Five-year mortality and related prognostic factors after inpatient stroke rehabilitation : A European multi-centre study

Objective: To determine 5-year mortality and its association with baseline characteristics and functional status 6 months post-stroke for patients who received inpatient rehabilitation. Design: A prospective rehabilitation-based cohort study. Subjects: A total of 532 consecutive stroke patients from 4 European rehabilitation centres. Methods: Predictors were recorded on admission. Barthel Index was assessed at 6 months (BI6mths) and patients were followed for 5 years post-stroke. Survival probability was computed using Kaplan-Meier analysis and compared across 3 BI6mths-classes (0-60, 65-90, 95-100) (log-rank test). Significant independent predictors were determined using multivariate Cox regression analysis (hazard ratio (HR)). Results: Five-year cumulative risk of death was 29.12% (95% confidence interval (CI): 22.86-35.38). Age (HR = 1.06, 95% CI: 1.04-1.09), cognitive impairment (HR = 1.77, 95% CI: 1.21-2.57), diabetes mellitus (HR = 1.68, 95% CI: 1.16- 2.41) and atrial fibrillation (HR = 1.52, 95% CI: 1.08-2.14) were independent predictors of increased mortality. Hyperlipidaemia (HR = 0.66, 95% CI: 0.46-0.94), and higher BI6mths (HR = 0.98, 95% CI: 0.97-0.99) were independent predictors of decreased mortality. Five-year survival probability was 0.85 (95% CI: 0.80-0.89) for patients in BI6mthsclass: 95-100, 0.72 (95% CI: 0.63-0.79) in BI6mths-class: 65-90 and 0.50 (95% CI: 0.40-0.60) in BI6mths-class: 0-60 (p < 0.0001). Conclusion: Nearly one-third of rehabilitation patients died during the first 5 years following stroke. Functional status at 6 months was a powerful predictor of long-term mortality. Maximum functional independence at 6 months post-stroke should be promoted through medical interventions and rehabilitation. Future studies are recommended to evaluate the direct effect of rehabilitation on long-term survival

Stroke patients’ outcomes and satisfaction with care at discharge from four referral hospitals in Malawi: A cross-sectional descriptive study in limited resource

BACKGROUND Stroke is the fourth leading cause of mortality and disability in Malawi. There is paucity of studies reporting on acute stroke functional outcomes, quality of life and satisfaction with care among patients with stroke. This study aimed to determine stroke outcomes and satisfaction with care in the country’s central hospitals. METHODS A descriptive cross-sectional study, recruiting 114 adult patients with stroke and their caregivers, was done. FIM, EQ-5D-5L, SASC and C-SASC were used to collect data. Univariate associations were assessed using the Kruskal-Wallis Test for categorical variables and the Wilcoxon Rank Sum Test for continuous variables. RESULTS With 79% of the original study sample taking part, there was improvement in patients’ functional status at discharge compared to on admission with notable improvement in self-care (p<0.001), sphincter control (p<0.001), locomotion (p<0.001), and social cognition (p<0.001), but no significant improvement in transfers (p=1.000), and communication (p=0.865). Satisfaction with care was high, with no significant differences between males and females (p=0.415), age in years (p=0.397), and distance to the clinic (p=0.615). Satisfaction ratings were also high from caregivers’ responses and their scores were not associated with age (p=0.663) or distance to the hospital (p=0.872). Quality of life was poor, most patients were either unable or had severe limitation in functional dimensions of mobility (22(28%), self-care (19(25%) and performance of usual activities (25(33%). Every additional year in age was associated with average of 0.36 decrease in quality of life score coefficient, -0.36 (95% CI: -0.63; -0.10); p=0.008. CONCLUSION Patients with stroke experience improvement in functional outcomes on discharge compared to on admission. Patients and caregivers were satisfied with care provision despite having poor quality of life post stroke treatment. There is need to focus proven interventions on areas of stroke care that can impact patients’ quality of life in resource limited settings

