisciplinary providers use to select discharge destination for patients with traumatic brain injury (TBI).

DESIGN

Cross-sectional, exploratory survey study.

METHODS

Data were collected from interdisciplinary providers at a U.S. Level I trauma centre via electronic survey. We invited 199 providers to participate and 27 responded (13.5% response rate). Responses were received from physicians and physical, occupational, and speech therapists.

RESULTS

Findings showed variability in standard criteria and clinical judgment criteria providers used to select discharge destination for patients with TBI receiving acute care. There was limited agreement on standard criteria used to select discharge destination. Findings showed some agreement between providers on clinical judgment criteria used to select home as discharge destination and to prevent discharge to home. Most common clinical judgment criteria included therapists' recommendations on discharge location, patient's level of independence in activities of daily living, planned family support and ventilator dependence. Agreement on clinical judgment criteria became more limited when stratifying by discipline, frequency of patient care and experience.

CONCLUSIONS

Findings on clinical judgment criteria providers use to select acute care discharge destination for patients with TBI are inconclusive.

Differential Effects of Time to Initiation of Therapy on Disability and Quality of Life in Patients With Mild and Moderate to Severe Ischemic Stroke

OBJECTIVE

To assess the effect of time to acute therapy on health-related quality of life (HRQoL) and disability after ischemic stroke.

DESIGN

Prospective cohort study.

SETTING

Comprehensive stroke care center in a large metropolitan city.

PARTICIPANTS

Patients (N=553; mean age, 67 y; 51.9% male; 64.4% white; 88.8% ischemic stroke) with ischemic stroke or transient ischemic attack (TIA) enrolled in a longitudinal observational study between August 2012 to January 2014 who received rehabilitation services.

INTERVENTION

Not applicable.

MAIN OUTCOME MEASURES

Disability status was assessed with the modified Rankin Scale (mRS) and Barthel Index (BI). HRQoL was assessed using the Quality of Life in Neurological Disorders measures of executive function, general cognitive concerns, upper extremity dexterity, and lower extremity mobility. Time to therapy consult and treatment were defined as the number of days from hospital admission to initial consult by a therapist and number of days from hospital admission to initial treatment, respectively.

RESULTS

Among the participants, the median number of days from hospital admission to acute therapy consult was 2 days (interquartile range, 1-3d). Multivariable linear and logistic regression models indicated that for those with the National Institutes of Health Stroke Scale (NIHSS) score<5, longer time to therapy consult was associated with worse BI scores (BI=100; odds ratio [OR], 0.818; P=.008), executive function T scores (b=-0.865; P=.001), and general cognitive concerns T scores (b=-0.609; P=.009) at 1-month in adjusted analyses. In those with NIHSS score≥5, longer time to therapy treatment led to increased disability (ie, mRS≥ 2; OR, 1.15; P=.039) and lower extremity mobility T scores (b=-0.591; P=.046) at 1 month in adjusted analyses.

CONCLUSIONS

Longer time to initiation of acute therapy has differential effects on poststroke disability and HRQoL up to 1-month after ischemic stroke and TIA. The effect of acute therapy consult is more notable for those with mild deficits, while the effect of acute therapy treatment is more notable for those with moderate to severe deficits. Minimizing time to therapy consults and treatments in the acute hospital period might improve outcomes after ischemic stroke and TIA.

Patients With Greater Stroke Severity and Premorbid Disability Are Less Likely to Receive Therapist Consultations and Intervention During Acute Care Hospitalization

BACKGROUND

A substantial number of patients with stroke never receive acute care therapy services, despite the fact that therapy after stroke reduces the odds of death and disability and improves patients' functioning.

OBJECTIVE

The aim of this study was to estimate the proportion of and factors associated with receipt of therapist consultations and interventions during acute care hospitalization following ischemic and hemorrhagic stroke.

DESIGN

This was a single-center longitudinal observational study.

METHODS

Adults with a diagnosis of ischemic or hemorrhagic stroke (N = 1366) were enrolled during their hospitalization in an acute stroke center in a large metropolitan area. The main outcomes were receipt of therapist consultations, interventions, or both.

