Ron L. Evans

Stroke: a family dilemma

Research studying the clinical effectiveness of stroke rehabilitation has focused on managing acute stages and on evaluating short-term treatment programmes. However, many studies suggest that stroke affects long-term quality of life and the well-being of the family. This article reviews the stroke literature relative to aging, disability, and rehabilitation. The social effects of stroke in terms of clinical problems which make rehabilitation a family dilemma are discussed. Issues identified include the need for family assessment, education, advocacy, and counselling to foster treatment compliance and social support.

Multidisciplinary rehabilitation versus medical care: A meta-analysis

Research studies in physical medicine have not demonstrated the effectiveness of inpatient rehabilitation services, primarily due to differences in methodological approaches which have led to inconsistent findings. Because of differing inclusion and outcome criteria, even meta-analyses have been inconclusive. To address this problem, research literature comparing the clinical effectiveness of rehabilitation programs with medical care was evaluated for three uniformly available outcome criteria: survival; functional ability; and discharge location. Published trials were obtained from citations in Index Medicus (Medicine) and Nursing and Allied Health Abstracts covering the recent 20 year period from 1974 to 1994. We used meta-analyses to test the hypotheses that specialized rehabilitative care (vs conventional medical care) improves health outcomes. Results of our meta-analyses indicated that rehabilitation services were significantly associated with better rates of survival and improved function during hospital stay (P < 0.01), but significance was not observed at follow-up. Also, rehabilitation patients returned to their homes and remained there more frequently than controls (P < 0.001). We concluded that patients who participate in inpatient rehabilitation programs function better at hospital discharge, have a better chance of short term survival, and return home more frequently than non-participants. However, long term survival and function were the same for experimental and control subjects. The sustaining benefit of returning home may suffice to justify the provision of inpatient rehabilitation. However, the lack of other long term benefits suggests that services may need to be continued at home or in subacute care settings to optimize their effectiveness.(ABSTRACT TRUNCATED AT 250 WORDS)

Poststroke Family Function: An Evaluation of the Family's Role in Rehabilitation

&NA; Stroke affects long‐term quality of life and well‐being for not only the patients themselves but also their families. However, the focus of most rehabilitation programs has been on managing the acute stage of stroke and evaluating the effectiveness of short‐term treatments. Families usually share in treatment, especially in the long term, and they are ultimately responsible for the patients welfare. This article reviews the literature as it relates to the clinical problems that make rehabilitation a family issue.

Families and stroke: The clinical implications of research findings

Clinical and research attention to stroke care has focused on managing the acute stage of recovery and on evaluating the short-term effectiveness of rehabilitation programs. However, studies suggest that stroke affects the quality of life and the well-being of the entire family over much longer time frames. This article reviews the stroke literature as it relates to stroke rehabilitation and the family. Research findings strongly suggest that stroke is a family affair and that more rigorous attention to family assessment, education, advocacy, and counseling is needed along with development of new intervention methods focused on addressing specific family dimensions that have a demonstrated relationship to specific stroke problems. It is clear that health professionals shou Id thi nk farm ly, involvethefamily, and work with the family.

Living with a Disability: A Synthesis and Critique of the Literature on Quality of Life, 1985–1989

The current study describes articles cross-indexed under the keywords “quality of life” and “disability” in Index Medicus for the years 1985 through 1989 to compare their relative merits in terms of research design, sampling details, and the type of quality of life criteria included. Of 833 articles indexed under “quality of life,” 52 (16%) included data about a a disabling condition requiring rehabilitation. Of those 52, only seven (13%) were randomized clinical trials. The modal design was a descriptive survey or case study (N = 22 or 42%). Given the limited rigor in research design and invalid measurements, conclusions about improvement in the quality of life for disabled individuals after rehabilitative care could not be drawn from the studies reviewed. It may be concluded that research on quality of life needs to be better designed and should include more uniform and valid criteria.

PREDICTING POSTSTROKE FAMILY FUNCTION- A CONTINUING DILEMMA

To determine what effect stroke might have on family interaction, common stroke outcome variables were used to predict family function for a sample of 78 families in which one member had recent onset of stroke. Traditional stroke-outcome predictors were not useful in accounting for variance in family function. The nature of family dynamics after disability may require additional research because the relationship is complex.