Variations in follow-up services after inpatient stroke rehabilitation: A multicentre study

Background: Care after discharge from inpatient stroke rehabilitation units varies across Europe. The aim of this study was to compare service delivery after discharge. Methods: A total of 532 consecutive patients after stroke were recruited from 4 European rehabilitation centres in Germany, Switzerland, Belgium and the UK. At 2-month intervals, clinical assessments and structured interviews were carried out to document functional status and delivery of services after discharge. Significant factors for receiving follow-up services were analysed using a logistic generalized estimating equation model. Results: After controlling for case-mix, the results showed that Belgian patients were most likely to receive physical therapy but least likely to receive occupational therapy. German patients were least likely to receive nursing care. UK patients were less likely to receive medical care from their general practitioner compared with the other patient groups. Conclusion: Clinical characteristics did not explain the variations in service delivery after discharge from inpatient stroke rehabilitation. The decision-making processes involved in the provision of follow-up services need to be better documented. To improve our understanding of events post-discharge, the influence of non-clinical factors, such as healthcare regulations, should be explored further

conceptual mapping of a complex adaptive system based on multi-disciplinary expert insights

Funding Information: This study was partially funded by VLIR-UOS. The study sponsors had no role in the study design, the collection, analysis and interpretation of data; in the writing of the report; and in the decision to submit the paper for publication. Publisher Copyright: © 2022, The Author(s).Background: HIV drug resistance (HIVDR) continues to threaten the effectiveness of worldwide antiretroviral therapy (ART). Emergence and transmission of HIVDR are driven by several interconnected factors. Though much has been done to uncover factors influencing HIVDR, overall interconnectedness between these factors remains unclear and African policy makers encounter difficulties setting priorities combating HIVDR. By viewing HIVDR as a complex adaptive system, through the eyes of multi-disciplinary HIVDR experts, we aimed to make a first attempt to linking different influencing factors and gaining a deeper understanding of the complexity of the system. Methods: We designed a detailed systems map of factors influencing HIVDR based on semi-structured interviews with 15 international HIVDR experts from or with experience in sub-Saharan Africa, from different disciplinary backgrounds and affiliated with different types of institutions. The resulting detailed system map was conceptualized into three main HIVDR feedback loops and further strengthened with literature evidence. Results: Factors influencing HIVDR in sub-Saharan Africa and their interactions were sorted in five categories: biology, individual, social context, healthcare system and ‘overarching’. We identified three causal loops cross-cutting these layers, which relate to three interconnected subsystems of mechanisms influencing HIVDR. The ‘adherence motivation’ subsystem concerns the interplay of factors influencing people living with HIV to alternate between adherence and non-adherence. The ‘healthcare burden’ subsystem is a reinforcing loop leading to an increase in HIVDR at local population level. The ‘ART overreliance’ subsystem is a balancing feedback loop leading to complacency among program managers when there is overreliance on ART with a perceived low risk to drug resistance. The three subsystems are interconnected at different levels. Conclusions: Interconnectedness of the three subsystems underlines the need to act on the entire system of factors surrounding HIVDR in sub-Saharan Africa in order to target interventions and to prevent unwanted effects on other parts of the system. The three theories that emerged while studying HIVDR as a complex adaptive system form a starting point for further qualitative and quantitative investigation.publishersversionpublishe

Prevalence, associated factors and outcomes of pressure injuries in adult intensive care unit patients: the DecubICUs study

