Functional Outcomes, Subsequent Healthcare Utilization, and Mortality of Stroke Postacute Care Patients in Taiwan: A Nationwide Propensity Score-matched Study

Effects of functional performance and national health insurance cost on length of hospitalization for postacute care in stroke: a retrospective observational study

BACKGROUND

The postacute care for cerebrovascular disease (PAC-CVD) program was launched in Taiwan nearly a decade ago. However, no clear regulations regarding length of stay (LOS) in the program and extension standards exist. Thus, the allocation of limited medical resources such as hospital beds is a major issue.

METHODS

This novel study retrospectively investigated the effects of functional performance and national health insurance (NHI) costs on PAC-CVD LOS. Data for 263 patients with stroke who participated in the PAC-CVD program were analysed. Hierarchical multiple regression was used to estimate the effects of functional performance and NHI costs on LOS at three time points: weeks 3, 6, and 9.

RESULTS

At week 3, age, NHI costs, modified Rankin scale score, and Barthel index significantly affected LOS, whereas at week 6, age and NHI costs were significant factors. However, functional performance and NHI costs were not significant factors at week 9.

CONCLUSIONS

The study provides crucial insights into the factors affecting LOS in the PAC-CVD program, and the results can enable medical decision-makers and health care teams to develop inpatient rehabilitation plans or provide transfer arrangements tailored to patients. Specifically, this study highlights the importance of early functional recovery and consideration of NHI costs when managing LOS in the PAC-CVD program.

Home-based rehabilitation versus hospital-based rehabilitation for stroke patients in post-acute care stage: Comparison on the quality of life

BACKGROUND

This study focused on the integrated post-acute care (PAC) stage of stroke patients, and employed a retrospective study to examine the satisfaction with life quality in two groups, one that received home-based rehabilitation and one that received hospital-based rehabilitation. A secondary purpose was to analyze the correlations among the index and components concerning their quality of life (QOL) and compare the advantages and disadvantages of these two approaches to PAC.

METHODS

This research was a retrospective study of 112 post-acute stroke patients. The home-based group received rehabilitation for one to two weeks, and two to four sessions per week. The hospital-based group received the rehabilitation for three to six weeks, and 15 sessions per week. The home-based group mainly received the training and guidance of daily activities at the patients' residence. The hospital-based group mainly received physical facilitation and functional training in the hospital setting.

RESULTS

The mean scores of QOL assessment for both groups were found to be significantly improved after intervention. Between-group comparisons showed that the hospital-based group had better improvement than the home-based group in mobility, self-care, pain/discomfort and depression/anxiety. In the home-based group, the MRS score and the participant's age can explain 39.4% of the variance of QOL scores.

CONCLUSION

The home-based rehabilitation was of lower intensity and duration than the hospital-based one, but it still achieved a significant improvement in QOL for the PAC stroke patients. The hospital-based rehabilitation offered more time and treatment sessions. Therefore hospital-based patients responded with better QOL outcomes than the home-based patients.

Policy-Driven Post-Acute Care Program Lowers Mortality Rate and Medical Expenditures After Hospitalization for Acute Heart Failure: A Nationwide Propensity Score-Matched Study

OBJECTIVE

The beneficial effects of multidisciplinary disease management programs have been demonstrated. The present study investigated the effects of a policy-driven, health insurance-reimbursed, heart failure (HF) post-acute care (PAC) program on mortality, health care service utilization, and readmission expenses for patients following hospitalization for HF.

DESIGN

This was a retrospective propensity score-matched cohort study using the Taiwan National Health Insurance Research Database.

SETTING AND PARTICIPANTS

In total, 4346 patients (2173 receiving HF-PAC and 2173 controls) with left ventricular ejection fraction of ≤40% who were discharged following hospitalization for HF were included for analysis.

METHODS

All patients were followed up after discharge for all-cause mortality, emergency visits within 30 days, and length of stay and medical expenses for readmission within 180 days after discharge.

