Destinations of stroke patients discharged from the Montreal area acute-care hospitals

The Unmet Needs of Community-Dwelling Stroke Survivors: A Systematic Review of Qualitative Studies

The unmet needs perceived by community-dwelling stroke survivors may truly reflect the needs of patients, which is crucial for pleasant emotional experiences and a better quality of life for community-dwelling survivors not living in institutionalized organizations. The purpose of the study is to identify the scope of unmet needs from the perspectives of stroke patients in the community. A qualitative meta-synthesis was performed according to the Joanna Briggs Institute method. Six electronic databases were searched from inception to February 2020. A total of 24 articles were involved, providing data on 378 stroke survivors. Eight categories were derived from 63 findings, and then summarized into four synthesized findings based on the framework of ICF: (1) unmet needs regarding with the disease-related information; (2) unmet physical recovery and activity/participation needs; (3) unmet needs for social environmental resources; (4) unmet psycho-emotional support needs. We found the framework of ICF mostly complete, but unmet information needs still remain. The needs that are mainly unsatisfied include physical, psychosocial and informational, as well as the practical support from professional or environment resources. The ever-present unmet needs perceived by community-dwelling stroke survivors who do not live in institutions are discoverable and mitigable. Future studies should focus on quantifying unmet needs comprehensively derived from experiential domains, assessing the rationality of the unmet needs expressed by patients' perspectives and developing flexible strategies for long-term and changing needs.

Exploring discharge destination following severe stroke

Background:

Patients with severe stroke frequently present with substantial impairments but are often not prioritised for post-discharge rehabilitation. There is a need to determine where these patients are discharged to in order to facilitate appropriate allocation of post-discharge pathway resources.

Aim:

The present study aimed to describe the discharge pathways of patients with severe stroke and to identify predictors of discharge destination for these patients.

Method:

A descriptive, retrospective design was utilised to determine the discharge destination for 770 patients with severe stroke in Queensland, Australia. Binomial logistic regression was used to determine the variables that predicted discharge destination.

Results:

The results indicated that 58.44% of patients were discharged home (n = 450). Age, length of stay, discharge ward and geographical region emerged as significant predictors of discharge destination. The full model containing all predictors was statistically significant and, as a whole, explained 36.50% of the variance in discharge destination.

Conclusion:

These results highlight the importance of these variables in influencing the outcomes of patients with severe stroke, which may assist post-hospital discharge services in allocating resources for patients with severe stroke.

Does service heterogeneity have an impact on acute hospital length of stay in stroke? A UK-based multicentre prospective cohort study

OBJECTIVES

To determine whether stroke patients' acute hospital length of stay (AHLOS) varies between hospitals, over and above case mix differences and to investigate the hospital-level explanatory factors.

DESIGN

A multicentre prospective cohort study.

SETTING

Eight National Health Service acute hospital trusts within the Anglia Stroke & Heart Clinical Network in the East of England, UK.

PARTICIPANTS

The study sample was systematically selected to include all consecutive patients admitted within a month to any of the eight hospitals, diagnosed with stroke by an accredited stroke physician every third month between October 2009 and September 2011.

PRIMARY AND SECONDARY OUTCOME MEASURES

AHLOS was defined as the number of days between date of hospital admission and discharge or death, whichever came first. We used a multiple linear regression model to investigate the association between hospital (as a fixed-effect) and AHLOS, adjusting for several important patient covariates, such as age, sex, stroke type, modified Rankin Scale score (mRS), comorbidities and inpatient complications. Exploratory data analysis was used to examine the hospital-level characteristics which may contribute to variance between hospitals. These included hospital type, stroke monthly case volume, service provisions (ie, onsite rehabilitation) and staffing levels.

RESULTS

A total of 2233 stroke admissions (52% female, median age (IQR) 79 (70 to 86) years, 83% ischaemic stroke) were included. The overall median AHLOS (IQR) was 9 (4 to 21) days. After adjusting for patient covariates, AHLOS still differed significantly between hospitals (p<0.001). Furthermore, hospitals with the longest adjusted AHLOS's had predominantly smaller stroke volumes.

