Angela Cheong

Trade‐offs between effectiveness and efficiency in stroke rehabilitation

Background Most stroke research has studied rehabilitation effectiveness and rehabilitation efficiency separately and not investigated the potential trade-offs between these two indices of rehabilitation. Aims To determine whether there is a trade-off between independent factors of rehabilitation effectiveness and rehabilitation efficiency. Methods Using a retrospective cohort study design, we studied all stroke patients (n = 2810) from two sub-acute rehabilitation hospitals from 1996 to 2005, representing 87·5% of national bed-years during the same period. Results Independent predictors of poorer rehabilitation effectiveness and log rehabilitation efficiency were older age race-ethnicity caregiver availability ischemic stroke longer time to admission dementia admission Barthel Index score, and length of stay. Rehabilitation effectiveness was lower in females, and the gender differences were significantly lower in those aged ≥70 years (β −4·7 (95% confidence interval −7·4 to −2·0)). There were trade-offs between effectiveness and efficiency with respect to admission Barthel Index score and length of stay. An increase of 10 in admission Barthel Index score predicted an increase of 3·6% (95% confidence interval 3·2–4·0) in effectiveness but a decrease of 0·04 (95% confidence interval −0·05 to −0·02) in log efficiency (a reduction of efficiency by 1·0 per 30 days). An increase in log length of stay by 1 (length of stay of 2·7 days) predicted an increase of 8·0% (95% confidence interval 5·7–10·3) in effectiveness but a decrease of 0·82 (95% confidence interval −0·90 to −0·74) in log efficiency (equivalent to a reduction in efficiency by 2·3 per 30 days). For optimal rehabilitation effectiveness and rehabilitation efficiency, the admission Barthel Index score was 30–62 and length of stay was 37–41 days. Conclusions There are trade-offs between effectiveness and efficiency during inpatient sub-acute stroke rehabilitation with respect to admission functional status and length of stay.

The synergistic effect of functional status and comorbidity burden on mortality: a 16-year survival analysis.

Objectives The relationship between disability and comorbidity on mortality is widely perceived as additive in clinical models of frailty. Design National data were retrospectively extracted from medical records of community hospital. Data Sources There were of 12,804 acutely-disabled patients admitted for inpatient rehabilitation in Singapore rehabilitation community hospitals from 1996 through 2005 were followed up for death till 31 December 2011. Outcome Measure Cox proportional-hazards regression to assess the interaction of comorbidity and disability at discharge on all-cause mortality. Results During a median follow-up of 10.9 years, there were 8,565 deaths (66.9%). The mean age was 73.0 (standard deviation: 11.5) years. Independent risk factors of mortality were higher comorbidity (p<0.001), severity of disability at discharge (p<0.001), being widowed (adjusted hazard ratio [aHR]: 1.38, 95% confidence interval [CI]:1.25–1.53), low socioeconomic status (aHR:1.40, 95%CI:1.29–1.53), discharge to nursing home (aHR:1.14, 95%CI:1.05–1.22) and re-admission into acute care (aHR:1.54, 95%CI:1.45–1.65). In the main effects model, those with high comorbidity had an aHR = 2.41 (95%CI:2.13–2.72) whereas those with total disability had an aHR = 2.28 (95%CI:2.12–2.46). In the interaction model, synergistic interaction existed between comorbidity and disability (p<0.001) where those with high comorbidity and total disability had much higher aHR = 6.57 (95%CI:5.15–8.37). Conclusions Patients with greater comorbidity and disability at discharge, discharge to nursing home or re-admission into acute care, lower socioeconomic status and being widowed had higher mortality risk. Our results identified predictive variables of mortality that map well onto the frailty cascade model. Increasing comorbidity and disability interacted synergistically to increase mortality risk.

Factors Associated with Nursing Home Placement of All Patients Admitted for Inpatient Rehabilitation in Singapore Community Hospitals from 1996 to 2005: A Disease Stratified Analysis

Objectives To (1) identify social and rehabilitation predictors of nursing home placement, (2) investigate the association between effectiveness and efficiency in rehabilitation and nursing home placement of patients admitted for inpatient rehabilitation from 1996 to 2005 by disease in Singapore. Design National data were retrospectively extracted from medical records of community hospital. Data Sources There were 12,506 first admissions for rehabilitation in four community hospitals. Of which, 8,594 (90.3%) patients were discharged home and 924 (9.7%) patients were discharged to a nursing home. Other discharge destinations such as sheltered home (n = 37), other community hospital (n = 31), death in community hospital (n = 12), acute hospital (n = 1,182) and discharge against doctor’s advice (n = 24) were excluded. Outcome Measure Nursing home placement. Results Those who were discharged to nursing home had 33% lower median rehabilitation effectiveness and 29% lower median rehabilitation efficiency compared to those who were discharged to nursing homes. Patients discharged to nursing homes were significantly older (mean age: 77 vs. 73 years), had lower mean Bathel Index scores (40 vs. 48), a longer median length of stay (40 vs. 33 days) and a longer time to rehabilitation (19 vs. 15 days), had a higher proportion without a caregiver (28 vs. 7%), being single (21 vs. 7%) and had dementia (23 vs. 10%). Patients admitted for lower limb amputation or falls had an increased odds of being discharged to a nursing home by 175% (p<0.001) and 65% (p = 0.043) respectively compared to stroke patients. Conclusions In our study, the odds of nursing home placement was found to be increased in Chinese, males, single or widowed or separated/divorced, patients in high subsidy wards for hospital care, patients with dementia, without caregivers, lower functional scores at admission, lower rehabilitation effectiveness or efficiency at discharge and primary diagnosis groups such as fractures, lower limb amputation and falls in comparison to strokes.

