Quality Indicators for Comparative Analysis of Stroke Outcomes

This project is a fellowship funded by the National Institute on Disability and Rehabilitation Research (NIDRR) to develop a set of quality indicators that assess the impact of medical rehabilitation on the lives of stroke survivors, from functional ability to community integration and quality of life. Stroke was chosen as the principle population of interest because it is one of the largest impairment groups, has potentially serious consequences if care is not of adequate quality, and provides the opportunity to develop quality measures which are generalizable to other populations.

The indicators built for this project represent a new approach to performance indicator development that integrates measurement and assesses progress throughout the rehabilitation and community reintegration process. This new model provides: 1) performance indicators that reflect a system of care, not merely isolated processes or outcomes, 2) evaluation integrated throughout the system of care to minimize burden and accurately reflect organizational structure, processes of care and patient outcomes, 3) information for decision-making by stroke survivors and their families, providers, payers, and purchasers, 4) the ability to track stroke survivors across the continuum of care, 5) evidence-based indicators to maximize effectiveness and enhance credibility, 6) the ability to update the performance indicators when new knowledge becomes available, 7) the ability to adapt the indicators to reflect performance as the delivery system responds to the changing health care environment, 8) information to uncover hidden processes and direction for quality improvement activities, 9) flexibility in data analysis, and 10) a system of performance indicators that are parsimonious and integrated.

Quality of life is the foundation for this system of performance indicators, and is measured throughout the rehabilitation process, including: 1) screening for rehabilitation services, 2) baseline assessment and goal setting, 3) managing the rehabilitation process, 4) assessing and managing risk, 5) improving functional abilities, and neurologic, affective and language disorders, 6) discharge planning, and 7) stroke disease management in the community.

Contact: Robin S. Turpin, Ph.D., Outcomes Research & Management, Merck & Co., Inc., (215) 652-5769. email: robin_turpin@merck.com.

Patients with Stroke :

Outcomes Across the Continuum

Specific Aims: The primary aim of this study is to evaluate outcomes of stroke patients treated initially at Hartford Hospital across the continuum of care. The secondary aim of the study is to compare the functional outcomes of patients whose discharge plan (level of care) followed that which was recommended by the stroke team and those patients whose discharge level of care differed from the recommendation made by the stroke team.

Null Hypothesis: 1) There will be no significant difference in the changes in functional status from baseline for patients of the same acuity being treated at various levels of care (e.g. rehab facility versus ECF). 2) There will be no significant difference between the functional improvement of patients whose discharge plan (level of care) followed that which was recommended by the Stroke team and those patients whose discharge level of care differed from the recommendation made by the Stroke team.

Research Design: This is a prospective longitudinal study which employs a repeated measure design. Patients will serve as their own controls as change is measured over time. The study team is multidisciplinary to include neurology, nursing, physical therapy, and primary researchers. Correlations and inferences will be based on outcomes evaluation of a variety of phases of care as well as participating facility.

Methods: Patients admitted to the neuroscience unit at Hartford Hospital with a primary diagnosis of a cerebral vascular accident (CVA) will be enrolled in the study. It is anticipated that approximately 400 subjects will be enrolled over one year. Exclusions include but are not limited to patients with a history of dementia or other conditions that will make them unable to participate in rehabilitative care. Subjects will be assessed at baseline (within the first 24 hours of the index hospitalization) on admission. In addition, subjects will be assessed at each hand-off (i.e. admission and discharge to any other facility/level of care during the one year follow up). The main measures included in the assessment are severity of stroke deficit, functional health status (FIM, Barthel, and SF-12), and resource utilization. Due to some areas of redundancy in the FIM and the Barthel, an interview process combining the two instruments will be developed. Reliability and validity studies will be conducted comparing the individuals tools alone and the combined interview process.

Implications: Results from the study are expected to contribute to the scientific literature on outcomes in general and to the use of outcome instruments in the Stroke population. The outcomes data derived from the study will also provide the foundation for future quality improvement efforts related to treatments and process of care.

Contact: Rose Maljanian, RN, MBA Director, Outcomes Research Management, Hartford Hospital, Hartford, CT. (860) 545-5311, email rmaljani@harthosp.org

The Quality of Post Acute Health Care in Los Angeles: Does Managed Care Make a Difference?

The Andrus Gerontology Center at the University of Southern California is conducting a study designed to evaluate how payment structure affects treatment and outcomes in post acute care. Subject are patients 65 years of age or older in rehabilitation risk plans. Subgroup analyses are being conducted for persons with stroke or hip fracture.

Because Southern California is one of the few health care markets that has high Medicare managed care penetration, it offers a unique opportunity to compare differences in treatment and outcomes by payment source. Treatment measures include number of units of therapy, types of therapy (e.g. physical, occupational, and speech), duration of rehabilitation, medications, and

number of physician visits.