CONCLUSIONS

We have clearly demonstrated that AHLOS varies between different hospitals, and that the most important patient-level explanatory variables are discharge mRS, dementia and inpatient complications. We highlight the potential importance of stroke volume in influencing these differences but cannot discount the potential effect of unmeasured confounders.

The Impact of Transferring Stroke Patients: An Analysis of National Administrative Data

BACKGROUND

Interhospital transfer is an important but resource-intensive pattern of care. The use for stroke patients is highly dependent upon health system structure. We examined the impact of hospital transfers for stroke care in Canada.

METHODS

We analyzed hospital administrative data within the Canadian Institute for Health Information (CIHI) Database for the 3 fiscal years 2011/12, 2012/13 and 2013/14. Patients with clinical stroke syndrome (ischemic or hemorrhagic) were identified using International Classification of Diseases. Stroke centers were defined by Heart & Stroke Foundation of Canada stroke report.

RESULTS

During the 3-year period,397 patients in Canada (excluding Quebec) were admitted to hospital for clinical stroke syndrome. Median age was 75 (interquartile range [IQR] 64-84) years; 50.6 % were male. Less than 5% (n=4030) of patients were transferred. Patients transferred to stroke centers were younger (p<0.001) and had shorter median length of stay (p<0.001). The highest probability of discharge home was associated with sole care at stroke center (43.8%). Transfer to stroke center from community hospital had the highest probability for discharge to rehabilitation facility (25%) and lowest to either long-term (2.1%) or complex community care (2.0%). Transferred patients had lower mortality at discharge.

CONCLUSION

Younger patients were transferred more frequently to stroke centers; older patients were more likely treated in community hospitals. Sole stroke center care was associated with high discharge rate to home; transfer to a stroke center was associated with high discharge rate to rehabilitation and lower mortality rates.

Ten-year trends in stroke admissions and outcomes in Canada

Background

We analyzed a 10-year stroke administrative dataset to examine trends in admissions, mortality, and discharge destination in Canada.

Methods

We conducted an analysis of hospital administrative data from April 1st 2003 to March 31st 2013 from the Canadian Institute of Health Information’s Discharge Abstract Database. Ten-year trends for population-based age- and sex-standardized admission rates were calculated. We reviewed 10-year trends in absolute stroke admissions for differences between provinces and age groups. Stroke 30-day in-hospital mortality rates were calculated and adjusted for sex, age, stroke type and comorbidities. We documented changes in discharge location for ischemic and hemorrhagic stroke patients discharged from acute care.

Results

The rate of hospital admissions has declined from 140.2 to 117.5 (per 100,000 people). The number of absolute stroke admissions within provinces increased in Alberta and British Columbia (21.7% and 16.2% respectively). The proportion of stroke patients aged 40-69 years old increased by 4.8% (p<0.0001) over the 10 years, whereas the proportion aged over 70 decreased by 4.9% (p<0.0001). Risk-adjusted 30-day in-hospital mortality decreased from: 18.5% to 14.9% for all strokes; 15.2% to 12.1% for ischemic strokes; 35.6% to 29.7% for intracerebral hemorrhage; and 25.1% to 18.0% for subarachnoid hemorrhage. The absolute increase in patients requiring inpatient and outpatient support increased by 4% (p<0.0001).

Conclusion

The rate of admissions for stroke is decreasing but there is an increase in stroke admissions for younger patients. In-hospital mortality is decreasing; fewer patients are going directly home without services and more are requiring support services.

Recovery Time of Independent Poststroke Abilities: Part I

The purposes of this study were to determine the time of the recovery of poststroke abilities and to identify prognostic indicators associated with recovery time among stroke patients undergoing a rehabilitation program. A sample of 421 stroke participants admitted to a rehabilitation center was recruited from medical records that were available from January 1987 to December 1992. The mean age was 61.8 years (range, 17-89 years). The relationship between the achievement of independent poststroke abilities and the potential covariates associated with recovery time was assessed through the analysis of survival data. Cox maximum-likelihood proportional hazard models were used for the analysis. Independent poststroke abilities included behavior, cognitive, perceptual, communication, visual, and motor status. The time from rehabilitation admission to complete independence was introduced to the model in relation to the covariates. The mean time of recovery of poststroke abilities ranged from 18.70 to 32.40 days from the rehabilitation admission. The survival analysis revealed that the time of recovery of the selected poststroke abilities was significantly influenced (p <.05) by one or several factors, among these were neuropsychological, physical, and life habits. With this precious information, stroke rehabilitation specialists may be able to reduce the length of time required to recover independent poststroke abilities by treating the specific neuropsychological, physical, and life habit characteristics identified in this study. A faster poststroke recovery will reduce the socioeconomic impact generated by stroke disability and will ensure a better quality of life to the stroke survivor.