RESULTS

Participants with acute hemorrhagic stroke (intracerebral: odds ratio [OR] = 0.34 [95% CI = 0.19-0.60]; subarachnoid: OR = 0.52 [95% CI = 0.28-0.99]) and with greater stroke severity by National Institutes of Health Stroke Scale (NIHSS) score (NIHSS score of > 15: OR = 0.34 [95% CI = 0.23-0.51]) were less likely to receive therapist consultations. Participants with moderate stroke severity (NIHSS score of 6-15: OR = 1.43 [95% CI = 1.01-2.33]) were more likely to receive therapy interventions. Those who were able to ambulate before admission were more than 5 times as likely to receive therapy interventions (OR = 5.08 [95% CI = 1.91-13.52]). Also, participants with longer lengths of stay (ie, more intensive care unit and non-intensive care unit days) were more likely to receive therapist consultations and interventions. Tests or procedures were the most common reasons for unsuccessful attempts to complete therapist consultations.

LIMITATIONS

Lack of operational and qualitative data prohibited detailed explorations of barriers to delivery of therapist consultations and interventions.

CONCLUSIONS

Approximately 1 in 4 participants with acute stroke received neither a consultation nor an intervention. Efforts to improve the delivery of acute care therapy services are needed to optimize care for these people.

Use of Outpatient Rehabilitation Among Adult Stroke Survivors - 20 States and the District of Columbia, 2013, and Four States, 2015

Stroke is a leading cause of mortality and disability in the United States (1,2). Approximately 800,000 American adults experience a stroke each year (2,3). Currently, approximately 6 million stroke survivors live in the United States (2). Participation in stroke rehabilitation (rehab), which occurs in diverse settings (i.e., in-hospital, postacute care, and outpatient settings), has been determined to reduce stroke recurrence and improve functional outcomes and quality of life (3,4). Despite longstanding national guidelines recommending stroke rehab, it remains underutilized, especially in the outpatient setting. Professional associations and evidence-based guidelines support the increasing stroke rehab use in health systems and are promoted by the public health community (3-6). An analysis of 2005 Behavioral Risk Factor Surveillance System (BRFSS) data revealed that 30.7% of stroke survivors reported participation in outpatient rehab for stroke after hospital discharge in 21 states and the District of Columbia (DC) (7). To update these estimates, 2013 and 2015 BRFSS data were analyzed to assess outpatient rehab use among adult stroke survivors. Overall, outpatient rehab use was 31.2% (20 states and DC) in 2013 and 35.5% (four states) in 2015. Disparities were evident by sex, race, Hispanic origin, and level of education. Focused attention on system-level interventions that ensure participation is needed, especially among disparate populations with lower levels of participation.

Assessment and provision of rehabilitation among patients hospitalized with acute ischemic stroke in China: Findings from the China National Stroke Registry II

Background Stroke rehabilitation improves functional recovery among stroke patients. However, little is known about clinical practice in China regarding the assessment and provision of rehabilitation among patients with acute ischemic stroke. Aims We examined the frequency and determinants of an assessment for rehabilitation among acute ischemic stroke patients from the China National Stroke Registry II. Methods Data for 19,294 acute ischemic stroke patients admitted to 219 hospitals from June 2012 to January 2013 were analyzed. The multivariable logistic regression model with the generalized estimating equation method accounting for in-hospital clustering was used to identify patient and hospital factors associated with having a rehabilitation assessment during the acute hospitalization. Results Among 19,294 acute ischemic stroke patients, 11,451 (59.4%) were assessed for rehabilitation. Rates of rehabilitation assessment varied among 219 hospitals (IQR 41.4% vs 81.5%). In the multivariable analysis, factors associated with increased likelihood of a rehabilitation assessment ( p < 0.05) included disability prior to stroke, higher NIHSS on admission, receipt of a dysphagia screen, deep venous thrombosis prophylaxis, carotid vessel imaging, longer length of stay, and treatment at a hospital with a higher number of hospital beds (per 100 units). In contrast, patients with a history of atrial fibrillation and hospitals with higher number of annual stroke discharges (per 100 patients) were less likely to receive rehabilitation assessment during the acute stroke hospitalization. Conclusions Rehabilitation assessment among acute ischemic stroke patients was suboptimal in China. Rates varied considerably among hospitals and support the need to improve adherence to recommended care for stroke survivors.