RESULTS

After propensity score matching, baseline characteristics of the HF-PAC and control groups were similar. During a mean follow-up period of 1.59 ± 0.92 years, according to the Cox multivariable analysis, HF-PAC reduced mortality by 48% compared with the control group, independent of traditional risk factors (hazard ratio = 0.520, 95% CI = 0.452-0.597, P < .001). Kaplan-Meier curves revealed that HF-PAC was associated with a higher cumulative survival rate (log-rank = 96.43, P < .001). HF-PAC also decreased the frequency of emergency visits after discharge by 23% in the 30 days post discharge and decreased length of stay and medical expenses related to readmission by 61% and 63%, respectively, in the 180 days post discharge (all P < .001).

CONCLUSIONS AND IMPLICATIONS

HF-PAC reduces short-term all-cause emergency visits, length of stay, and medical expenses for all-cause readmission and all-cause mortality in patients discharged following hospitalization for HF. Our findings suggest that PAC should include care continuity, optimal adaptation of transitional care components, and HF cardiologist engagement with multidisciplinary coordination.

Efficacy and Cost over 12 Hospitalization Weeks of Postacute Care for Stroke

Few studies have investigated changes in functional outcomes and economic burden in patients in the postacute care cerebrovascular disease (PAC-CVD) program. We, for the first time, retrospectively investigated changes in functional performance and the national health insurance (NHI) cost over 12 PAC-CVD hospitalization weeks and evaluated the therapeutic effects of the PAC-CVD program on the NHI cost. Specifically, the functional outcomes and NHI cost of 263 stroke patients in the PAC-CVD program were analyzed. The repeated measures t test was used to compare functional performance over 0-3 weeks, and a one-way repeated measures multivariate analysis of variance was used to compare functional performance and NHI costs during weeks 0-6 and 0-9. The Wilcoxon signed-rank test was used to compare functional performance over weeks 9-12. Hierarchical multiple regression was used to estimate the effects of functional performance on NHI costs during weeks 3, 6, and 9. Over weeks 0-12, all functional performance measures demonstrated significant improvements. Changes in NHI costs varied depending on whether hospitalization was extended. At any time point, functional performance did not have a significant impact on NHI cost. Therefore, the PAC-CVD program may aid patients with stroke in sustainably regaining functional performance and effectively controlling economic burden.

The Association of Changes in Physical Performance During Geriatric Inpatient Rehabilitation With Short-Term Hospital Readmission, Institutionalization, and Mortality: RESORT

OBJECTIVES

Geriatric inpatient rehabilitation aims to restore function, marked by physical performance, to enable patients to return and remain home after hospitalization. However, after discharge some patients are soon readmitted, institutionalized, or may die. Whether changes in physical performance during geriatric rehabilitation are associated with these short-term adverse outcomes is unknown. This study aimed to determine the association of changes in physical performance during geriatric inpatient rehabilitation with short-term adverse outcomes.

DESIGN

Observational longitudinal study.

SETTING AND PARTICIPANTS

Geriatric rehabilitation inpatients of the REStORing health of acutely unwell adulTs (RESORT) cohort study of the XXXX (Melbourne, Australia) were included.

METHODS

The change from admission to discharge in the Short Physical Performance Battery (SPPB) score, balance, gait speed (GS), chair stand test (CST), and hand grip strength (HGS) were calculated and analyzed using logistic regression analysis with readmission, incidence of institutionalization, and mortality, and ≥1 adverse outcome within 3 months postdischarge.

RESULTS

Of 693 inpatients, 11 died during hospitalization and 572 patients (mean age 82.6 ± 7.6 years, 57.9% female) had available physical performance data. Within 3 months postdischarge, 47.3% of patients had ≥1 adverse outcome: readmission was 20.8%, institutionalization was 26.6%, and mortality was 7.9%. Improved SPPB score, balance, GS, CST, and HGS were associated with lower odds of institutionalization and mortality. Improved GS was additionally associated with lower odds of readmission [odds ratio (OR) 0.35, 95% CI 0.16-0.79]. CST score had the largest effect, with a 1-point increase associating with 40% lower odds of being institutionalized (OR 0.60, 95% CI 0.42-0.86), 52% lower odds of mortality (OR 0.48, 95% CI 0.29-0.81), and a 24% lower odds of ≥1 adverse outcome (OR 0.76, 95% CI 0.59-0.97).