To measure outcomes, the study examines function and health-related quality of life at entry to rehabilitation (baseline), at discharge and 90 days post discharge. Baseline measures include the Short-Form 36 and the Sickness Impact Profile. These instruments are readministered at discharge and 90 day follow up. In addition, the Consumer Assessment of Health Plans as well as mortality, discharge destination, rehospitalization are used to measure outcomes at 90 days post discharge.

The study, which began in August, 1997 will conclude in July, 1999. Initial results suggest that managed care treatment includes significantly less of all three types of therapy and significantly shortened lengths of stays.

Contact: Kathleen H. Wiber, Ph.D, University of Southern California, Los Angeles, CA 90089-0191 or email wilber@usc.edu

Cognitive Predictors of Outcomes in Stoke Survivors

The purpose of the current project was to examine whether cognitive status, as measured by the Neurobehavioral Cognitive Status Exam (NCSE), would predict 3 month outcomes in acute stroke survivors. Consecutive patients admitted to the acute stroke service at the QEII Health Sciences Centre were invited to participate if they were able to be tested using the NCSE within two weeks of admission. Predictor variables included their profile on the NCSE, a cognitive screening examination with subscale scores in 10 different cognitive domains and their Barthel index score, calculated 2-4 days prior to discharge. Three months post-stroke, the patients were contacted via telephone to complete a follow-up Barthel index and two quality of life measures. The quality of life questionnaires included a subjective, disease-specific scale (Reintregration to Normal Living Scale, RNL) and the more general health-related quality of life measure, the SF-36. Step-wise regression analysis indicated that the discharge BI score and the Orientation subscale of the NCSE predicted 3-month functional outcome on the BI as well as subjective quality of life on the RNL. No cognitive or functional variables appeared to predict health-related quality of life as measured by the SF-36 in this sample. Further studies to investigate predictors of short term stroke outcome using a range of medical, functional, and cognitive variables collected in the Stroke Registry at the QEII HSC are ongoing.

Co-Investigators: A. Isreali, S. Phillips, E. MacKinnon, K. Contact: Gail Eakes, Ph.D., Department of Psychology, Queen Elizabeth II Health Sciences Centre, Buchanen, Halifax, Nova Scotia, Canada B3H 4K4.

SF-36 Health Survey Results in Family Caregivers of Stroke Patients

Previous research has revealed increased emotional and general ill-health in family caregivers of stroke patients compared to community samples. The functional status of stroke patients and caregiver emotional ill-health have been related to decreases in social activity for family caregivers of stroke patients. The purpose of this study was to compare SF-36 Health Survey results from a sample of 104 family caregivers of stroke patients with data from 3445 patients with chronic medical and psychiatric conditions.

Data from the two samples were quite similar for the physical functioning, bodily pain, and role (emotion) functioning subscales of the SF-36. Family caregivers of stroke patients exhibited better role (physical) functioning, general health, social functioning, and mental health than the chronic medical and psychiatric sample. Although the vitality subscale had a low reliability for the family caregiver sample, scores were lower for family caregivers than for the chronic medical and psychiatric sample. In other words, family caregivers felt worn out and tired, with a lack of energy, perhaps due to their continual caregiving duties. During the interview process, a number of caregivers commented that their role and social functioning were greatly influenced by their caregiving situation, rather than by their own physical health.

Contact: Tamilyn Bakas, DNS, RN, Assistant Professor, Indiana University School of Nursing, 1111 Middle Drive, NU 417, Indianapolis, IN 46202-5107, (317) 274-1478 USA.

VA Acute Stroke (VASt) Study

The objective of this multi-site, national prospective cohort study is to ascertain: (1) the broad spectrum of physical and psychological health outcomes of stroke patients during the first year following stroke onset; (2) the patterns of diagnosis and treatment during the acute phase; and (3) the association between practice patterns and outcomes.

The cohort is comprised of 1,073 patients, previously community-dwelling, who were hospitalized at nine VA medical centers from across the nation within 7 days of stroke onset (ICD-9-CM 430-432, 434, 436) between April, 1995 and March, 1997. There is also a pilot phase cohort of 64 patients who were hospitalized at four of the sites between January, 1995 and March, 1996.

Data on outcomes were from telephone interviews of patients or proxies at one, six and 12-months post-stroke. Outcome measures included functional status (Barthel Index), readmission for stroke or myocardial infarction, and death. Psychological health outcomes included depression (abbreviated CES-D), health-related quality of life (SF-36), and utilities (preference for current health state based on the time-trade off method). Psychological health information was provided only by patients who were not severely cognitively impaired (as determined by the Short Portable Mental Status Questionnaire). Patterns of care data were abstracted from the medical record. Stroke severity is being measured by the Canadian Neurological Scale that has been modified for retrospective use with medical record data. The TOAST classification system is being used to assign ischemic stroke sub-type.Data analyses are in progress. n

Contact: Ron Horner, PhD. Director of Epidemiology Research and Information Center at VA Medical Center, Durham, NC, 27705, (919) 286-6936