Admission to and Continuation of Inpatient Stroke Rehabilitation in Queensland, Australia: A Survey of Factors that Contribute to the Consultant's Decision

Aim: To evaluate factors that may contribute to the decision of the consultant medical officer (CMO) to: (1) admit a person with stroke to inpatient rehabilitation from acute hospitalisation; and (2) continue or cease inpatient rehabilitation.

Methods: A web-based survey of CMOs practising in Queensland Australia, who were members of the Australian and New Zealand Society of Geriatric Medicine (n ~ 90) or the Queensland Stroke Clinical Network (n ~ 30) was completed. The survey contained two sections to explore factors that could: (1) favour or disfavour admission to inpatient rehabilitation from acute hospitalisation; and (2) favour continuation or cessation of inpatient rehabilitation. Open and closed questions were used.

Results: Twenty-one CMOs (13–20% response rate, 43% geriatrician) completed the survey. Factors related to physical function, along with the presence of social supports favoured admission, while the presence of behavioural and cognitive impairments and a lack of staff capacity disfavoured admission. Improvements in function favoured continuation of inpatient rehabilitation, while a lack of improvement favoured cessation.

Conclusion: Factors related to the patient, their social support network and the organisation were found to influence the decision of the CMO to admit a person with stroke to inpatient rehabilitation from acute hospitalisation. Once in rehabilitation, demonstration of benefit was consistently reported to indicate continued service need.

Identifying the best treatment among common nonsurgical neck pain treatments: a decision analysis

STUDY DESIGN

Decision analysis.

OBJECTIVE

To identify the best treatment for nonspecific neck pain.

SUMMARY OF BACKGROUND DATA

In Canada and the United States, the most commonly prescribed neck pain treatments are nonsteroidal anti-inflammatory drugs (NSAIDs), exercise, and manual therapy. Deciding which treatment is best is difficult because of the trade-offs between beneficial and harmful effects, and because of the uncertainty of these effects.

METHODS

(Quality-adjusted) life expectancy associated with standard NSAIDs, Cox-2 NSAIDs, exercise, mobilization, and manipulation were compared in a decisionanalytic model. Estimates of the course of neck pain, background risk of adverse events in the general population, treatment effectiveness and risk, and patient-preferences were input into the model. Assuming equal effectiveness, we conducted a baseline analysis using risk of harm only. We assessed the stability of the baseline results by conducting a second analysis that incorporated effectiveness data from a high-quality randomized trial.

RESULTS

There were no important differences across treatments. The difference between the highest and lowest ranked treatments predicted by the baseline model was 4.5 days of life expectancy and 3.4 quality-adjusted life-days. The difference between the highest and lowest ranked treatments predicted by the second model was 7.3 quality-adjusted life-days.

CONCLUSION

When the objective is to maximize life expectancy and quality-adjusted life expectancy, none of the treatments in our analysis were clearly superior.

Identifying the best treatment among common nonsurgical neck pain treatments: a decision analysis

STUDY DESIGN

Decision analysis.

OBJECTIVE

To identify the best treatment for nonspecific neck pain.

SUMMARY OF BACKGROUND DATA

In Canada and the United States, the most commonly prescribed neck pain treatments are nonsteroidal anti-inflammatory drugs (NSAIDs), exercise, and manual therapy. Deciding which treatment is best is difficult because of the trade-offs between beneficial and harmful effects, and because of the uncertainty of these effects.

