Roger Beech

A Long-term Follow-up of Stroke Patients

BACKGROUND AND PURPOSE Two hundred ninety-one residents of southeast London, younger than 75 years, suffered their first stroke in 1989/1990. The objectives of this study were to determine the long-term outcome of this cohort of stroke patients in terms of impairment, disability, handicap, and quality of life and their use of services and prevention measures subsequent to their stroke. METHODS The survivors and their identified caregivers were traced and completed a structured interview questionnaire that included the Barthel Index, modified Rankin Scale, Hospital Anxiety and Depression Scale (HAD), Mini-Mental State Examination, Frenchay Activities Index, and Caregiver Strain Index. RESULTS One hundred twenty-three people (42%) were alive, of whom 106 were interviewed. The mean interval between the stroke and the long-term follow-up was 4.9 years. Thirty-one of the survivors (29%) were severely or moderately disabled, 39 (37%) were mildly disabled, and 36 (34%) were functionally independent. Of the 96 people who completed the HAD, 35 (36%) had scores suggesting that they were depressed or had borderline depression. The most likely nontherapy services to have been provided were chiropody and district nursing. Five people had received respite care. Of the 104 subjects for whom information about their home was available, 53 (51%) had had an adaptation. Seventy-five people (71%) had an aid or appliance. Sixty-five people (61%) were on aspirin, and an additional 14 (13%) were on warfarin. Fifty subjects (47%) identified a main caregiver. No one with a moderate or more severe disability was living at home without an identified caregiver. CONCLUSIONS The levels of both health and social service provision are likely to be inadequate for this population. The use of prevention measures is encouraging. There is a clear need for a coordinated policy to guide assessment and management across sectors.

Randomised controlled trial to evaluate early discharge scheme for patients with stroke

Abstract Objective: To assess the clinical effectiveness of an early discharge policy for patients with stroke by using a community based rehabilitation team. Design: Randomised controlled trial to compare conventional care with an early discharge policy. Setting: Two teaching hospitals in inner London. Subjects: 331 medically stable patients with stroke (mean age 71) who lived alone and were able to transfer independently or who lived with a resident carer and were able to transfer with help. Interventions: 167 patients received specialist community rehabilitation for up to 3 months after randomisation. 164 patients continued with conventional hospital and community care. Main outcome measures: Barthel score at 12 months. Secondary outcomes measured impairment with motoricity index, minimental state examination, and Frenchay aphasia screening test; disability with the Rivermead activity of daily living scales, hospital anxiety and depression scale, and 5 m walk; handicap with the Nottingham health profile; carer stress with caregiver strain index and patient and carer satisfaction. The main process measure was length of stay after randomisation. Results: One year after randomisation no significant differences in clinical outcomes were found apart from increased satisfaction with hospital care in the community therapy group. Length of stay after randomisation in the community therapy group was significantly reduced (12 v 18 days; P<0.0001). Patients with impairments were more likely to receive treatment in the community therapy group. Conclusions: Early discharge with specialist community rehabilitation after stroke is feasible, as clinically effective as conventional care, and acceptable to patients. Considerable reductions in use of hospital beds are achievable. Key messages Early discharge from hospital after stroke with specialist rehabilitation at home is feasible without an increase in readmission rates or stress to carers This randomised controlled trial shows this method to be as effective as conventional care when assessed with a range of measures of impairment, disability, handicap, carer stress, and patient and carer satisfaction at 1 year Significant reductions in bed usage can be achieved by the provision of a community rehabilitation team with no significant increase in rehabilitation services

Variations in Case Fatality and Dependency From Stroke in Western and Central Europe

