Variations in care and outcome in the first year after stroke: a Western and Central European perspective

European comparison of stroke rehabilitation

BACKGROUND

Our understanding of the components of stroke rehabilitation critical to patients' outcomes is limited. Comparing practices and outcomes across countries may give clues to how to improve rehabilitation services.

METHOD

In the CERISE project (Collaborative Evaluation of Rehabilitation in Stroke across Europe), clinical and organisational aspects of stroke rehabilitation were compared among four European rehabilitation centres (United Kingdom, Belgium, Switzerland, and Germany). Main findings were summarised and interpreted.

RESULTS

Gross motor and functional recovery were significantly better in the German and Swiss centres compared to the British centre, respectively. Insights in admission criteria, patients' therapy time, content of therapy, and task characteristics of physiotherapists and occupational therapists were in line with the differences in recovery. In Germany, neurorehabilitation is more structured with clearly defined phases, each linked with specific criteria and reimbursement schemes. In Belgium, more variation exists in the rehabilitation trajectories.

CONCLUSION

Stroke rehabilitation services are embedded in health care systems, creating contextual constraints with various (dis)incentives. These constraints vary between countries, resulting in differences in the organisation of stroke rehabilitation. Studies on the effectiveness of stroke rehabilitation should incorporate contextual elements of the organisation of the unit.

Stroke Outcome in Clinical Trial Patients Deriving From Different Countries

Background and Purpose— Stroke incidence and outcome vary widely within and across geographical locations. We examined whether differences in index stroke severity, stroke risk factors, mortality, and stroke outcome across geographical locations remain after adjusting for case mix.

Methods— We analyzed 3284 patients from the Virtual International Stroke Trials Archive (VISTA). We used logistic regression to examine the incidence of mild index stroke, functional, and neurological outcomes after accounting for age, medical history, year of trial recruitment, and initial stroke severity in the functional and neurological outcome analyses. We examined mortality between geographical regions using a Cox proportional hazards model, accounting for age, initial stroke severity, medical history, and year of trial recruitment.

Results— Patients enrolled in the USA and Canada had the most severe index strokes. Those recruited in Austria and Switzerland had the best functional and neurological outcomes at 90 days ( P <0.05), whereas those enrolled in Germany had the worst functional outcome at 90 days ( P =0.013). Patients enrolled in Austria, Switzerland, Belgium, Netherlands, Finland, Germany, Greece, Israel, Spain, and Portugal had a significantly better survival rate when compared with those enrolled in USA and Canada. Patients enrolled in trials after 1998 had more severe index strokes, with no significant difference in outcome compared with those enrolled before 1998.

Conclusion— We identified regional variations in index stroke severity, outcome, and mortality for patients enrolled in ischemic stroke clinical trials over the past 13 years that were not fully explained by case mix. Index stroke severity was greater in patients enrolled after 1998, with no significant improvement in outcomes compared to those enrolled before 1998.

Motor and Functional Recovery After Stroke

BACKGROUND AND PURPOSE

Outcome after first stroke varies significantly across Europe. This study was designed to compare motor and functional recovery after stroke between four European rehabilitation centers.

METHODS

Consecutive stroke patients (532 patients) were recruited. They were assessed on admission and at 2, 4, and 6 months after stroke with the Barthel Index, Rivermead Motor Assessment of Gross Function, Rivermead Motor Assessment of Leg/Trunk, Rivermead Motor Assessment of Arm, and Nottingham Extended Activities of Daily Living (except on admission). Data were analyzed using random effects ordinal logistic models adjusting for case-mix and multiple testing.

RESULTS

Patients in the UK center were more likely to stay in lower Rivermead Motor Assessment of Gross Function classes compared with patients in the German center (DeltaOR, 2.4; 95% CI, 1.3 to 4.3). In the Swiss center, patients were less likely to stay in lower Nottingham Extended Activities of Daily Living classes compared with patients in the UK center (DeltaOR, 0.7; 95% CI, 0.5 to 0.9). The latter were less likely to stay in lower Barthel Index classes compared with the patients in the German center (DeltaOR, 0.6; 95%CI, 0.4 to 0.8). Recovery patterns of Rivermead Motor Assessment of Leg/Trunk and Rivermead Motor Assessment of Arm were not significantly different between centers.

CONCLUSIONS

Gross motor and functional recovery were better in the German and Swiss centers compared with the UK center, respectively. Personal self-care recovery was better in the UK compared with the German center. Previous studies in the same centers indicated that German and Swiss patients received more therapy per day. This was not the result of more staff but of a more efficient use of human resources. This study indicates potential for improving rehabilitation outcomes in the UK and Belgian centers.