Assessment of rehabilitation technologies in stroke. Outcomes and costs

A novel one arm motorized walker for hemiplegic stroke survivors: a feasibility study

BACKGROUND

A hemiplegic stroke survivor with a moderate to severe gait disturbance may have difficulty walking using a one-arm walker. This study aimed to test the safety and feasibility of a prototype one-arm motorized walker that uses a power-driven device to provide gait assistance to hemiplegic stroke survivors with moderate to severe gait disturbances.

METHODS

A one-arm motorized walker with a power-driven device was developed and tested with respect to 10 distinct variables, including weight, degrees of freedom, handle, handle substitution function, two-sided use function, variable handle height, redirecting function, electric moving parts through the handle control, brake function using the handle control, folding chairs, and design stability. Its safety and feasibility were tested in 19 hemiplegic stroke individuals using the Likert scale and a simple interview.

RESULTS

The walker consists of a frame platform including a handle, electric motor for driving, one wheel for driving, two wheels for turning, unlocking sensor, driving button, and turning buttons. The walker is programmed so that a touch sensor in the handle can unlock the locking system. Furthermore, it is programmed so that a user can propel it by pushing the handle downward or pressing a button and can control directions for turning right or left by pressing buttons. Safety and performance testing was achieved for 10 separate variables, and a Likert scale score of 3.5 of 5 was recorded.

CONCLUSION

This walker's novel design was developed for hemiplegic stroke survivors with moderate to severe gait disturbances. Our findings indicate that the walker is both safe and feasible for providing walking assistance to hemiplegic stroke survivors and establish the potential advantages of the one-arm motorized walker.

Equipment provision after stroke: A scoping review of the use of personal care and mobility aids in rehabilitation

Introduction

The aim of this scoping review was to examine and synthesise literature on adaptive equipment use for personal care and mobility after stroke.

Method

We searched databases including Medline, EMBASE, AMED, CINAHL and Scopus to February 2016. Two authors independently screened 789 titles, identifying 28 studies for inclusion in the review.

Results

Findings were grouped into four themes: (1) stroke-specific impairments and consequences for equipment use and training; (2) meaning of equipment for people with stroke; (3) cost of equipment after stroke; and (4) conflicts between equipment provision and models of stroke rehabilitation.

Conclusion

The wide range of impairments after stroke increases complexity of how people use equipment. Nonetheless, training needs and the relationship between social context, identity and equipment use are increasingly better understood,. The findings highlight a tension between practice that seeks to re-train function by ‘normal’ movement without equipment and restoration of function by using compensation strategies involving use of equipment. However, there is no evidence that compensation strategies impede recovery of physical abilities. High-quality evidence about costs of equipment after stroke, which could inform policy decisions, is urgently needed.

Immediate effects of cane use on gait symmetry in individuals with subacute stroke

PURPOSE

In stroke rehabilitation, there is a lack of consensus regarding the effects of cane use on gait symmetry. This study aimed to evaluate the immediate effects on gait symmetry of ambulating with a standard cane and a quad cane among individuals with subacute stroke.

METHOD

A within-subject experimental design was used to evaluate symmetry in in-patients with subacute stroke during ambulation on a pressure-sensitive walkway for three task conditions: with no cane, with standard single-point cane, and with quad cane.

RESULTS

Fourteen patients were classified as symmetric (n = 5) or asymmetric (n = 9) based on their gait symmetry while walking without an aid. Overall, use of a standard cane during ambulation significantly improved symmetry in asymmetric patients (p = 0.028). In contrast, the use of a quad cane did not improve symmetry (p = 0.36). There was no effect on symmetry in symmetric patients with use of either a standard cane (p = 0.88) or a quad cane (p = 0.32).

CONCLUSIONS

These results indicate that the immediate effect of a standard cane is to improve symmetry in patients with subacute stroke who have asymmetric gait. Future studies are required to determine the long-term effects of canes on gait symmetry in this population.

Costs of stroke using patient-level data: a critical review of the literature

BACKGROUND AND PURPOSE

With decision-analytic models becoming more popular to assess the cost-effectiveness of health care interventions, the need for robust estimates on the costs of cerebrovascular disease is paramount. This study reports the results from a literature review of the costs of cerebrovascular diseases, and assesses the quality of the published evidence against a set of defined criteria.

