A simplified stroke rehabilitation assessment of movement instrument

Background and Purpose. An efficient, reliable, and valid instrument for assessing motor function in patients with stroke is needed by both clinicians and researchers. To improve administration efficiency, we applied the multidimensional Rasch model to the 30-item, 3-subscale Stroke Rehabilitation Assessment of Movement (STREAM) instrument to produce a concise, reliable, and valid instrument (simplified STREAM [S-STREAM]) for measuring motor function in patients with stroke. Subjects and Methods. The STREAM (consisting of 3 subscales: upper-limb movements, lower-limb movements, and mobility) was administered to 351 subjects with first stroke occurrence and a median time after stroke of 19.5 months. The unidimensionality of each subscale of the STREAM first was verified with unidimensional Rasch analysis. Each subscale of the STREAM then was simplified by deleting redundant items on the basis of expert opinion and the results of the Rasch analysis. The Rasch reliability of the S-STREAM and the concurrent validity of the S-STREAM with the STREAM were examined with multidimensional Rasch analysis and the intraclass correlation coefficient (ICC), respectively. Results. After deleting the items that did not fit the Rasch model, we found that the 8-item upper-limb movement subscale, the 9-item lower-limb movement subscale, and the 10-item mobility subscale assessed single, unidimensional upper-limb movements, lower-limb movements, and mobility, respectively. We selected 5 items from each subscale to construct the S-STREAM and found that the reliability of each subscale of the resulting simplified instrument was high (Rasch reliability coefficients of [greater than or equal to] .91). The agreement between the subscale scores (Rasch estimates) of the S-STREAM and those of the STREAM was excellent (ICC of [greater than or equal to] .99, with a lower limit for the 95% confidence interval of [greater than or equal to] .985), indicating good concurrent validity of the S-STREAM with the STREAM. Discussion and Conclusion. The S-STREAM demonstrates high Rasch reliability, unidimensionality, and concurrent validity with the STREAM in patients with stroke. Furthermore, the S-STREAM is efficient to administer, as it consists of only half the number of items in the original STREAM. Additional studies to examine other psychometric properties (eg, predictive validity and responsiveness) of the S-STREAM or its psychometric properties in various recovery stages after stroke are needed to further establish its utility in both clinical and research settings.

Assessing cost-effectiveness in mental health : vocational rehabilitation for schizophrenia and related conditions

Objective: Existing evidence suggests that vocational rehabilitation services, in particular individual placement and support (IPS), are effective in assisting people with schizophrenia and related conditions gain open employment. Despite this, such services are not available to all unemployed people with schizophrenia who wish to work. Existing evidence suggests that while IPS confers no clinical advantages over routine care, it does improve the proportion of people returning to employment. The objective of the current study is to investigate the net benefit of introducing IPS services into current mental health services in Australia.

Method: The net benefit of IPS is assessed from a health sector perspective using cost–benefit analysis. A two-stage approach is taken to the assessment of benefit. The first stage involves a quantitative analysis of the net benefit, defined as the benefits of IPS (comprising transfer payments averted, income tax accrued and individual income earned) minus the costs. The second stage involves application of 'second-filter' criteria (including equity, strength of evidence, feasibility and acceptability to stakeholders) to results. The robustness of results is tested using the multivariate probabilistic sensitivity analysis.

Results: The costs of IPS are $A10.3M (95% uncertainty interval $A7.4M–$A13.6M), the benefits are $A4.7M ($A3.1M–$A6.5M), resulting in a negative net benefit of $A5.6M ($A8.4M–$A3.4M).

Conclusions: The current analysis suggests that IPS costs are greater than the monetary benefits. However, the evidence-base of the current analysis is weak. Structural conditions surrounding welfare payments in Australia create disincentives to full-time employment for people with disabilities.

Long-term risk factor control after a cardiac rehabilitation programme

This study examined the hypothesis that Phase II cardiac rehabilitation participants (CRP) had better long-term risk factor control, self-rated perception of health and return to work rates than non-participants (NP) between 18 and 36 months post myocardial infarction (MI). It was a comparative study in a 550 bed hospital.

Approximately half of both groups did not achieve a total cholesterol (TC) of 5.5mmol/L or less. Compared with NP, CRP were significantly more likely to have a TC<=6.5mmol/L (7% vs. 28%) (p=0.006). NP with TC>6.5mmol/L were significantly less likely to be on treatment (p=0.002). CRP were more likely to regularly exercise than NP (79% vs. 61%) (p=0.038). The success rate for blood pressure targets, return to work rates and self-rated perception of health were similar in both groups.

In conclusion, CRP had better long-term control of some risk factors than NP. The study provides comparative longer term patient outcomes after an Australian cardiac rehabilitation (CR) programme and forms the basis for further outcome measurement.

Predicting the grade of disability 1 year after stroke following rehabilitation

The purpose of this study was to identify predictors of grades of disability at least 1 year after stroke rehabilitation therapy. We recruited stroke patients from the inpatient rehabilitation department of a university hospital. The degree of disability was graded using the disability evaluation at least 1 year after stroke onset. Functional ability was evaluated using the Functional Independence Measure instrument on admission, on discharge from the inpatient rehabilitation program, and at the 6-month follow-up visit after discharge. Major sociodemographic, medical, and rehabilitative factors were also collected during the hospitalization period. Of the 109 patients surveyed, 64 (58.7%) had severe or very severe grades of disability. The correlates of severe or very severe disability in logistic regression analyses were bilaterally affected (odds ratio, OR, 10.8), impaired orientation (OR, 3.6), and poorer functional ability at discharge (OR, 7.6). Based on the significant predictors identified, the logistic regression model correctly classified severe or very severe disability in 68.0% of subjects. The higher frequency of severe or very severe disability in this study may have been due to the relatively more severely affected stroke patient population in the inpatient rehabilitation service and the use of unique disability evaluation criteria. These results may provide information useful in planning continuous rehabilitation care and setting relevant socio-welfare policies for stroke victims.