Wireless wearable range-of-motion sensor system for upper and lower extremity joints: a validation study.

Range-of-motion (ROM) assessment is a critical assessment tool during the rehabilitation process. The conventional approach uses the goniometer which remains the most reliable instrument but it is usually time-consuming and subject to both intra- and inter-therapist measurement errors. An automated wireless wearable sensor system for the measurement of ROM has previously been developed by the current authors. Presented is the correlation and accuracy of the automated wireless wearable sensor system against a goniometer in measuring ROM in the major joints of upper (UEs) and lower extremities (LEs) in 19 healthy subjects and 20 newly disabled inpatients through intra (same) subject comparison of ROM assessments between the sensor system against goniometer measurements by physical therapists. In healthy subjects, ROM measurements using the new sensor system were highly correlated with goniometry, with 95% of differences < 20° and 10° for most movements in major joints of UE and LE, respectively. Among inpatients undergoing rehabilitation, ROM measurements using the new sensor system were also highly correlated with goniometry, with 95% of the differences being < 20° and 25° for most movements in the major joints of UE and LE, respectively.

Can caregivers report their care recipients’ post-stroke hospitalizations and outpatient visits accurately? Findings of an Asian prospective stroke cohort

BackgroundHealth services research aimed at understanding service use and improving resource allocation often relies on collecting subjectively reported or proxy-reported healthcare service utilization (HSU) data. It is important to know the discrepancies in such self or proxy reports, as they have significant financial and policy implications. In high-dependency populations, such as stroke survivors, with varying levels of cognitive impairment and dysphasia, caregivers are often potential sources of stroke survivors’ HSU information. Most of the work conducted on agreement analysis to date has focused on validating different sources of self-reported data, with few studies exploring the validity of caregiver-reported data. Addressing this gap, our study aimed to quantify the agreement across the caregiver-reported and national claims-based HSU of stroke patients.MethodsA prospective study comprising multi-ethnic stroke patient and caregiver dyads (N = 485) in Singapore was the basis of the current analysis, which used linked national claims records. Caregiver-reported health services data were collected via face-to-face and telephone interviews, and similar health services data were extracted from the national claims records. The main outcome variable was the modified intraclass correlation coefficient (ICC), which provided the level of agreement across both data sources. We further identified the amount of over- or under-reporting by caregivers across different service types.ResultsWe observed variations in agreement for different health services, with agreement across caregiver reports and national claims records being the highest for outpatient visits (specialist and primary care), followed by hospitalizations and emergency department visits. Interestingly, caregivers over-reported hospitalizations by approximately 49% and under-reported specialist and primary care visits by approximately 20 to 30%.ConclusionsThe accuracy of the caregiver-reported HSU of stroke patients varies across different service types. Relatively more objective data sources, such as national claims records, should be considered as a first choice for quantifying health care usage before considering caregiver-reported usage. Caregiver-reported outpatient service use was relatively more accurate than inpatient service use over shorter recall periods. Therefore, in situations where objective data sources are limited, caregiver-reported outpatient information can be considered for low volumes of healthcare consumption, using an appropriate correction to account for potential under-reporting.

Caregivers: Do They Make a Difference to Patient Recovery in Subacute Stroke?