METHODS

A broad literature search was conducted. Those studies reporting mean/median costs of cerebrovascular diseases derived from patient-level data in a developed country setting were included. Data were abstracted using standardized reporting forms and assessed against 4 predefined criteria: use of adequate methodologies, use of a population-based study, inclusion of premorbid resource use, and reporting of costs by different patient subgroups.

RESULTS

A total of 120 cost studies were identified. The cost estimates of stroke were compared by taking into account the effects of inflation and price differentials between countries. Average costs of stroke ranged from $468 to $146 149. Differences in costs were also found within country, with estimates in the USA varying 20-fold. Although the costing methodologies used were generally appropriate, only 5 studies were based on population-based studies, which are the gold standard study design when comparing incidence, outcome, and costs.

CONCLUSIONS

This review showed large variations in the costs of stroke, mainly attributable to differences in the populations studied, methods, and cost categories included. The wide range of cost estimates could lead to selection bias in secondary health economic analyses, with authors including those costs that are more likely to produce the desired results.

In patient stroke rehabilitation efficiency: influence of organization of service delivery and staff numbers

Background

Outcomes of inpatient stroke rehabilitation need to be reviewed in terms of optimal resource utilization (staff time, service organization, and duration of stay). We compared FIM efficiency scores between three hospitals, and also variation in FIM scores over a ten year period in one hospital undergoing reduction in staff numbers, to examine the relationship between outcome and service characteristics.

Method

This is a retrospective study comparing the mean FIM efficiency for stroke patients (FIM score – FIM admission score) divided by duration of stay for 2005 among three rehabilitation hospitals adjusting for age and baseline FIM score, and a longitudinal study of changes in mean FIM efficiency during a ten year period in one hospital, to examine the effects of different service organization and staff numbers.

Results

FIM efficiency (FIMEG) was inversely associated with age, and positively associated with admission FIM score. FIMEG was higher in the hospital with a coordinated care plan involving medical, nursing, occupational, physiotherapy staff and other healthcare providers working as a team, with a seamless interface with community rehabilitation services. Over a ten year period, reduction in staff numbers was associated with reduction in FIMEG, which may be offset to some extent by service re-engineering.

Conclusion

Within hospital organization of stroke rehabilitation services may influence outcome. A critical number of staff may be identified for the provision of services, below which rehabilitation efficiency may be affected.

The Barthel Index and modified Rankin Scale as prognostic tools for long-term outcomes after stroke: a qualitative review of the literature

OBJECTIVE

Providing a quantitative prognosis after a stroke is important to clinicians and patients as well as to researchers interested in projecting the results of clinical trials and other studies. Thus, we critically reviewed the evidence supporting the prognostic value of two frequently-used measures, the Barthel Index (BI) and modified Rankin Scale (mRS) for long-term outcomes.

METHODS

A narrative review of the peer-reviewed medical literature obtained by searching Medline 1966 to January 2004--using the phrase '[stroke] AND [Barthel OR Rankin]'--was conducted to assess the strength of the evidence for these measures and answer three main questions: How good are the BI and mRS at predicting (1) the level of care required, (2) the time-course of recovery, and (3) mortality. Abstracts were screened for the presence of actual data on the prognostic impact of BI and mRS on these endpoints, and selected articles were fully reviewed and abstracted. Additional articles were identified from bibliographies of the retrieved papers.

RESULTS

Of 753 abstracts screened, 89 articles were selected for detailed assessment. Early disability and global outcome (< or = 7 days) were shown in 21 studies to be strong predictors of care needs. This relation appears to be mainly biological, not country-specific. Recovery was shown in 18 studies to be strongly related to early BI. In contrast, the 11 studies examining mortality provided insufficient information to directly support the prognostic value of either measure. Key limitations of this review include heterogeneity of available studies (e.g., time-points, outcome, parameterization) and relative lack of information on the mRS.

CONCLUSIONS

Despite the lack of uniformity in existing studies, the evidence overall is quite strong, supporting the use of BI and mRS as prognostic tools. External non-treatment modifiable factors which also determine long-term outcome (e.g., social support) have to be taken into account.