Inequities in access to inpatient rehabilitation after stroke: an international scoping review

Background Inequities in accessing inpatient rehabilitation after stroke have been reported in many countries and impact on patient outcomes. Objective To explore variation in international recommendations regarding which patients should receive inpatient rehabilitation after stroke and to describe reported access to rehabilitation. Methods A scoping review was conducted to identify clinical guidelines with recommendations regarding which patients should access inpatient rehabilitation after stroke, and data regarding the proportion of patients accessing stroke rehabilitation. Four bibliographic databases and grey literature were searched. Results Twenty-eight documents were included. Selection criteria for post-acute inpatient rehabilitation were identified for 14 countries or regions and summary data on the proportion of patients receiving inpatient rehabilitation were identified for 14 countries. In Australia, New Zealand, and the United Kingdom, it is recommended that all patients with stroke symptoms should access rehabilitation, whereas guidelines from the United States, Canada, and Europe did not consistently recommend rehabilitation for people with severe stroke. Access to inpatient rehabilitation ranged from 13% in Sweden to 57% in Israel. Differences in availability of early supported discharge/home rehabilitation programs and variations in reporting methods may influence the ability to reliably compare access to rehabilitation between regions. Conclusion Recommendations regarding which patients with moderate and severe strokes should access ongoing rehabilitation are inconsistent. Clinical practice guidelines from different countries regarding post-stroke rehabilitation do not always reflect the evidence regarding the likely benefits to people with stroke. Inequity in access to rehabilitation after stroke is an international issue.

Factors associated with access to physical rehabilitation for victims of traffic accidents

OBJECTIVE

Evaluate the level of access to physical rehabilitation for survivors of traffic accidents and the associated factors.

METHODS

A cross-sectional study performed in Natal, Northeastern Brazil, through a telephone survey of 155 victims of traffic accidents admitted to an emergency hospital between January and August of 2013, with a diagnosis of fracture, traumatic brain injury or amputation. Participants were identified in the database of the reference hospital for care of traffic accident victims. We calculated point estimates and confidence interval (95%CI) for the frequency of subjects who had access, in addition to multivariate analysis (logistic regression) between access (dependent variable) and sociodemographic, clinical, and assistance variables.

RESULTS

Among the 155 respondents, the majority were adolescents and adults between 15–29 years of age (47.7%), men (82.6%), education up to high school (92.3%), income of up to two minimum wages (78.0%) and bikers (75.5%). Although 85.8% of traffic accident survivors reported the need for physical rehabilitation, there was little access (51.6%; 95%CI 43.7–59.4) and a delay to start the physical rehabilitation (average = 67 days). We classified factors associated with access to physical rehabilitation as: (i) unmodifiable individuals in the short term – family income greater than two minimum wages (OR = 3.7), informal worker (OR = 0.11) or unemployed (OR = 0.15) and possession of a private health care plan (OR = 0.07); and (ii) assistance modifiable by service management – written referral for physical rehabilitation (OR = 27.5) and perceived need of physical rehabilitation (OR = 10).

CONCLUSIONS

This study found a low and slow access to physical rehabilitation for individuals potentially in need. The associated factors were the organizational processes of health care (health information and referral) and social determinants (income, occupation and private health care plan).

Impact of Insurance Status on Outcomes and Use of Rehabilitation Services in Acute Ischemic Stroke: Findings From Get With The Guidelines-Stroke

Background

Insurance status affects access to care, which may affect health outcomes. The objective was to determine whether patients without insurance or with government‐sponsored insurance had worse quality of care or in‐hospital outcomes in acute ischemic stroke.