CONCLUSIONS AND IMPLICATIONS

Improvement in physical performance was associated with lower odds of short-term institutionalization and mortality indicating the prognostic value of physical performance improvement during geriatric inpatient rehabilitation.

Predicting 30-Day Readmission for Stroke Using Machine Learning Algorithms: A Prospective Cohort Study

Background

Machine learning algorithms for predicting 30-day stroke readmission are rarely discussed. The aims of this study were to identify significant predictors of 30-day readmission after stroke and to compare prediction accuracy and area under the receiver operating characteristic (AUROC) curve in five models: artificial neural network (ANN), K nearest neighbor (KNN), random forest (RF), support vector machine (SVM), naive Bayes classifier (NBC), and Cox regression (COX) models.

Methods

The subjects of this prospective cohort study were 1,476 patients with a history of admission for stroke to one of six hospitals between March, 2014, and September, 2019. A training dataset (n = 1,033) was used for model development, and a testing dataset (n = 443) was used for internal validation. Another 167 patients with stroke recruited from October, to December, 2019, were enrolled in the dataset for external validation. A feature importance analysis was also performed to identify the significance of the selected input variables.

Results

For predicting 30-day readmission after stroke, the ANN model had significantly (P &lt; 0.001) higher performance indices compared to the other models. According to the ANN model results, the best predictor of 30-day readmission was PAC followed by nasogastric tube insertion and stroke type (P &lt; 0.05). Using a machine learning ANN model to obtain an accurate estimate of 30-day readmission for stroke and to identify risk factors may improve the precision and efficacy of management for these patients.

Conclusion

Using a machine-learning ANN model to obtain an accurate estimate of 30-day readmission for stroke and to identify risk factors may improve the precision and efficacy of management for these patients. For stroke patients who are candidates for PAC rehabilitation, these predictors have practical applications in educating patients in the expected course of recovery and health outcomes.

Physical Exercise Program on Fall Prevention Using Technological Interface: Pretest Study

BACKGROUND

Prevention of falls among older adults has boosted the development of technological solutions, requiring testing in clinical contexts and robust studies that need prior validation of procedures and data collection tools.

OBJECTIVE

The objectives of our study were to test the data collection procedure, train the team, and test the usability of the FallSensing Games app by older adults in a community setting.

METHODS

This study was conducted as a pretest of a future pilot study. Older adults were recruited in a day care center, and several tests were applied. Physical exercise sessions were held using the interactive FallSensing Games app. Nurse training strategies was completed.

RESULTS

A total of 11 older adults participated. The mean age was 75.08 (SD 3.80) years, mostly female (10/11, 91%) and with low (3-6 years) schooling (10/11, 91%). Clinically, the results show a group of older adults with comorbidities. Cognitive evaluation of the participants through the Mini Mental State Examination showed results with an average score of 25.64 (SD 3.5). Functional capacity assessed using the Lawton Instrumental Activities of Daily Living Scale (overall score from 0-23, with lower scores reflecting worse capacity to perform activities) showed impairment in different instrumental activities of daily living (average score 14.27). The data collection tool proved to enable easy interpretation; however, its structure needed small adjustments to facilitate the data collection process. Despite the length of the questionnaire, its implementation took an average of 21 minutes. For the assessment of the prevalence of fear of falling, the need to add a question was identified. The performance of functional tests under the guidance and presence of rehabilitation nurses ensured the safety of the participants. The interactive games were well accepted by the participants, and the physical exercises allowed data collection on the functionality of the older adults, such as the number of repetitions in the tests, range of movement (angle), duration of the movements, and execution of each cycle. Concerning the training of the nurses, it was crucial that they had experience with the platform, specifically the position of the chair facing the platform, the position of the feet, the posture of participants, and the use of sensors.

CONCLUSIONS

In the future pilot study, the researchers point out the need to design a study with mixed methods (quantitative and qualitative), thus enriching the study results.

Combined Functional Assessment for Predicting Clinical Outcomes in Stroke Patients After Post-acute Care: A Retrospective Multi-Center Cohort in Central Taiwan

Background and Objective

In 2014, Taiwan’s National Health Insurance administration launched a post-acute care (PAC) program for patients to improve their functions after acute stroke. The present study was aimed to determine PAC assessment parameters, either alone or in combination, for predicting clinical outcomes.