METHODS

(Quality-adjusted) life expectancy associated with standard NSAIDs, Cox-2 NSAIDs, exercise, mobilization, and manipulation were compared in a decision-analytic model. Estimates of the course of neck pain, background risk of adverse events in the general population, treatment effectiveness and risk, and patient-preferences were input into the model. Assuming equal effectiveness, we conducted a baseline analysis using risk of harm only. We assessed the stability of the baseline results by conducting a second analysis that incorporated effectiveness data from a high-quality randomized trial.

RESULTS

There were no important differences across treatments. The difference between the highest and lowest ranked treatments predicted by the baseline model was 4.5 days of life expectancy and 3.4 quality-adjusted life-days. The difference between the highest and lowest ranked treatments predicted by the second model was 7.3 quality-adjusted life-days.

CONCLUSION

When the objective is to maximize life expectancy and quality-adjusted life expectancy, none of the treatments in our analysis were clearly superior.

Racial differences in hospital discharge disposition among stroke patients in Maryland

OBJECTIVE

The objective of this retrospective study was to assess the evidence for racial differences in discharge disposition among patients hospitalized for stroke.

DATA

Hospital discharge data from the Maryland Health Services Cost Review Commission were used in the analysis. The data covered the period from January 2000 to September 2003.

STUDY DESIGN

Discharge-disposition categories were ordered such that higher numbers corresponded to less desirable outcomes: 1 = discharge to home; 2 = discharge to any medical care facility; 3 = death. We analyzed the influence of black race on the discharge disposition by estimating a partial proportional odds logit regression model that included demographic and clinical covariates.

DATA EXTRACTION

The study inclusion criteria were 1) stroke (ICD9 431-434; 436-438) as a primary admission diagnosis and 2) patient race identified as black or white. Patients discharged against medical advice were excluded. The sample contained 51,564 stroke hospitalizations.

PRINCIPAL FINDINGS

Based on the relative odds ratios (OR; 95% confidence interval [CI]), black males were more likely to be discharged to higher ranked (i.e., less desirable) discharge categories (OR = 1.66; CI 1.55-1.77) compared to white males. Black females were more likely to die (OR = 1.14; CI 1.02-1.28) and more likely either to die or to be discharged to medical care (OR = 1.38; CI 1.24-1.54) compared to white males.

CONCLUSIONS

Blacks are at greater mortality risk following stroke hospitalizations and face less desirable discharge dispositions if they survive. These results are consistent with prior reports of lower survival rates among blacks and are robust to adjustments for various confounding factors.

Gender and family composition related to discharge destination and length of hospital stay after acute stroke

Informal care by family members still plays an important role in home care after acute stroke. This study determined the clinical and demographic factors, such as family structure, that predict discharge to home and length of hospital stay (LOS) after acute stroke hospitalization. We reviewed the sex, age, family structure before stroke, type of stroke, size of the lesion, activities of daily living (ADL) function at discharge, discharge destination, and LOS of stroke patients (114 cerebral infarctions and 44 intracerebral hemorrhages) admitted to a neurosurgical hospital. Patients with cerebral infarction were older than those with intracerebral hemorrhage (median 75 vs 66 years). Ninety-eight were discharged to home (62%). In the logistic regression analysis, low ADL function, medium or large infarction, and intracerebral hemorrhage (vs lacunar infarction) were significantly associated with discharge to a destination other than home. Of the patients discharged home, low ADL function was strongly associated with LOS in the multiple regression analysis. In addition, living with a spouse only had the opposite effect on LOS in men and women (p=0.050 and 0.071, respectively). LOS tended to be shorter for men with a wife, but longer for women with a husband. The structure and gender roles in a stroke patient's household may need further attention for the efficient use of hospital resources.