Funder: European Society of Intensive Care Medicine; doi: http://dx.doi.org/10.13039/501100013347Funder: Flemish Society for Critical Care NursesAbstract: Purpose: Intensive care unit (ICU) patients are particularly susceptible to developing pressure injuries. Epidemiologic data is however unavailable. We aimed to provide an international picture of the extent of pressure injuries and factors associated with ICU-acquired pressure injuries in adult ICU patients. Methods: International 1-day point-prevalence study; follow-up for outcome assessment until hospital discharge (maximum 12 weeks). Factors associated with ICU-acquired pressure injury and hospital mortality were assessed by generalised linear mixed-effects regression analysis. Results: Data from 13,254 patients in 1117 ICUs (90 countries) revealed 6747 pressure injuries; 3997 (59.2%) were ICU-acquired. Overall prevalence was 26.6% (95% confidence interval [CI] 25.9–27.3). ICU-acquired prevalence was 16.2% (95% CI 15.6–16.8). Sacrum (37%) and heels (19.5%) were most affected. Factors independently associated with ICU-acquired pressure injuries were older age, male sex, being underweight, emergency surgery, higher Simplified Acute Physiology Score II, Braden score 3 days, comorbidities (chronic obstructive pulmonary disease, immunodeficiency), organ support (renal replacement, mechanical ventilation on ICU admission), and being in a low or lower-middle income-economy. Gradually increasing associations with mortality were identified for increasing severity of pressure injury: stage I (odds ratio [OR] 1.5; 95% CI 1.2–1.8), stage II (OR 1.6; 95% CI 1.4–1.9), and stage III or worse (OR 2.8; 95% CI 2.3–3.3). Conclusion: Pressure injuries are common in adult ICU patients. ICU-acquired pressure injuries are associated with mainly intrinsic factors and mortality. Optimal care standards, increased awareness, appropriate resource allocation, and further research into optimal prevention are pivotal to tackle this important patient safety threat

Correction to: Prevalence, associated factors and outcomes of pressure injuries in adult intensive care unit patients: the DecubICUs study

The original version of this article unfortunately contained a mistake

Prevalence, associated factors and outcomes of pressure injuries in adult intensive care unit patients: the DecubICUs study

Funder: European Society of Intensive Care Medicine; doi: http://dx.doi.org/10.13039/501100013347Funder: Flemish Society for Critical Care NursesAbstract: Purpose: Intensive care unit (ICU) patients are particularly susceptible to developing pressure injuries. Epidemiologic data is however unavailable. We aimed to provide an international picture of the extent of pressure injuries and factors associated with ICU-acquired pressure injuries in adult ICU patients. Methods: International 1-day point-prevalence study; follow-up for outcome assessment until hospital discharge (maximum 12 weeks). Factors associated with ICU-acquired pressure injury and hospital mortality were assessed by generalised linear mixed-effects regression analysis. Results: Data from 13,254 patients in 1117 ICUs (90 countries) revealed 6747 pressure injuries; 3997 (59.2%) were ICU-acquired. Overall prevalence was 26.6% (95% confidence interval [CI] 25.9–27.3). ICU-acquired prevalence was 16.2% (95% CI 15.6–16.8). Sacrum (37%) and heels (19.5%) were most affected. Factors independently associated with ICU-acquired pressure injuries were older age, male sex, being underweight, emergency surgery, higher Simplified Acute Physiology Score II, Braden score 3 days, comorbidities (chronic obstructive pulmonary disease, immunodeficiency), organ support (renal replacement, mechanical ventilation on ICU admission), and being in a low or lower-middle income-economy. Gradually increasing associations with mortality were identified for increasing severity of pressure injury: stage I (odds ratio [OR] 1.5; 95% CI 1.2–1.8), stage II (OR 1.6; 95% CI 1.4–1.9), and stage III or worse (OR 2.8; 95% CI 2.3–3.3). Conclusion: Pressure injuries are common in adult ICU patients. ICU-acquired pressure injuries are associated with mainly intrinsic factors and mortality. Optimal care standards, increased awareness, appropriate resource allocation, and further research into optimal prevention are pivotal to tackle this important patient safety threat

Collaborative evaluation of rehabilitation in stroke across Europe : clinical aspects