Methods

We retrospectively enrolled stroke adult patients through one PAC network in central Taiwan between January 2014 and December 2020. We collected data on post-stroke patients’ functional ability at baseline and after PAC stay. The comprehensive assessment included the following: Modified Rankin Scale (MRS), Functional Oral Intake Scale (FOIS), Mini-Nutritional Assessment (MNA), Berg Balance Scale (BBS), Fugl-Meyer Assessment (FMA), Mini-Mental State Examination (MMSE), aphasia test, and quality of life. The above items were assessed first at baseline and again at discharge from PAC. Logistic regression was used to determine factors that were associated with PAC length of stay (LOS), 14-day hospital readmission, and 1-year mortality.

Results

A total of 267 adults (mean age 67.2 ± 14.7 years) with completed data were analyzed. MRS, activities of daily living (ADLs), instrumental activities of daily living (IADLs), BBS, and MMSE all had improved between disease onset and PAC discharge. Higher baseline and greater improvement of physical and cognitive functions between initial and final PAC assessments were significantly associated with less readmission, and lower mortality. Furthermore, the improved ADLs, FOIS, MNA, FMA-motor, and MMSE scores were related to LOS during PAC. Using logistic regression, we found that functional improvements ≥5 items [adjusted odds ratio (aOR) = 0.16; 95% confidence interval (CI) = 0.05–0.45] and improved MMSE (aOR = 0.19; 95% CI = 0.05–0.68) were significantly associated with reduced post-PAC mortality or readmission. Whereas, functional improvements ≥7 items, improved FOIS, and MNA significantly prolonged LOS during PAC.

Conclusion

Physical performance parameters of patients with acute stroke improved after PAC. PAC assessment with multiple parameters better predicted clinical outcomes. These parameters could provide information on rehabilitation therapy for acute stroke patients receiving PAC.

Analysis of the Cost and Case-mix of Post-acute Stroke Patients in China Using Quantile Regression and the Decision-tree Models

Purpose

Post-acute care is fast developing in China, yet a payment system for post-acute care has not been established. As stroke is the leading cause of mortality and disability in China, patients constitute a large share of post-acute-care patients among all hospitalized patients. This study was to identify the cost determinants and establish a case-mix classification of the post-acute care system for stroke patients in China.

Patients and Methods

A total of 5401 post-acute stroke patients in seven hospitals of Jinhua City from January 2018 to December 2020 were selected. Demographic characteristics, medical status, functional measures (eg, the Barthel Index, Mini-Mental State Examination, Gugging Swallowing Screen, Hamilton Depression Scale), and cost data were extracted. Generalized linear model (GLM) and quantile regression (QR) were conducted to determine the predictors of cost, and a case-mix classification model was established using the decision-tree analysis.

Results

The GLM regression revealed that gender, tracheostomy, complication or comorbidity (CC), activities of daily living (ADL), and cognitive impairment were the main variables significantly affecting the hospitalization expenses of post-acute stroke patients. The QR model showed that the gender, tracheostomy and CC factors had a more significant impact on per diem costs on the upper quantiles. In contrast, cognitive impairment had a more substantial effect on the lower quantiles, and ADL significantly impacted the central quantile. Using tracheostomy, CC, and ADL as node variables of the regression tree, 12 classes were generated. The case-mix classification performed reliably and robustly, as measured by the reduction in the variation statistic (RIV=0.46) and class-specific coefficients of variation (CV less than 1.0; range: 0.18–0.81).

Conclusion

QR has strengths in comprehensively identifying cost predictors across cost groups. Tracheostomy, CC, and ADL significantly can predict the expenses of post-acute care for stroke patients. The established case-mix classification system can inform the future payment policy of post-acute care in China.