Methods and Results

Multivariable logistic regressions with generalized estimating equations stratified by age under or at least 65 years were adjusted for patient demographics and comorbidities, presenting factors, and hospital characteristics to determine differences in in‐hospital mortality and postdischarge destination. We included 589 320 ischemic stroke patients treated at 1604 US hospitals participating in the Get With The Guidelines‐Stroke program between 2012 and 2015. Uninsured patients with hypertension, high cholesterol, or diabetes mellitus were less likely to be taking appropriate control medications prior to stroke, to use an ambulance to arrive to the ED, or to arrive early after symptom onset. Even after adjustment, the uninsured were more likely than the privately insured to die in the hospital (<65 years, OR 1.33 [95% CI 1.22‐1.45]; ≥65 years OR 1.54 [95% CI 1.34‐1.75]), and among survivors, were less likely to go to inpatient rehab (<65 OR 0.63 [95% CI 0.6‐0.67]; ≥65 OR 0.56 [95% CI 0.5‐0.63]). In contrast, patients with Medicare and Medicaid were more likely to be discharged to a Skilled Nursing Facility (<65 years OR 2.08 [CI 1.96‐2.2]; OR 2.01 [95% CI 1.91‐2.13]; ≥65 years OR 1.1 [95% CI 1.07‐1.13]; OR 1.41 [95% CI 1.35‐1.46]).

Conclusions

Preventative care prior to ischemic stroke, time to presentation for acute treatment, access to rehabilitation, and in‐hospital mortality differ by patient insurance status.

Education-only versus a multifaceted intervention for improving assessment of rehabilitation needs after stroke; a cluster randomised trial

Background

In 2011, more than half of the patients with stroke in Australian hospitals were not assessed for the need for rehabilitation. Further, there were no recommended criteria to guide rehabilitation assessment decisions. Subsequently, a decision-making tool called the Assessment for Rehabilitation Tool (ART) was developed. The ART was designed to assist Australian hospital clinicians to identify the rehabilitation needs of patients with stroke using evidence-based criteria. The ART was released and made freely available for use in 2012. This study evaluated the effectiveness of an education-only intervention (1 onsite education session and distribution of the ART) and a multifaceted intervention (2 or more onsite education sessions, distribution of the ART, audit and feedback, barrier identification, site-specific strategy development, promotion of interdisciplinary teamwork, opinion leaders and reminders) for improving assessments of rehabilitation needs after stroke.

Methods

Ten hospitals in 2 states of Australia were randomly assigned to an education-only or a multifaceted intervention. Medical records were audited by assessors blinded to group allocation before and after the implementation period. Difference in the proportion of patients assessed for rehabilitation before and after the intervention was analysed using mixed-effects logistic regression analysis, with time period as the dependent variable, an interaction between intervention type and time included to test for differences between the interventions, and hospital included as the random effect to account for patient clustering.

Results

Data from 586 patients (284 pre-intervention; 302 post-intervention; age 76 years, 59 % male) showed that the multifaceted intervention was not more effective than education-only in improving the proportion of patients whose rehabilitation needs were assessed (reference category education-only; odds ratio 1.29, 95 % confidence interval 0.63–2.67, p = 0.483). Post-intervention, the odds of a patient’s rehabilitation needs being assessed was 3.69 times greater than pre-intervention (95 % confidence interval 2.57–5.30, p < 0.001). Evidence-based criteria were not consistently used when patients were deemed to have no rehabilitation needs.

Conclusions

A multifaceted intervention was not more effective than education-only in improving the assessment of rehabilitation needs of patients with stroke. Further interventions are required to ensure that all patients are assessed for the need for rehabilitation using evidence-based criteria.

Trial registration

ANZCTR (Australian New Zealand Clinical Trials Registry), ACTRN12616000340437

Electronic supplementary material

The online version of this article (doi:10.1186/s13012-016-0487-2) contains supplementary material, which is available to authorized users.