Stroke is a major health burden throughout Europe and consumes a large amount of health care resources.1 Great differences exist in stroke management and outcome in Europe. Optimal models for delivery of stroke care, resulting in optimal outcome at reasonable cost are of great importance.1 Our understanding of the components of inpatient stroke rehabilitation that are critical for patients’ outcome is still limited. Comparing practice and outcome across European countries may give clues that can help to develop new hypotheses and intervention strategies. Therefore, longitudinal long-term follow-up studies are needed to monitor the progress of individual patients, to assess the performance of hospital and community services and to evaluate intervention.2 Optimally, such research should take place in a multi-centre study in a collaborative framework. The overall aim of this doctoral thesis was to identify components of inpatient stroke rehabilitation that have an impact on patients’ recovery. Therefore three studies were set up in four European rehabilitation centres (BE, UK, CH, DE). The findings of these studies are summarized below. In study 1, the use of time of stroke patients while in the rehabilitation centre was documented. In each centre, 60 patients were monitored during 30 time sampling sessions: 10 morning (7.00 am-12.00 noon), 10 afternoon (12.00 noon-5.00 pm) and 10 evening sessions (5.00 pm-10.00 pm). Therapy time was minimal in the evening session. Therefore, the data of the evening sessions were not included in statistical analysis. The data of morning and afternoon sessions were analyzed with a generalized estimating equation model, controlling for serial dependency of the data and for confounders as age, initial motor and functional deficit. The main significant finding was that patients in the UK centre spent significantly less time in therapy compared to the other centres. The average absolute time in therapy was 1 hour in the UK centre, 2 hours in the Belgian centre, 2 hours 20 minutes in the German centre and 2 hours and 46 minutes in the Swiss centre. Low therapy time in the UK centre was in contrast to the time available for patients from all professional groups. A possible explanation may be the different division of tasks. Participant observations indicated that professionals in the UK centre spent more time in legally required administration, leaving less time for patient care. In all four centres, physiotherapy and occupational therapy together accounted for more than half the total therapy time. Compared with the other centres, patients in the UK centre spent less time in occupational therapy, but received more nursing care. This was probably the results of the high nurse staff levels. Sports-related activities and autonomous exercising were rarely observed in any centre, suggesting a potential for self-directed remedial therapy. Overall, this study revealed that in the participating centres, stroke patients spent a large amount of the day in their rooms, inactive, and without any interaction. Sitting, lying and sleeping accounted for a third to half of the day. The evidence that more intensive rehabilitation improves outcome after stroke3 was not reflected in the rehabilitation practice observed. Still, great differences occurred across the centres with patients in the UK and Belgian centres spending less time in therapy compared to patients in the Swiss and German centres. The latter centres had a more structured rehabilitation program. This may have resulted in more therapy time and a more challenging environment for the patients, physically and mentally. Therapy time devoted to stroke patients in a rehabilitation setting seems to be more dependent on the management style than on the number of staff available. In study 2, the content of physiotherapy and occupational therapy for stroke patients was compared across the centres. First a scoring list was developed to define the content of individual physiotherapy and occupational therapy sessions for stroke patients. The therapeutic categories of the list were based on previous lists,4,5 neurological textbooks of stroke rehabilitation6 and existing videotapes of physiotherapy and occupational therapy sessions with stroke patients, made in different European rehabilitation centres. The list was finalized considering the suggestions of five physiotherapists and five occupational therapists, who had more than two years of experience in the field of neurological rehabilitation. The final scoring list consisted of 12 categories and 46 subcategories. An inter-rater reliability study was carried out with the four researchers of the different centres. Comparing the frequency of occurrence of the categories resulted in intra-class correlation coefficients, indicating high reliability for eight categories, good reliability for one category, and fair for two categories. One