Factors related to home discharge of cerebrovascular disease patients: 1-year follow-up interview survey of caregivers of hospitalized patients in 53 acute care hospitals in Japan

In Japan, many disabled elderly people remain hospitalized for long periods. Cerebrovascular diseases (CVD) are the most causes responsible for such disability. To examine the predictors of home discharge in CVD patients, we performed a 1-year follow-up interview of the main caregivers of patients hospitalized with a CVD event. The initial cohort consisted of CVD patients hospitalized in all the second level emergency and general hospitals in Ibaraki Prefecture in February 1992 (N=888 patients in 53 hospitals). In the following year, we performed an interview survey of the main caregivers of these CVD patients. The survey items included the characteristics of the patients (including medical and socioeconomic conditions), caregivers, and family members. The final study population included the main caregivers of 187 home patients and 90 institutionalized patients. We compared these two groups in terms of predictors of discharge to home. The results of multiple logistic regression analysis showed that the following seven factors were related to home discharge; better baseline activities of daily living (ADL), larger improvement in ADL, larger family size, spouse as the caregiver, caregiver without a full-time job, better economic status of the caregiver, and sources of the patient's income. Our study indicated that the caregiver's conditions were closely related to home discharge of the CVD patients. More attention should, therefore, be centered on the caregiver's well-being and economic aspects as well as the patient's conditions in order to encourage home discharge of stroke patients.

A model to aid in the prediction of discharge location for stroke rehabilitation patients11No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the author(s) or upon any organization with which the author(s) is/are associated

OBJECTIVE

To determine which demographic and medical factors recorded on admission to a rehabilitation unit best predict discharge accommodation outcomes.

DESIGN

Retrospective chart review.

SETTING

Inpatient rehabilitation unit in an academic hospital in southwestern Ontario, Canada.

PARTICIPANTS

One hundred four stroke patients (54 women, 50 men; mean age, 72.0y) admitted to the rehabilitation unit over a 4-year period.

INTERVENTIONS

All patients underwent evaluations by the physical therapy, occupational therapy, social work, speech pathology, and psychology departments. Patients were divided into 2 groups: (1) no change in premorbid accommodation and (2) change in premorbid accommodation.

MAIN OUTCOME MEASURES

Demographic, clinical, and housing information (premorbid, discharge) and functional data (FIM trade mark instrument, Chedoke-McMaster Stroke Assessment [CMSA] Impairment Inventory, Berg Balance Scale [BBS]) were recorded for each patient.

RESULTS

Of 104 patients, 24 were discharged with a change in premorbid accommodation. Change in discharge location was significantly associated with age, gender, and the presence of premorbid social support (P<.01), but not with type of premorbid living arrangement. Statistically significant differences were noted between total FIM scores (P<.001), BBS scores (P<.001), and the postural component of the CMSA Impairment Inventory (P<.03). A logistic regression model, predicting 67% of the variance, was created to predict discharge accommodations.

CONCLUSIONS

Patients admitted to the rehabilitation unit can be scored to obtain their predicted chance of being discharged with a change from their premorbid accommodations. The equation is relatively easy to calculate and is based on data that are commonly collected in rehabilitation.

Cost of managing complications resulting from type 2 diabetes mellitus in Canada

BACKGROUND

Decision makers need to have Canadian-specific cost information in order to develop an accurate picture of diabetes management. The objective of this study is to estimate direct medical costs of managing complications of diabetes. Complication costs were estimated by applying unit costs to typical resource use profiles. For each complication, the event costs refer to those associated with the acute episode and subsequent care in the first year. State costs are the annual costs of continued management. Data were obtained from many Canadian sources, including the Ontario Case Cost Project, physician and laboratory fee schedules, formularies, reports, and literature. All costs are expressed in 2000 Canadian dollars.

RESULTS

Major events (e.g., acute myocardial infarction: 18,635 dollars event cost; 1,193 dollars state cost), generate a greater financial burden than early stage complications (e.g., microalbuminuria: 62 dollars event cost; 10 dollars state cost). Yet, complications that are initially relatively low in cost (e.g., microalbuminuria) can progress to more costly advanced stages (e.g., end-stage renal disease, 63,045 dollars state cost).

CONCLUSIONS

Macrovascular and microvascular complication costs should be included in any economic analysis of diabetes. This paper provides Canadian-based cost information needed to inform critical decisions about spending limited health care dollars on emerging new therapies and public health initiatives.

Changes in the status of hospitalized stroke patients since inception of the prospective payment system in 1983

OBJECTIVE

To describe epidemiologically the changes in acute-care delivery services for stroke victims since the inception of the 1983 prospective payment system (PPS).