OBJECTIVE To evaluate the relationship between caregiver nature and availability, and rehabilitation outcomes in subacute stroke. DESIGN Retrospective cohort study. SETTING Four community rehabilitation hospitals. PARTICIPANTS Patients with subacute, first-time stroke (N=4042; 48.5% men; mean age ± SD, 70.12±10.4y; 51.5% women; mean age ± SD, 72.54 ±10.0y). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Rehabilitation effectiveness, defined as the percentage of potential improvement eventually achieved with rehabilitation; and rehabilitation efficiency, defined as the rate of functional improvement during rehabilitation. RESULTS In our cohort, 96.7% had available caregiver(s), of which 42.0% were primarily supported by foreign domestic workers (FDWs), 25.9% by spouses, 19.3% by first-degree relatives, 7.8% by other relatives, and 5.1% by other caregivers. Using quantile regression, we found that having a caregiver was independently associated with rehabilitation efficiency (β=-3.83; 95% confidence interval [CI], -6.99 to -0.66; P=.018). The relationship between caregiver availability and rehabilitation effectiveness was modified by patient sex in that the negative association was significantly greater in men (β=-22.81; 95% CI, -32.70 to -12.94; P<.001) than women (β=-5.64; 95% CI, -14.72 to 3.44; P=.223). Having a FDW as a caregiver compared with a spousal caregiver was negatively associated with rehabilitation effectiveness (β=-3.95; 95% CI, -6.94 to -0.95; P=.01) and rehabilitation efficiency (β=-1.83; 95% CI, -3.14 to -0.53; P=.006). The number of potential caregivers was only significantly associated with rehabilitation effectiveness at the bivariate level (P=.006). CONCLUSIONS Caregiver identity, and possibly availability, appears to negatively affect rehabilitation outcomes in subacute stroke. A better understanding of these relationships has potential implications on clinical practice and policy directions.

Is there an Association Between Caregiver Factors and Rehabilitation Outcomes in Stroke

Research Objectives: To evaluate the relationship between caregiver factors and rehabilitation outcomes in subacute stroke patients. Design: Retrospective cohort study. Setting: Four subacute inpatient rehabilitation units in Singapore. Participants: 4042 subacute stroke patients. Interventions: Not applicable. Main Outcome Measure(s): (i) Rehabilitation effectiveness (REs), defined as the percentage of potential improvement achieved with rehabilitation; and (ii) rehabilitation efficiency (REy), defined as the rate of functional improvement during rehabilitation. Results: Among stroke survivors undergoing inpatient rehabilitation, 96.73% had potential caregivers, of which 41.97%were supported by foreign domestic workers (FDWs), 25.86% by spouses and 19.28% by first-degree relatives. At a bivariate level, caregiver availability and caregiver identity was significantly associated with REs and REy (all p<0.05), whilst the number of caregivers was only significantly associated with REs (pZ0.006). After adjusting for identified confounders using quantile regression, having a caregiver was associated with poorer REy (-3.83, 95% CI -6.99 to -0.66, pZ0.018). We found a significant interactive effect between gender and caregiver availability with respect to REs. Though REs is lower in general amongst those with caregivers, the difference was significantly greater among males (-22.81, 95% CI -32.70 to -12.94, p<0.001). In terms of caregiver identity, having a FDWas a caregiver was associated with poorer REs (-3.95, 95% CI -6.94 to -0.95, pZ0.01) and REy (-1.83, 95%CI -3.14 to -0.53, pZ0.006) when compared to spousal caregivers. Interestingly, having non-relative, unpaid caregivers was associated with better REs (8.36, 95% CI 1.89 to 14.83, pZ0.011). Conclusions: Caregiver availability and identity appears to be associated with rehabilitation outcomes. A better understanding of these relationships has potential implications on current and future clinical practice andpolicy directions.

696 SCREENING FOR CARDIOVASCULAR DISEASE RISK FACTORS AT BASELINE AND POST-INTERVENTION AMONGST ADULTS WITH INTELLECTUAL DISABILITIES IN AN URBANISED ASIAN SOCIETY

Background: Adults with intellectual disabilities (ID) face significant barriers to screening participation. We determined predictors for regular cardiovascular health screening at baseline amongst adults with ID in Singapore; and evaluated the effectiveness of a three-month screening intervention. Methods: The study population involved all adults with ID aged ≥40 years receiving services from the Movement for the Intellectually Disabled of Singapore (MINDS), the largest such provider in Singapore. Over three months in 2011, adult clients not screened regularly at baseline for hypertension, diabetes and dyslipidemia were offered free and convenient blood pressure, fasting blood glucose and lipid testing; data on other cardiovascular disease risk factors were also collected. Chi-square and logistic regression identified predictors of regular screening at baseline. Results: Participation was 95.0% (227/239). At baseline, amongst adults with ID, 61.8% (118/191), 24.8% (52/210), and 18.2% (34/187) had gone for regular hypertension, diabetes and dyslipidemia screening, respectively; post-intervention, rates rose to 96.9%, 89.5% and 88.8%, respectively. Prevalence of cardiovascular disease risk factors (22.5% with hypertension, 10.6% with diabetes, 34.8% with dyslipidemia, 10.7% obese, 93.4% lacking regular exercise) was high compared against the general population. While receiving residential services was associated with regular hypertension screening, receiving non-residential services and being independently mobile were associated with regular participation in fasting blood tests (all p < 0.05). Conclusions: Cardiovascular disease risk factors are common amongst adults with ID and clinicians should proactively screen such populations. Provision of free and convenient screening for cardiovascular disease risk improved screening participation.