category was not observed. The developed scoring list was a helpful and reliable tool to unravel and compare the content of individual physiotherapy and occupational therapy sessions for stroke patients in inpatient rehabilitation settings in various European countries. The results encourage further use of the list in future research and practice aiming to improve evidence-based stroke rehabilitation. In a second phase, the list was used to compare the content of physiotherapy and occupational therapy sessions between the four rehabilitation centres. Every researcher scored 15 physiotherapy and 15 occupational therapy sessions, recorded in their own centre. Patients with different impairments might receive different treatments. Therefore therapy sessions were recorded from stroke patients fitting predetermined clinical criteria. This was done to cover the full spectrum of potential disabilities and to ensure an equivalent patient group in each centre. Additionally the data was pooled over the centres to compare the content of both therapeutic disciplines. Data were analyzed using a generalized estimating equation model controlling for serial dependency of the data and for confounders as age and duration of the treatment session. Comparison of physiotherapy and occupational therapy between centres revealed significant differences for only two of the twelve categories. Ambulatory exercises occurred more often in the physiotherapy sessions in the Belgian and UK centres and relearning selective movements occurred less in the physiotherapy and occupational therapy sessions in the UK centre. Comparison of the two therapeutic disciplines on the pooled data of the four centres, revealed that ambulatory exercises, transfers, exercises & balance in standing and lying occurred significantly more often in the physiotherapy sessions. ADL, domestic and leisure activities and sensory, perceptual training & cognition occurred significantly more often in the occupational therapy sessions. This study revealed that the content of each therapeutic discipline was consistent between the four centres. Physiotherapy and occupational therapy proved to be distinct professions with clear demarcation of roles. In study 3, motor and functional recovery patterns were compared across centres. In the four centres, 532 stroke patients were recruited. On admission to the centre and at two, four and six months after stroke the Barthel Index (BI)7 and Rivermead Motor Assessment-Gross Function (RMA-GF)8 were assessed. At two, four and six months, also the Nottingham Extended Activities of Daily Living (NEADL)9 was assessed. The statistical comparison of the recovery patterns across centres over time required an adjustment for case-mix and a mechanism for handling missing data (intention-to-treat analysis). Two other issues that complicated the comparison were the skewed distribution of the outcome variables and the earlier baseline measurement in the UK centre compared to the other centres. Therefore random effects ordinal logistic models were used for the analysis. The results showed that patients in the UK centre were significantly more likely to stay in lower RMA-GF classes compared to patients in the German centre. In the Swiss centre, patients were significantly less likely to stay in lower NEADL classes compared to patients in the UK centre. These findings should be interpreted in view of the previous studies. In chapter 1, we found that overall therapy time in the UK centre was significantly less compared to the other three centers.10 Also time in occupational therapy was significantly less in the UK, compared to the Swiss centre. In all centres, physiotherapy and occupational therapy comprised more than 50% of therapeutic time. In the UK centre, 35% of therapy time consisted of nursing care, which was more than in the other centres. In chapter 2, we reported that the content of physiotherapy and occupational therapy was consistent over the centres. The higher input of therapy in the Swiss and German centres was not related to higher staffing levels, but to a different time allocation of therapists and a strictly timed rehabilitation program for patients and therapists. This formal management led to a higher input of therapy, which in turn resulted in better motor and functional recovery for the patients. In contrast to the results for RMA-GF and NEADL, patients in the UK centre were significantly less likely to stay in lower BI classes compared to those in the German centre. This might be the result of the ceiling effect of the BI, the higher input of nursing care in the UK centre, the emphasis on self care to enable early discharge and the fact that middle band patients can expect more functional gain.11 The recovery patterns of the Belgian patients did not differ significantly from patients in any other centre. In summary, motor and functional recovery in