Cost Utility Analysis of Multidisciplinary Postacute Care for Stroke: A Prospective Six-Hospital Cohort Study

Background

Few studies have compared the optimal duration and intensity of organized multidisciplinary neurological/rehabilitative care delivered in a regional/district hospital with the standard rehabilitative care delivered in the general neurology/rehabilitation ward of a medical center. This study measured functional outcomes and conducted cost-utility analysis of an organized multidisciplinary postacute care (PAC) project in secondary care compared with standard rehabilitative care delivered in tertiary care.

Methods

This prospective cohort study enrolled 1,476 patients who had a stroke between March 2014 and March 2018 and had a modified Rankin scale score of 2–4. After exact matching for age ± 1 year, sex, year of stroke diagnosis, nasogastric tube, and Foley catheter and propensity score matching for the other covariates, we obtained 120 patients receiving PAC (the PAC group) from four regional/district hospitals and 120 patients not receiving PAC (the non-PAC group) from two medical centers.

Results

At baseline, the non-PAC group showed significantly better functional outcomes than the PAC group, including EuroQol-5 dimensions (EQ-5D), Mini-Mental State Examination (MMSE) and Barthel index (BI). During weeks 7–12 of rehabilitation, improvements in all functional outcomes were significantly larger in the PAC group (P < 0.001) except for Functional Oral Intake Scale (FOIS). Cost-utility analysis revealed that the PAC group had a significantly lower mean (± standard deviation) of direct medical costs (US$3,480 ± $1,758 vs. US$3,785 ± $3,840, P < 0.001) and a significantly higher average gain of quality-adjusted life years (0.1993 vs. 0.1233, P < 0.001). The PAC project was an economically “dominant” strategy.

Conclusions

The PAC project saved costs and significantly improved the functional outcomes of patients with stroke with slight to moderately severe disabilities. Randomized control trials are required to corroborate these results.

The Comparison and Interpretation of Machine-Learning Models in Post-Stroke Functional Outcome Prediction

Prediction of post-stroke functional outcomes is crucial for allocating medical resources. In this study, a total of 577 patients were enrolled in the Post-Acute Care-Cerebrovascular Disease (PAC-CVD) program, and 77 predictors were collected at admission. The outcome was whether a patient could achieve a Barthel Index (BI) score of >60 upon discharge. Eight machine-learning (ML) methods were applied, and their results were integrated by stacking method. The area under the curve (AUC) of the eight ML models ranged from 0.83 to 0.887, with random forest, stacking, logistic regression, and support vector machine demonstrating superior performance. The feature importance analysis indicated that the initial Berg Balance Test (BBS-I), initial BI (BI-I), and initial Concise Chinese Aphasia Test (CCAT-I) were the top three predictors of BI scores at discharge. The partial dependence plot (PDP) and individual conditional expectation (ICE) plot indicated that the predictors’ ability to predict outcomes was the most pronounced within a specific value range (e.g., BBS-I < 40 and BI-I < 60). BI at discharge could be predicted by information collected at admission with the aid of various ML models, and the PDP and ICE plots indicated that the predictors could predict outcomes at a certain value range.

A Technological-Based Platform for Risk Assessment, Detection, and Prevention of Falls Among Home-Dwelling Older Adults: Protocol for a Quasi-Experimental Study

BACKGROUND

According to the United Nations, it is estimated that by 2050, the number of people aged 80 years and older will have increased by 3 times. Increased longevity is often accompanied by structural and functional changes that occur throughout an individual's lifespan. These changes are often aggravated by chronic comorbidities, adopted behaviors or lifestyles, and environmental exposure, among other factors. Some of the related outcomes are loss of muscle strength, decreased balance control, and mobility impairments, which are strongly associated with the occurrence of falls in the elderly. Despite the continued undervaluation of the importance of knowledge on fall prevention among the elderly population by primary care health professionals, several evidence-based (single or multifaceted) fall prevention programs such as the Otago Exercise Program (OEP) have demonstrated a significant reduction in the risk of falls and fall-related injuries in the elderly within community settings. Recent studies have strived to integrate technology into physical exercise programs, which is effective for adherence and overcoming barriers to exercise, as well as improving physical functioning.

OBJECTIVE

This study aims to assess the impact of the OEP on the functionality of home-dwelling elderly using a common technological platform. Particularly, the impact on muscle strength, balance, mobility, risk of falling, the perception of fear of falling, and the perception of the elderly regarding the ease of use of technology are being examined in this study.