Costs of coronary heart disease and stroke: the case of Sweden

OBJECTIVES

To estimate the annual costs in Sweden of coronary heart disease (CHD) and stroke, and the potential cost savings if these clinical 'events' are avoided. The analysis is undertaken from a societal perspective, including both direct and indirect costs. Costs are calculated for five clinical conditions: (i) acute myocardial infarction (AMI), (ii) angina pectoris (AP), (iii) unstable angina (UA), (iv) congestive heart failure (CHF), and (v) stroke.

DESIGN

A retrospective study including patients admitted to the Department of Medicine at Södertälje Hospital during the period January 1993 to March 1995 with CHD or a stroke. Each patient was followed for 1 year after admission to the hospital. To estimate potential cost savings, the patient was used as his or her own control. The potential savings in direct costs if CHD or a stroke is avoided were estimated as the difference between costs for 1 year after and 1 year before the event. The indirect costs were calculated as the difference between the values of market production of goods and services the year before the event and the year after.

SETTING

The Department of Medicine at Södertälje Hospital, Södertälje, Sweden.

SUBJECTS

The patients included in the study were patients at the Department of Medicine at Södertälje Hospital in Sweden. The inclusion criterion was that the patients should have been admitted for the first time for CHD or stroke during the year 1994. To obtain 25 patients for each clinical category we first had to expand the inclusion period to cover January 1993 to March 1995. Secondly, we also had to include 36 patients with an earlier established uncomplicated CHD or stroke. Despite this, no more than 22 patients with UA were found.

INTERVENTIONS

Patients were followed in medical practice.

MAIN OUTCOME MEASURES

Costs, direct and indirect costs, and potential savings.

RESULTS

The mean direct costs during the year after a clinical event range between Swedish kronor (SEK) 41 000 for CHF and SEK 96 000 for stroke, whereas the mean potential savings in direct costs range from SEK 36 000 for CHF to SEK 91 000 for UA. The potential mean savings in indirect costs range between SEK 24 000 for CHF and SEK 102 000 for AMI. The direct costs for first-time patients are lower than those for patients with an earlier established CHD or stroke. No systematic differences have been found in potential direct cost savings and indirect costs between the two patient groups.

CONCLUSIONS

CHD and stroke are associated with high costs during the year after admission to the Department of Medicine. There are also large potential cost savings from the prevention of CHD and stroke. However, further studies, including more patients and costs arising in the municipality, are needed to establish more precise and complete estimates of the costs related to CHD and stroke.

Performing cost-effectiveness analysis by integrating randomized trial data with a comprehensive decision model: application to treatment of acute ischemic stroke

A recent national panel on cost-effectiveness in health and medicine has recommended that cost-effectiveness analysis (CEA) of randomized controlled trials (RCTs) should reflect the effect of treatments on long-term outcomes. Because the follow-up period of RCTs tends to be relatively short, long-term implications of treatments must be assessed using other sources. We used a comprehensive simulation model of the natural history of stroke to estimate long-term outcomes after a hypothetical RCT of an acute stroke treatment. The RCT generates estimates of short-term quality-adjusted survival and cost and also the pattern of disability at the conclusion of follow-up. The simulation model incorporates the effect of disability on long-term outcomes, thus supporting a comprehensive CEA. Treatments that produce relatively modest improvements in the pattern of outcomes after ischemic stroke are likely to be cost-effective. This conclusion was robust to modifying the assumptions underlying the analysis. More effective treatments in the acute phase immediately following stroke would generate significant public health benefits, even if these treatments have a high price and result in relatively small reductions in disability. Simulation-based modeling can provide the critical link between a treatment's short-term effects and its long-term implications and can thus support comprehensive CEA.

Assistive technologies in stroke rehabilitation from a user perspective

The purpose of the study was to provide knowledge, from a user perspective, about the selection process for assistive devices. Thirty-eight persons who had suffered stroke were interviewed about their assistive devices, approximately one year after stroke. It was found that the patients had little influence on the choice of assistive devices and that the maintenance and follow-up routines varied among patients. In some cases follow-up was not done at all. Despite these deficits, the patients used their assistive devices as intended.

Cost-utility analysis of assistive technologies in the European Commission's TIDE Program. Technology Initiative for Disabled and Elderly People

Socioeconomic evaluation is an issue dealt with in the European Commission's research program TIDE. The principles of cost-utility analysis have been examined for usability in the assessment of rehabilitative technologies. A case study, the choice of a type of wheelchair, is described to demonstrate how estimates of utility can be derived and how cost-utility ratios can be used to guide decision making.