the Swiss and German centres was better compared to the UK centre, with exception of self care recovery in the UK centre. In the German and Swiss centres, patients received noticeably more therapy per day. This higher therapy input was not a consequence of higher staffing levels, but of a more efficient organization of rehabilitation services. This study indicates a potential for further improvement of the services in the UK and Belgian centres without additional cost. In study 4, the prevalence and predictors of post-stroke affective disorders were documented. Post-stroke depression and anxiety were assessed with the Hospital Anxiety and Depression scale (HADS)12 at two, four and six months after stroke. Based on the original publication, a score >7 on HADS-depression or anxiety subscale (range 0-21) was considered to reflect the syndrome of depression or anxiety, respectively.12 Prevalence and severity were compared across centres using Chi² and Kruskal-Wallis tests, respectively. Predictors and time course of severity of depression and anxiety were examined using linear mixed models on the pooled data. Of the 532 patients enrolled in the study, the HADS was not completed at any time for 27 patients. Consequently, 505 patients were included in the analysis. Overall the prevalence of depression at the several evaluation points varied between 21% and 39%. The overall prevalence of anxiety ranged between 15% and 30%. There was no significant difference in the prevalence or severity of both affective disorders between centres. Therefore we pooled the data from the four centres to examine if the high proportion of depressed and anxious patients at each time point comprised the same individuals. Results showed that patients reporting an affective disorder at six months comprised only half those with an onset before two months. The other half had a later onset. Linear mixed models analyses showed that stroke severity, functional disability, motor impairment and baseline sensory deficit were univariate predictors of severity of both depression and anxiety. Additionally baseline cognitive disorder, dysarthria, pre-stroke Barthel index and age were associated with the severity of depression. In the multivariate models only the initial Barthel Index was retained. After correction for predictive factors, levels of depression were stable over time, while anxiety levels decreased slightly. In conclusion, this study showed that the prevalence and severity of affective disorders after stroke was similar in the four European centres. Monitoring for affective disorders is crucial as many patients risk becoming depressed or anxious in the first 6 months after stroke. The multivariate models suggest a relationship between emotional distress and functional disability after stroke. References 1. Markus H. Variations in care and outcome in the first year after stroke: a Western and Central European perspective. J Neurol Neurosurg Psychiatry. 2004;75:1660-1661. 2. Hewer RL. Outcome measures in stroke. A British view. Stroke. 1990;21(9 Suppl):II52-II55. 3. Kwakkel G, van Peppen R, Wagenaar RC, Wood Dauphinee S, Richards C, Ashburn A, Miller K, Lincoln N, Partrdige C, Wellwood I, Langhorne P. Effects of augmented exercise therapy time after stroke: a meta-analysis. Stroke. 2004; 35:2529-2539. 4. Ballinger C, Ashburn A, Low J, Roderick P. Unpacking the black box of therapy – A pilot study to describe occupational therapy and physiotherapy interventions for people with stroke. Clin Rehabil. 1999;13:301-309. Gladman JHF, Juby LC, Clarke PA, Lincoln NB. Survey of a domiciliary stroke rehabilitation service. Clin Rehabil. 1995;9:245-249. 5. Davies PM. Steps to follow. The comprehensive treatment of patients with hemiplegia, Second edition, Springer, 2000. 6. Mahoney FI, Barthel DW. Functional evaluation: the Barthel Index. Md State Med J. 1965;14:61-65. 7. Lincoln N, Leadbitter D. Assessment of motor function in stroke patients. Physiotherapy. 1979; 65:48-51. 8. Nouri FM, Lincoln NB. An extended activity of daily living scale for stroke patients. Clin Rehabil. 1978;1:301-305. 9. De Wit L, Putman K, Dejaeger E, Baert I, Berman B, Bogaerts K, Brinkmann N, Connell L, Feys H, Jenni W, Kaske C, Lesaffre E, Leys M, Lincoln N, Louckx F, Schuback B, Schupp W, Smith B, De Weerdt W. Use of time by stroke patients: a comparison of four European rehabilitation centres. Stroke. 2005. 36:1977-83. 10. Alexander MP. Stroke rehabilitation outcome. A potential use of predictive variables to establish levels of care. Stroke 1999;25:128-34. 11. Zigmond AS, Snaith RP. The hospital anxiety and depression scale. Acta Psychiatr Scan. 1983;67:361-370. 12. Horn SD, DeJong G, Ryser DK, Veazie PJ, Teraoka J. Another look at observational studies in rehabilitation research: going beyond the holy grail of the randomized controlled trial. Arch Phys Med Rehabil. 2005;86:S8-S15.status: publishe