METHODS

A quasi-experimental study (before and after; single group) will be conducted with male and female participants aged 65 years or older living at home in the district of Porto. Participants will be recruited through the network COLABORAR, with a minimum of 30 participants meeting the study inclusion and exclusion criteria. All participants will sign informed consent forms. The data collection instrument consists of sociodemographic and clinical variables (self-reported), functional evaluation variables, and environmental risk variables. The data collection tool integrates primary and secondary outcome variables. The primary outcome is gait (timed-up and go test; normal step). The secondary outcome variables are lower limb strength and muscle resistance (30-second chair stand test), balance (4-stage balance test), frequency of falls, functional capacity (Lawton and Brody - Portuguese version), fear of falling (Falls Efficacy Scale International - Portuguese version), usability of the technology (System Usability Scale - Portuguese version), and environmental risk variables (home fall prevention checklist for older adults). Technological solutions, such as the FallSensing Home application and Kallisto wearable device, will be used, which will allow the detection and prevention of falls. The intervention is characterized by conducting the OEP through a common technological platform 3 times a week for 8 weeks. Throughout these weeks, the participants will be followed up in person or by telephone contact by the rehabilitation nurse. Considering the COVID-19 outbreak, all guidelines from the National Health Service will be followed. The project was funded by InnoStars, in collaboration with the Local EIT Health Regional Innovation Scheme Hub of the University of Porto.

RESULTS

This study was approved on October 9, 2020 by the Ethics Committee of Escola Superior de Enfermagem do Porto (ESEP). The recruitment process was meant to start in October, but due to the COVID-19 pandemic, it was suspended. We expect to restart the study by the beginning of the third quarter of 2021.

CONCLUSIONS

The findings of this study protocol will contribute to the design and development of future robust studies for technological tests in a clinical context.

TRIAL REGISTRATION

ISRCTN 15895163; https://www.isrctn.com/ISRCTN15895163.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/25781.

Longer length of post-acute care stay causes greater functional improvements in poststroke patients

Post-acute care (PAC) is a type of transitional care for poststroke patients after the acute medical stage; it offers a relatively intensive rehabilitative program. Under Taiwan's National Health Insurance guidelines, the only patients who can transfer to PAC institutions are those who have had an acute stroke in the previous month, are in a relatively stable medical condition, and have the potential for improvement after aggressive rehabilitation. Poststroke patients receive physical, occupational, and speech therapy in PAC facility. However, few studies have evaluated the effects of PAC in poststroke patients since PAC's initiation in Taiwan. Thus, this study aims to investigate whether the length of stay in a PAC institution correlates with patients' improvements.This retrospective and single-center study in Taiwan enrolled 193 poststroke patients who had received acute care at Chi-Mei Medical Center, Taiwan, at any period between 2014 and 2017. Data on their length of stay in the PAC institution were collected. Poststroke patients' functional ability-such as activities of daily living (ADL) function and swallowing ability-as well as their corresponding scales were assessed on the first and last day of PAC stay. Statistical analysis was conducted by SPSS version 21.0 .The average duration of PAC stay was 35.01 ± 16.373 days. Duration of PAC stay was significantly positively correlated with the Barthel index (P < .001), Berg balance test score (P < .001), gait speed (P = .002), and upper sensory function and upper motor function within the Fugl-Meyer Assessment (both P < .001).Poststroke patients with longer stay in a PAC institution had superior ADL function, balance and coordination, walking speed, and upper-limb dexterity and sensory function.