Physiatrist referral preferences for postacute stroke rehabilitation

This study was intended to determine if there is variation among physiatrists in referral preferences for postacute rehabilitation for stroke patients based on physician demographic characteristics or geography.A cross-sectional survey study was developed with 5 fictional case vignettes that included information about medical, social, and functional domains. Eighty-six physiatrist residents, fellows, and attendings were asked to select the most appropriate postacute rehabilitation setting and also to rank, by importance, 15 factors influencing the referral decision. Chi-square bivariate analysis was used to analyze the data.Eighty-six surveys were collected over a 3-day period. Bivariate analysis (using chi-square) showed no statistically significant relationship between any of the demographic variables and poststroke rehabilitation preference for any of the cases. The prognosis for functional outcome and quality of postacute facility had the highest mean influence ratings (8.63 and 8.31, respectively), whereas location of postacute facility and insurance had the lowest mean influence ratings (5.74 and 5.76, respectively).Physiatrists' referral preferences did not vary with any identified practitioner variables or geographic region; referral preferences only varied significantly by case.

A qualitative study using the Theoretical Domains Framework to investigate why patients were or were not assessed for rehabilitation after stroke

Objective:

To explore the factors perceived to affect rehabilitation assessment and referral practices for patients with stroke.

Design:

Qualitative study using data from focus groups analysed thematically and then mapped to the Theoretical Domains Framework.

Setting:

Eight acute stroke units in two states of Australia.

Subjects:

Health professionals working in acute stroke units.

Interventions:

Health professionals at all sites had participated in interventions to improve rehabilitation assessment and referral practices, which included provision of copies of an evidence-based decision-making rehabilitation Assessment Tool and pathway.

Results:

Eight focus groups were conducted (32 total participants). Reported rehabilitation assessment and referral practices varied markedly between units. Continence and mood were not routinely assessed (4 units), and people with stroke symptoms were not consistently referred to rehabilitation (4 units). Key factors influencing practice were identified and included whether health professionals perceived that use of the Assessment Tool would improve rehabilitation assessment practices (theoretical domain ‘social and professional role’); beliefs about outcomes from changing practice such as increased equity for patients or conversely that changing rehabilitation referral patterns would not affect access to rehabilitation (‘belief about consequences’); the influence of the unit’s relationships with other groups including rehabilitation teams (‘social influences’ domain) and understanding within the acute stroke unit team of the purpose of changing assessment practices (‘knowledge’ domain).

Conclusion:

This study has identified that health professionals’ perceived roles, beliefs about consequences from changing practice and relationships with rehabilitation service providers were perceived to influence rehabilitation assessment and referral practices on Australian acute stroke units.

Guidelines for Adult Stroke Rehabilitation and Recovery: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association

PURPOSE

The aim of this guideline is to provide a synopsis of best clinical practices in the rehabilitative care of adults recovering from stroke.

METHODS

Writing group members were nominated by the committee chair on the basis of their previous work in relevant topic areas and were approved by the American Heart Association (AHA) Stroke Council's Scientific Statement Oversight Committee and the AHA's Manuscript Oversight Committee. The panel reviewed relevant articles on adults using computerized searches of the medical literature through 2014. The evidence is organized within the context of the AHA framework and is classified according to the joint AHA/American College of Cardiology and supplementary AHA methods of classifying the level of certainty and the class and level of evidence. The document underwent extensive AHA internal and external peer review, Stroke Council Leadership review, and Scientific Statements Oversight Committee review before consideration and approval by the AHA Science Advisory and Coordinating Committee.

RESULTS

Stroke rehabilitation requires a sustained and coordinated effort from a large team, including the patient and his or her goals, family and friends, other caregivers (eg, personal care attendants), physicians, nurses, physical and occupational therapists, speech-language pathologists, recreation therapists, psychologists, nutritionists, social workers, and others. Communication and coordination among these team members are paramount in maximizing the effectiveness and efficiency of rehabilitation and underlie this entire guideline. Without communication and coordination, isolated efforts to rehabilitate the stroke survivor are unlikely to achieve their full potential.