Prediction of functional oucomes in stroke inpatients receiving rehabilitation

Background and Purpose: Early identification of predictive factors relevant to functional outcomes for stroke patients is important to the establishment of an effective continuing care program. The objective of this studywas to identify the predictive factors related to functional outcome at discharge after stroke rehabilitation therapy. Methods: 105 first-time stroke patients admitted to the inpatient rehabilitation department of a university-based medical center were recruited for this prospective study. The functional outcomes of the patients were assessed at admission and at discharge using the Functional Independence Measure (FIM). Severity of stroke was determined using the Canadian Neurological Scale (CNS). Age, gender, side of hemiplegia (SIDE), type of stroke (TYPE), onset to admission interval (OAI), and length of rehabilitation stay (LORS) were also included as predictor variables. Results: The mean (′SD) FIM score at discharge (76.6 ′ 26.4) correlated strongly (r = 0.78, p < 0.001) with the admission FIM score (56.3 ′ 24.1), moderately (r = 0.46, p < 0.001) with the admission CNS score (6.1 ′ 2.2), negatively (r = -0.38, p < 0.001) with age (63.2 ′ 12.3 years), negatively (r = -0.26, p = 0.009) with OAI (24.2 ′ 16.0 days), and negatively (r = -0.29, p = 0.002) with LORS (34.7 ′ 16.8 ays). Stepwise regression analyses indicated that admission FIM score, age, and admission CNS score were the stronge predictors of functional outcome and accounted for 66% of the total variation in discharge FIM total score. The admission FIM score was the best predictor and accounted for 61% of the variation. Conclusions: The findings of this study imply that the admission FIM scores for inpatients receiving stroke rehabilitation can be used to predict functional outcomes at discharge from hospital.

Cardiac rehabilitation in south west Victoria : factors influencing attendance

Background : The benefits of cardiac rehabilitation (CR) programs are well established. Despite these benefits their utilisation remains sub-optimal, with an average of 24% of eligible cardiac patients attending outpatient CR programs across Victoria.
Aims & rationale/Objectives : The objectives of this study were to (a) identify local barriers and enablers to the uptake of hospital-based CR programs, and (b) identify preferred alternatives for the delivery of CR.
Methods : Six hospital-based CR programs within the region agreed to participate in this study. A consecutive series of patients referred to the programs were surveyed by the CR coordinators to identify the local barriers and enablers influencing CR program attendance. In addition, focus groups with CR participants and health professionals were conducted at two hospitals in order to ascertain their views on current programs, suggestions for improvements and alternative methods of CR delivery.
Principal findings : Survey data was obtained from a total of 97 patients referred to the CR programs during the study period, 27 (28%) females and 70 (72%) males. Main reasons given for CR non-attendance were related to distance to travel, cost of petrol, reliance on others for transport and lack of interest or motivation to attend. For CR attenders, main enablers included encouragement by family, medical and other health professionals, and having someone else to drive them. Suggestions for alternative methods of CR delivery included more programs in outlying communities, home and GP based programs, telephone support and a patient manual or workbook.
Discussion : The results of this study provide valuable information for designing strategies to increase utilisation of existing CR programs as well as pilot testing alternative modes of CR program delivery for cardiac patients in rural areas unable to access hospital-based CR.
Implications : These findings suggest that many of the barriers identified could be addressed by a more creative use of existing resources and the provision of CR services in primary care settings.
Presentation type : Poster

Economic evaluation alongside a phase II, multi-centre, randomised controlled trial of very early rehabilitation after stroke (AVERT)

BACKGROUND/PURPOSE: The effectiveness and costs of very early rehabilitation after stroke are unknown. This study assessed the cost effectiveness of very early mobilisation in addition to standard care (VEM) compared with standard care alone (SC). METHODS: Cost-effectiveness analysis alongside a phase II, multi-centre, randomised controlled trial (RCT) with blinded outcome assessments. Less than 24 h after stroke, patients were recruited from two stroke units and randomised to receive VEM or SC. The intervention continued until discharge or 14 days, whichever was sooner. The efficacy measure was a dichotomised modified Rankin Scale (mRS) at 3 months with mRS < or =2 representing good outcome. Costs were determined from medical records and patient interviews at 3, 6 and 12 months. National average (where available) or local costs were applied for the reference year 2004. Differences in mean total costs at 3 and 12 months were tested using t test assuming unequal variances. An incremental cost-effectiveness ratio was calculated and probabilistic uncertainty analysis was undertaken. RESULTS: The sample consisted of 38 VEM and 33 SC patients. A trend for good outcome with VEM compared to SC was found (adjusted OR 4.10, 95% CI 0.99-16.88, p = 0.051). Patients receiving VEM incurred significantly less costs at 3 months (AUD 13,559) compared with SC (AUD 21,860; p = 0.02). This difference in mean per patient total cost persisted at the 12-month assessment (VEM: AUD 17,564; SC: AUD 29,750; p = 0.03). VEM was found to be a 'dominant' (more effective, less cost) intervention when compared to SC at 3 months. CONCLUSION: These findings provide preliminary evidence that VEM is likely to be cost-effective. A large RCT is currently underway to confirm the cost effectiveness of VEM.