Stroke and neurodegenerative disorders: 2. Poststroke medical complications

Cost-effectiveness of an intervention to improve the quality of nursing care among immobile patients with stroke in China: A multicenter study

BACKGROUND

While a nursing intervention program for immobile patients with stroke can improve clinic outcomes, less is known about the cost-effectiveness of these interventions.

OBJECTIVES

The goal of this study was to evaluate the cost-effectiveness of the intervention program for immobile patients with stroke in China.

DESIGN

A cost-effectiveness analysis alongside a pre-test/post-test (before and after) study was undertaken from a health care perspective.

SETTINGS

Participants were recruited from 25 hospitals among six provinces or municipal cities in eastern (Guangdong province, Zhejiang province, and Beijing municipal city), western (Sichuan province), and central (Henan province and Hubei province) China.

PARTICIPANTS

A total of 7,653 immobile stroke patients were included in our sample. Patients in routine care settings were recruited from November 2015 to June 2016, and the recruitment of the intervention group patients was from November 2016 to July 2017.

METHODS

To adjust for potential bias from confounding variables, the 1:1 propensity score matching yielded matched pairs of 2,966 patients in the routine care group and 2,966 patients in the intervention group, with no significant differences in sociodemographic or clinical characteristics between two groups. All patients were followed-up 3 months after enrolment in the study. Total healthcare costs were extracted from the hospital information system, with the health outcome effectiveness of the intervention program measured using the EuroQol five-dimensional questionnaire (EQ-5D) instrument and the cost-effectiveness of the intervention measured by the incremental cost-effectiveness ratio with a time horizon of 3 months.

RESULTS

Compared to routine care, the intervention program decreased the total costs of stroke patients by CN¥4,600 (95% confidence interval [CI]: [-7050, -2151]), while increasing quality-adjusted life year 0.009 (95% CI: [0.005, 0.013]). The incremental cost-effectiveness ratios over 3 months was CN¥-517,011 per quality-adjusted life year (95% CI: [-1,111,442, -203,912]). Subgroup analysis reveals that both the health-related quality of life and cost effectiveness improved significantly for ischemic patients and tertiary hospitals patients while for hemorrhagic patients and non-tertiary hospital patients only the health-related quality of life improved significantly.

CONCLUSIONS

Findings from this first cost-effectiveness analysis in immobile stroke patients provide evidence that an intervention program provided significant cost saving, but mainly in ischemic patients and tertiary hospital patients. Wider adoption of such programs may be a sensible approach to reducing the burden of stroke and for immobile patients more generally.

The effects of a standardized nursing intervention model on immobile patients with stroke: a multicenter study in China

BACKGROUND

Immobility complications, including pressure injuries (PIs), deep vein thrombosis (DVT), pneumonia, and urinary tract infections (UTIs), affect the clinical outcomes of stroke patients. A standardized nursing intervention model (SNIM) was constructed and implemented to improve the quality of care and clinical outcomes among immobile patients with stroke.

AIMS

To assess the benefit of SNIM for immobility complication rates, including PIs, DVT, pneumonia, and UTIs, and mortalities in immobile patients with stroke.

METHODS

A before and after study design was used. Patients were divided into a pre- and post-SNIM training original cohort and matched for socioeconomic, demographic, and disease characteristics using propensity score. We fitted logistic regression models to examine the effect of SNIM, and whether the benefit differed between tertiary and non-tertiary hospitals.

RESULTS

In the original cohort, the rate of pneumonia, UTIs, and mortality was lower after SNIM training. Furthermore, in the matched cohort, the difference in PI rates was significant. Logistic regression analysis revealed that the probability of PIs, pneumonia, UTIs, and mortality were significantly reduced after SNIM training in the original cohort and this estimated value changed little in the matched cohort. Our results show that the decreased rates of pneumonia, UTIs, and mortality were mainly among non-tertiary hospitals.

CONCLUSIONS

A structured and systematic SNIM benefited immobile stroke patients' clinical outcomes, but mainly in non-tertiary hospitals in China. Standardized nursing training is needed in non-tertiary hospitals.

Patients receiving chiropractic care in a neurorehabilitation hospital: a descriptive study

Objectives

Individuals rehabilitating from complex neurological injury require a multidisciplinary approach, which typically does not include chiropractic care. This study describes inpatients receiving multidisciplinary rehabilitation including chiropractic care for brain injury, spinal cord injury (SCI), stroke, and other complex neurological conditions.

Design

Chiropractic services were integrated into Crotched Mountain Specialty Hospital (CMSH) through this project. Patient characteristics and chiropractic care data were collected to describe those receiving care and the interventions during the first 15 months when chiropractic services were available.

Setting

CMSH, a 62-bed subacute multidisciplinary rehabilitation, skilled nursing facility located in Greenfield, New Hampshire, USA.

Results

Patient mean (SD) age (n=27) was 42.8 (13) years, ranging from 20 to 64 years. Males (n=18, 67%) and those of white race/ethnicity (n=23, 85%) comprised the majority. Brain injury (n=20) was the most common admitting condition caused by trauma (n=9), hemorrhage (n=7), infarction (n=2), and general anoxia (n=2). Three patients were admitted for cervical SCI, 1 for ankylosing spondylitis, 1 for traumatic polyarthropathy, and 2 for respiratory failure with encephalopathy. Other common comorbid diagnoses potentially complicating the treatment and recovery process included myospasm (n=13), depression (n=11), anxiety (n=10), dysphagia (n=8), substance abuse (n=8), and candidiasis (n=7). Chiropractic procedures employed, by visit (n=641), included manual myofascial therapies (93%), mechanical percussion (83%), manual muscle stretching (75%), and thrust manipulation (65%) to address patients with spinal-related pain (n=15, 54%), joint or regional stiffness (n= 14, 50%), and extremity pain (n=13, 46%). Care often required adapting to participant limitations or conditions. Such adaptations not commonly encountered in outpatient settings where chiropractic care is usually delivered included the need for lift assistance, wheelchair dependence, contractures, impaired speech, quadriplegia/paraplegia, and the presence of feeding tubes and urinary catheters.

Conclusion

Patients suffered significant functional limitations and comorbidity resulting in modifications to the typical delivery of chiropractic care. Chiropractic services focused on relieving musculoskeletal pain and stiffness.