CONCLUSIONS

As systems of care evolve in response to healthcare reform efforts, postacute care and rehabilitation are often considered a costly area of care to be trimmed but without recognition of their clinical impact and ability to reduce the risk of downstream medical morbidity resulting from immobility, depression, loss of autonomy, and reduced functional independence. The provision of comprehensive rehabilitation programs with adequate resources, dose, and duration is an essential aspect of stroke care and should be a priority in these redesign efforts. (Stroke.2016;47:e98-e169. DOI: 10.1161/STR.0000000000000098.).

Rehabilitation assessments for patients with stroke in Australian hospitals do not always reflect the patients' rehabilitation requirements

OBJECTIVES

To examine the frequency and factors associated with patients with stroke in Australian hospitals receiving documented rehabilitation assessments; to examine the criteria used when rehabilitation was not recommended; and to examine whether being assessed for rehabilitation affected access to rehabilitation.

DESIGN

Retrospective medical record audit of patients with a diagnosis of stroke who were discharged consecutively between 2013 and 2014.

SETTING

Acute care public hospitals.

PARTICIPANTS

Adults with stroke (N=333) receiving care in participating hospitals.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

Documented assessment regarding patient suitability for rehabilitation during acute hospitalization.

RESULTS

Data from 292 patients were included for analysis (60% men; mean age, 72y). Of the patients, 42% were assessed for rehabilitation by a health professional providing care in the hospital, 43% were assessed for rehabilitation by a representative from a rehabilitation service, and 37% did not receive any documented rehabilitation assessment. In multivariable analysis, patients were significantly more likely to be assessed for rehabilitation if they lived in the community before their stroke, had moderate severity strokes, or received occupational therapy during hospital admission. Rehabilitation was not recommended in 9% of assessments despite the presence of stroke-related symptoms. Patients not assessed for rehabilitation were significantly less likely to access rehabilitation than patients who were assessed.

CONCLUSIONS

More than one third of patients were not assessed for rehabilitation. When assessed, rehabilitation was not consistently recommended for patients with stroke-related symptoms. This study highlights factors that increase the likelihood of being assessed for rehabilitation.

Influence of hospital-level practices on readmission after ischemic stroke

OBJECTIVE

To inform stroke quality improvement initiatives by determining the relationship between hospital-level stroke practices and readmission after accounting for patient-level factors.

METHODS

Retrospective cohort study of adult patients hospitalized for ischemic stroke (principal ICD-9-CM codes 433.x1, 434.x1, and 436) in 5 states from 2003 to 2009 from State Inpatient Databases. The primary outcome was any unplanned readmission within 30 days. Multilevel logistic regression was used to estimate the association between hospital-level practice patterns of care (diagnostic testing, procedures, intensive care unit, tissue plasminogen activator, and therapeutic modalities) and readmission after adjustment for patient factors and whether individual patients received a given practice.

RESULTS

Thirty-day unplanned readmission occurred in 15.2% of stroke admissions; the median hospital readmission rate was 13.6% (interquartile range 9.8%-18.2%). Of the 25 hospital practice patterns of care analyzed, 3 practices were associated with readmission: hospitals with higher use of occupational therapy and higher proportion of transfers from other hospitals had lower adjusted readmission rates, whereas hospitals with higher use of hospice had higher predicted readmission rates. Readmission rates in lowest vs highest utilizing quintile were as follows: occupational therapy 16.2% (95% confidence interval [CI] 14.5%-18.0%) vs 12.3% (95% CI 11.3%-13.2%); transfers 13.8% (95% CI 13.2%-14.5%) vs 12.5% (95% CI 11.6%-13.5%); and hospice 13.1% (95% CI 12.3%-14.0%) vs 14.8% (95% CI 13.5%-16.1%).

CONCLUSIONS

Hospital practices have a role in stroke readmission that is complex and poorly understood. Further work is needed to identify specific strategies to reduce readmission rates and to ensure that public reporting of readmission rates will not result in adverse unintended consequences.