Comparison of subacute rehabilitative care with outpatient primary medical care

Purpose: Prior rehabilitation outcome studies have had many weaknesses, but they gradually observe a lack of long-term benefits from inpatient care alone. The goal of this study was to measure the additive effect of outpatient, subacute rehabilitation (compared with usual outpatient primary medical care) for adults diagnosed with a disabling disorder in four major diagnostic groups (nervous, circulatory, musculoskeletal and injury). Method: A randomized clinical trial was conducted to determine the effects of outpatient, subacute rehabilitative care on: (1) physical function; (2) health; (3) well being; (4) family function; and (5) social support. Patients hospitalized for the first time with a disabling condition (n 180) were provided inpatient rehabilitation and then were randomly assigned to either outpatient, subacute rehabilitation at home (n 90) or to usual outpatient follow-up (n 90) in which only primary care medical services were provided. To compare the two groups, univariate analyses of covariance were conducted for the outcome variables. Results: The major finding of this study was that of no significant effect of the intervention on any outcome variable. Conclusions: Based on current study results, we conclude that any long term additive benefit of outpatient, subacute rehabilitation may not be detectable across disability categories and may require closer evaluation in studies with a more homogeneous population than in the current study. Providing complex follow-up case management services to all clients is apparently not beneficial and might better be provided using selection criteria based on need. Future studies should determine if services are more effective when provided to those with the most unmet rehabilitative needs. Further outpatient, subacute care rehabilitation studies should address the specific needs of the patients and be adapted individually to those needs.PURPOSE Prior rehabilitation outcome studies have had many weaknesses. but they gradually observe a lack of long-term benefits from inpatient care alone. The goal of this study was to measure the additive effect of outpatient, subacute rehabilitation (compared with usual outpatient primary medical care) for adults diagnosed with a disabling disorder in four major diagnostic groups (nervous, circulatory, musculoskeletal and injury). METHOD A randomized clinical trial was conducted to determine the effects of outpatient, subacute rehabilitative care on: (1) physical function; (2) health; (3) well being; (4) family function; and (5) social support. Patients hospitalized for the first time with a disabling condition (n = 180) were provided inpatient rehabilitation and then were randomly assigned to either outpatient, subacute rehabilitation at home (n = 90) or to usual outpatient follow-up (n = 90) in which only primary care medical services were provided. To compare the two groups, univariate analyses of covariance were conducted for the outcome variables. RESULTS The major finding of this study was that of no significant effect of the intervention on any outcome variable. CONCLUSIONS Based on current study results, we conclude that any long term additive benefit of outpatient, subacute rehabilitation may not be detectable across disability categories and may require closer evaluation in studies with a more homogeneous population than in the current study. Providing complex follow-up case management services to all clients is apparently not beneficial and might better be provided using selection criteria based on need. Future studies should determine if services are more effective when provided to those with the most unmet rehabilitative needs. Further outpatient, subacute care rehabilitation studies should address the specific needs of the patients and be adapted individually to those needs.

RISK SCREENING FOR ADVERSE OUTCOMES IN SUBACUTE CARE

Purpose of this study was to identify variables near hospital admission that could identify patients at risk for placement, death, or readmission. The goals were to assess sensitivity and specificity of screening strategies in predicting adverse outcomes that deter or affect home health care. We evaluated whether generic screens might efficiently identify type of outcome. Criteria reported in the literature were used to predict outcomes for 1,332 admissions. Factors that discriminated type of outcome included comorbidity, mental status, living arrangement, transfer to special care, prior admission, iatrogenic trauma, and pending litigation. We conclude risk scores can accurately predict outcome of hospital treatment, which may be useful in targeting patients for intervention. Using billing data, although rather insensitive, was the most cost-effective strategy.

PROGRAM REVIEW OF COMMUNITY RESIDENTIAL CARE

This article provides an overview of the Department of Veterans Affairs Community Residential Care Program and summarizes key literature about programs developed in the United States Descriptive data for 1995 and 1996 are provided to assist program planners in comparing and contrasting client characteristics and services. The authors conclude that, in addition to being cost effective, the residential care program strengthens relationships between the health care facility and the community it serves.

CAN META-ANALYSIS HELP DETERMINE WHETHER REHABILITATION MEDICINE IMPROVES OUTCOME? '

Critical assessment of current meta-analyses of research evaluating outcomes of programs in rehabilitation is presented as are recommendations for use of appropriate selection criteria and data in future meta-analyses.