Comparison of Cost-Effectiveness between Inpatient and Home-Based Post-Acute Care Models for Stroke Rehabilitation in Taiwan

Stroke rehabilitation focuses on alleviating post-stroke disability. Post-acute care (PAC) offers an intensive rehabilitative program as transitional care following acute stroke. A novel home-based PAC program has been initiated in Taiwan since 2019. Our study aimed to compare the current inpatient PAC model with a novel home-based PAC model in cost-effectiveness and functional recovery for stroke patients in Taiwan. One hundred ninety-seven stroke patients eligible for the PAC program were divided into two different health interventional groups. One received rehabilitation during hospitalization, and the other received rehabilitation by therapists at home. To evaluate the health economics, we assessed the total medical expenditure on rehabilitation using the health system of Taiwan national health insurance and performed cost-effectiveness analyses using improvements of daily activity in stroke patients based on the Barthel index (BI). Total rehabilitative duration and functional recovery were also documented. The total rehabilitative cost was cheaper in the home-based PAC group (p < 0.001), and the cost-effectiveness is USD 152.474 ± USD 164.661 in the inpatient group, and USD 48.184 ± USD 35.018 in the home group (p < 0.001). Lesser rehabilitative hours per 1-point increase of BI score was noted in the home-PAC group with similar improvements in daily activities, life quality and nutrition in both groups. Home-based PAC is more cost-effective than inpatient PAC for stroke rehabilitation.

FeetMe® Monitor-connected insoles are a valid and reliable alternative for the evaluation of gait speed after stroke

BACKGROUND

One of the main challenges after stroke is gait recovery. To provide patients with an individualized rehabilitation program, it is helpful to have real-life objective evaluations at baseline and at regular follow-ups to adjust the program and verify potential improvements.

OBJECTIVES

To evaluate the accuracy and reliability of a fully stand-alone system of connected insoles (FeetMe® Monitor) against a widely used clinical walkway system (GAITRite®).

METHODS

Twenty-nine subjects with a stroke that occurred >6 months prior participated in the study. Their comfortable gait over three 8-m trials was evaluated by four raters, on Day 1 and Day 7, using simultaneously FeetMe® Monitor and GAITRite®. Velocity, stride length, cadence, stance, and swing duration were calculated on both sides over three sequences of gait: one single stride, 8 m, and three 8-m trials pooled. The Intra-class Correlation Coefficient (ICC) and the Bland-Altman plot evaluated the construct validity (inter-device) and the reliability (test-retest and inter-rater) of FeetMe® Monitor.

RESULTS

Through all gait analysis sequences, the inter-device ICCs were >0.95 for velocity, stride length, and cadence. Ranges of inter-device ICCs were [0.77-0.94] for stance duration for both limbs, and for swing duration [0.32-0.57] on the non-paretic side and [0.75-0.90] on the paretic side. Test-retest and inter-rater ICCs for all parameters were >0.73 for one single stride, >0.88 for 8-m trials and >0.94 for three 8-m trials.

CONCLUSION

FeetMe® Monitor is an accurate and reliable system for measurement of gait velocity, stride length, cadence, and stance duration in chronic hemiparesis.

Multidiscipline Stroke Post-Acute Care Transfer System: Propensity-Score-Based Comparison of Functional Status

Few studies have investigated the characteristics of stroke inpatients after post-acute care (PAC) rehabilitation, and few studies have applied propensity score matching (PSM) in a natural experimental design to examine the longitudinal impacts of a medical referral system on functional status. This study coupled a natural experimental design with PSM to assess the impact of a medical referral system in stroke patients and to examine the longitudinal effects of the system on functional status. The intervention was a hospital-based, function oriented, 12-week to 1-year rehabilitative PAC intervention for patients with cerebrovascular diseases. The average duration of PAC in the intra-hospital transfer group (31.52 days) was significantly shorter than that in the inter-hospital transfer group (37.1 days) (p < 0.001). The intra-hospital transfer group also had better functional outcomes. The training effect was larger in patients with moderate disability (Modified Rankin Scale, MRS = 3) and moderately severe disability (MRS = 4) compared to patients with slight disability (MRS = 2). Intensive post-stroke rehabilitative care delivered by per-diem payment is effective in terms of improving functional status. To construct a vertically integrated medical system, strengthening the qualified local hospitals with PAC wards, accelerating the inter-hospital transfer, and offering sufficient intensive rehabilitative PAC days are the most essential requirements.