DESIGN

A cross-sectional comparison of 2 acute-care hospitalized samples of stroke patients before and after implementation of PPS.

SETTING

Fifteen acute-care hospitals.

PARTICIPANTS

A total of 1992 stroke patients discharged from 15 acute care hospitals in 1995-1996 were compared with 1665 patients studied in the same geographic area in 1981-1982.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Incidence rates, length of stay (LOS), discharge destinations, in-hospital transfers, and mortality.

RESULTS

Incidence rates between the 2 time periods remained similar (1.13-1.14/1000). Major changes between 1981-1982 and 1995-1996 included reengineering of hospitals to establish subacute units with an increased use of rehabilitation units, a 63% decrease in acute hospital LOS, a 44% increase in discharges to long-term care facilities, a 39% decrease in mortality, and a 5% decrease in discharge to home. Age (avg, 71y), gender, and living arrangements confounded discharge destinations. Significantly more men in 1995-1996 had strokes at younger ages, but overall 53% were women.

CONCLUSIONS

Institution of the PPS has dramatically influenced hospital LOS, location of treatment, and discharge destinations with no improvement in home discharges.

Responsiveness and predictability of gait speed and other disability measures in acute stroke

OBJECTIVES

To identify the most responsive method of measuring gait speed, to estimate the responsiveness of other outcome measures, and to determine whether gait speed predicts discharge destination in acute stroke.

DESIGN

A prospective cohort study.

SETTING

Five acute-care hospitals.

PATIENTS

Fifty subjects with residual gait deficits after a first-time stroke.

INTERVENTIONS

Five- (5mWT) and 10-meter walk tests (10mWT) at comfortable and maximum speeds, with 2 evaluations conducted an average +/- standard deviation (SD) of 8 +/- 3 and 38 +/- 5 days poststroke.

MAIN OUTCOME MEASURE

Standardized response mean (SRM = mean change/SD of change) was used to estimate responsiveness for each walk test, the Berg Balance Scale, the Barthel Index, the Stroke Rehabilitation Assessment of Movement (STREAM), and the Timed Up and Go (TUG).

RESULTS

The SRMs were 1.22 and 1.00 for the 5mWT, and.92 and.83 for the 10mWT performed at a comfortable and maximum pace, respectively. The SRMs for the Berg Balance Scale, the Barthel Index, the STREAM, and the TUG were 1.04,.99,.89, and.73, respectively. The probability of discharge to a rehabilitation center for persons walking at < or = 0.3m/s or > 0.6m/s at the first evaluation was.95 and.22, respectively.

CONCLUSIONS

The 5mWT at a comfortable pace is recommended as the measure of choice for clinicians and researchers who need to detect longitudinal change in walking disability in the first 5 weeks poststroke.

Survival after percutaneous endoscopic gastrostomy among older residents of Quebec

CONTEXT

Percutaneous endoscopic gastrostomy has become a mainstay of nutritional support for individuals with swallowing dysfunction. There is little population-based data to guide the use of this intervention in older individuals.

OBJECTIVE

To describe the use of percutaneous endoscopic gastrostomy among older residents of Quebec and to evaluate patient characteristics associated with subsequent survival and hospital discharge.

DESIGN

A population-based cohort study.

SETTING

Quebec, Canada.

PATIENTS

175 individuals with a billing claim for percutaneous endoscopic gastrostomy performed in 1993.

MEASUREMENTS

Billing and hospitalization databases were used to collect patient characteristics, medical diagnoses, discharge destinations, and dates of death. The relationships between demographic and diagnostic variables before gastrostomy, and subsequent survival and discharge home, were evaluated using survival analysis.

RESULTS

Median survival after gastrostomy was 210 days. Mortality at 30 days was 18.3%. Decreased survival was associated with a previous diagnosis of malignancy (risk ratio (RR) = 1.71; 95% CI, 1.09-2.68); mortality did not increase with increasing age. Of 163 individuals hospitalized at the time of gastrostomy, 42 (26%) were discharged home. Individuals with a previous diagnosis of stroke (RR = 2.80; 95% CI 1.01-7.77) were more likely to be discharged home than other individuals.