BACKGROUND AND PURPOSE There are significant variations in mortality rates from stroke in Europe. A European Union BIOMED Concerted Action was established to assess and determine the reasons for the variations in case fatality and disability after stroke. METHODS Hospital-based stroke registers were established in 12 centers in 7 western and central European countries to collect demographic, clinical, and resource use details at the time of first-ever stroke during 1993-1994. At 3 months, details of survival, activity of daily living score, and use of health services were recorded. Multinomial logistic regression was used to estimate the relationship between centers and outcome (dead, functionally independent, functionally dependent), with adjustment for case mix and resource use variables, and to predict outcomes for the full cohort. This should minimize the bias due to loss to follow-up. RESULTS A total of 4534 stroke events were registered. The mean age was 71.9 years (SD, 12.53). There were significant differences between centers for all case mix and resource use variables (P<0. 001). Multinomial logistic regression modeling of outcome indicated that for those patients initially unconscious (588), center was not significantly related to outcome (P=0.427). For those initially conscious, there were wide variations in death and dependency between centers after adjustment for case mix, type of bed, and use of CT scan. The predicted proportion dead at 3 months ranged from 42% (95% CI, 35% to 49%) in one UK center to 19% (95% CI, 14% to 24%) in France. CONCLUSIONS Areas with high mortality rates within western and central Europe have been identified for stroke outcome, and there appears to be opportunity for considerable health gain in certain centers. Adjustment for case mix and health service resource use does not explain these differences in outcome. Although there are true differences in outcome, the aspects of care that need to be altered to improve outcome remain unclear despite detailed data collection. Comparisons of outcome of the same design used in the present study do not allow rational policy decisions to be made.

The uptake and costs of guidelines for stroke in a district of southern England.

STUDY OBJECTIVE: To assess the impact of guidelines for stroke management on the utilisation of services by patients and the cost consequences of implementation. DESIGN: Prospective audit. SETTING: District health authority in southern England. PATIENTS: A total of 468 live non-comatose stroke patients registered between November 1991 and May 1993. MAIN OUTCOME MEASURES: A comparison between the three, six month periods for investigations performed and rehabilitation received and their associated costs. RESULTS: The appropriateness of the use of investigations improved over time to between 88 and 92% except for computed tomography (CT) (24%). Younger, more severely impaired patients in a medical bed were more likely to have CT. Overall levels of rehabilitation were low. There was no change in use of physiotherapy (61% to 63%), a significant increase in occupational therapy (26% to 39%) and a non significant change in speech therapy (34% to 25%) over time. Guideline introduction caused a modest 23 Pounds increase in costs per patient in the 2nd six months and 41 Pounds in the 3rd six months but this sum could rise to 430 Pounds per patient if full implementation of the guidelines occurred which is still only around 13% of the costs of nursing care while in hospital. CONCLUSIONS: This 18 month aduit shows only modest changes in practice compared with guidelines, and overall levels of rehabilitation were low. The costs of full implementation seem considerable, but in fact constitute only a small proportion of nursing care costs.

Implications for the funding of the service costs of research and evaluation in the new British NHS

The NHS reforms and creation of the UK internal market have led to changes in funding arrangements and incentives. Similar health care reforms are occurring across many developed countries, though at differing rates. These reforms have potentially serious implications for research funding and in particular, the service costs of health services research. Within the new NHS framework, the incentive to fund the service costs does not automatically fall on any agency and the main mechanism which should cover ‘excess’ service costs, the Service Increment For Teaching and Research (SIFTR), is in its present form inadequate, being unresponsive and non-comprehensive. This can and has led to partially funded research projects, an outcome which is not sustainable in the longer term. This paper discusses the emerging problem and argues that a dearer definition of research costs is required, so that both service and research costs are considered synonymously with the whole cost of the research to funders being identified and agreed at the outset. The service costs of research must most importantly now be considered to be an integral part of the research budget. This will help ensure that projects are adequately funded and can be carried out efficiently to promote high quality, cost-effective care in the NHS. An NHS Research & Development (R&D) Consultative Taskforce was set up to review the present situation and make recommendations for the way forward. We hope that our elucidation of the problem and our recommendations, aid or strengthen those of the Taskforce in this current debate.