Post-Acute Care as a Key Component in a Healthcare System for Older Adults

Older adults often experience functional decline following acute medical care. This functional decline may lead to permanent disability, which will increase the burden on the medical and long-term care systems, families, and society as a whole. Post-acute care aims to promote the functional recovery of older adults, prevent unnecessary hospital readmission, and avoid premature admission to a long-term care facility. Research has shown that post-acute care is a cost-effective service model, with both the hospital-at-home and community hospital post-acute care models being highly effective. This paper describes the post-acute care models of the United States and the United Kingdom and uses the example of Taiwan’s highly effective post-acute care system to explain the benefits and importance of post-acute care. In the face of rapid demographic aging and smaller household size, a post-acute care system can lower medical costs and improve the health of older adults after hospitalization.

Functional recovery of stroke patients with postacute care: a retrospective study in a northern medical center

BACKGROUND

Taiwan's NHI Administration proposed a nationwide postacute care-cerebral vascular disease (PAC-CVD) program, which transfers stroke patients at postacute phase in medical centers to community hospitals. Its aim is mainly to prevent a prolonged stay in medical centers, which usually results in higher medical costs. The present study evaluated the 3-months functional outcomes of stroke patients receiving PAC-CVD.

METHODS

We retrogradely retrieved patients' data from Stroke Registry of a Northern medical center. Patients admitted between January 2014 and March 2018 were screened. We included patients receiving PAC-CVD and age/sex/stroke severity/functional status-matched acute stroke patients (regular rehabilitation group). Baseline clinical characteristics and 3-months functional outcomes were analyzed. We defined 3-months mRS 0 to 2 as better, 3 to 4 as same, and 5 to 6 as worse functional recovery.

RESULTS

One-hundred-and-seventy-three patients receiving PAC-CVD and 173 matched controls (68.2 ± 14.0-years-old, 68.5% ± 11.22% men) were recruited. All patients were with mRS 3 to 4 at discharge from our medical center. The distributions of 3-months functional recovery in two groups were as follows: better/same/worse 3-months functional outcomes, PAC-CVD = 40.4%/57.8%/1.8%; controls (regular rehabilitation) = 33.9%/50.3%/5.8%. Multivariate analyses adjusted for age, sex, NIHSS, and cardiovascular risk factors were performed to evaluate whether PAC-CVD predicted better or poor functional outcomes. The results showed that compared with controls, PAC-CVD group had similar frequency of better functional recovery (odds ratio [OR] = 0.97, 95% CI = 0.54-1.74, p = 0.924) but less frequency of worse functional outcomes (OR = 0.08, 95% CI = 0.008-0.84, p = 0.035).

CONCLUSION

About one-third of patients with mRS 3 to 4 recovered well in 3-months after stroke in both PAC-CVD and regular rehabilitation groups. Our results showed that PAC-CVD program can significantly decrease functional decline after acute stroke.

Dental Status is Associated With Incident Functional Disability in Community-Dwelling Older Japanese: A Prospective Cohort Study Using Propensity Score Matching

Background

A growing number of epidemiology studies have shown that poor oral health is associated with an increased incidence of functional disability. However, there are few studies in which the confounding bias is adjusted appropriately. In this study, we examined whether dental status is associated with functional disability in elderly Japanese using a 13-year prospective cohort study after elimination of confounding factors with propensity score matching.

Methods

Participants were community-dwelling Japanese aged 70 years or older who lived in the Tsurugaya district of Sendai (n = 838). The number of remaining teeth (over 20 teeth vs 0–19 teeth) was defined as the exposure variable. The outcome was the incidence of functional disability, defined as the first certification of long-term care insurance (LTCI) in Japan. The variables that were used to determine propensity score matching were age, sex, body mass index (BMI), medical history (stroke, hypertension, myocardial infarction, cancer, and diabetes), smoking, alcohol consumption, educational attainment, depression symptoms, cognitive impairment, physical function, social support, and marital status.

Results

As a result of the propensity score matching, 574 participants were selected. Participants with 0–19 teeth were more likely to develop functional disability than those with 20 or more teeth (hazard ratio 1.33; 95% confidence interval, 1.01–1.75).

Conclusions

In this prospective cohort study targeting community-dwelling older adults in Japan, having less than 20 teeth was confirmed to be an independent risk factor for functional disability even after conducting propensity score matching. This study supports previous publications showing that oral health is associated with functional disability.