CONCLUSIONS

Survival after percutaneous endoscopic gastrostomy is poor; the requirement for such a procedure appears to be a marker for severe underlying disease. The greater likelihood of return home after gastrostomy among individuals with stroke suggests that the use of this intervention as an adjunct to rehabilitation is appropriate in these individuals.

Predicting ability to drive after stroke

OBJECTIVE

To determine the ability of perceptual testing to predict on-road driving outcome in subjects with stroke.

STUDY DESIGN

Historical cohort study of 84 individuals with stroke who completed both the perceptual testing and the on-road driving evaluation conducted in a driving evaluation service.

MEASURES

Perceptual tests, such as the Motor Free Visual Perception Test (MVPT) and Trail Making B test, and an on-road driving evaluation. Based on driving behaviors, a pass or fail outcome was determined by the examiners.

RESULTS

Subjects who passed the on-road evaluation had better average scores on the majority of perceptual tests compared with those who failed. The MVPT was the most predictive of on-road performance (positive predictive value=86.1%; negative predictive value=58.3%). The combination of tests resulting in the most predictive and parsimonious model was the MVPT plus Trail Making B, such that those who scored poorly on both were 22 times more likely to fail the on-road evaluation.

CONCLUSION

A screening process is useful in identifying persons who are not ready to undergo an on-road driving evaluation.

Post-stroke inpatient rehabilitation. II. Predicting discharge disposition

This study was undertaken to identify indicators that predict discharge disposition after an acute stroke rehabilitation program. A cohort of 152 incident cases suffering from stroke (76 women and 76 men) voluntarily participated in this study. They were recruited from a general hospital in which they were participating in a rehabilitation program. Post-stroke biologic, sociodemographic, and psychosocial characteristics were considered in our analyses. A polychotomous nominal logistic regression analysis was used to predict inpatient rehabilitation discharge disposition. The three discharge disposition categories were (1) private home, (2) rehabilitation center, and (3) long-term care facility. Significant predictors related to the discharge toward a rehabilitation center were functional status at admission, presence of social support, and gait status. Significant predictors for discharge to a long-term care facility were functional status at admission, presence of social support, gait status, and presence of medical complications. Functional status measured on rehabilitation admission should be considered, in conjunction with the patient's social support, gait status, and presence of medical complications, to be predictive of post-stroke rehabilitation discharge disposition.

Avoidable mortality in Québec and its regions

Avoidable mortality has been proposed as an outcome measure of health services and our aim, in this study, is to trace its general features and regional variations in Québec. For that purpose, comparisons are established between two time periods (1969-73 and 1982-90) and with several countries. Furthermore, regional SMRs (for the period 1982-90) are submitted to the Gail heterogeneity test and introduced in a stepwise regression with variables describing health services, socio-economic context and prevalence or incidence of related diseases. An analysis of proportional mortality is carried out in the two northern regions of Kativik and Baie-James. Avoidable mortality has dropped substantially in Québec, except in the case of asthma, and now displays excellent scores at the international level. Only three causes of death show significant regional variations: tuberculosis, hypertensive and cerebrovascular diseases and perinatal mortality. These variations are mainly associated with socio-economic factors but also with health services. Furthermore, the highest rates of avoidable death have been observed in Gaspésie, Saguenay/Lac St-Jean and in the two northern regions. These results are discussed through information already available on health services in Québec.

Analysis of diagnostic procedure costs for cerebrovascular disease admission to a highly specialized hospital

Length of stay and hospital costs for cerebrovascular disease admissions depend on several hospital-, patient- and disease-related factors. To determine the incidence of each of these factors we studied 240 admissions for cerebrovascular diseases in a neurology division and in two medical divisions of a highly specialized hospital. Statistical analysis of the data collected from the case records revealed the effect of several factors. Some increased only the length of stay (severe neurological sequels on discharge; stay in general medicine, diagnosis of hemorrhage, arterial hypertension). Others increased investigation costs (length of stay, marital status), and costs were higher in a specialists ward. Length of stay was shorter where the nurse/bed ratio was higher. Old age and male sex were associated with a lower cost of diagnostic procedures.