long-term outcomes after acute stroke treatment
DESCRIPTION
Long-Term Outcomes after Acute Stroke Treatment. Larry B. Goldstein, M.D. Professor of Medicine (Neurology) Center for Cerebrovascular Disease Center for Clinical Health Policy Research Duke University and Durham VA Medical Center. Disclosures None relevant. Quality of life. - PowerPoint PPT PresentationTRANSCRIPT
Long-Term Outcomes after Acute Stroke Treatment
Larry B. Goldstein, M.D.Professor of Medicine (Neurology)
Center for Cerebrovascular DiseaseCenter for Clinical Health Policy Research
Duke University and
Durham VA Medical Center
DisclosuresNone relevant
Quality of life
Levels of Outcome MeasurementWorld Health Organization
Handicap
Disability
Impair-Impair-mentment
Quality of life
ParticipationDimension
ActivitiesDimension
BodyBodyDimensionDimension
Level of Measurement
SeverityComorbidity
Disease BodyDimension
ParticipationDimension
ActivitiesDimension
SeverityComorbidity
MotivationDepressionSocial Sup.
SeverityComorbidity
MotivationDepressionSocial Sup.
EducationOccupationAccess
Which Scales?
Reliable Valid Sensitive to change Logistically feasible
Reliability (Precision)
Degree of agreement between or among observers Inter-observer agreement
Degree of agreement between observations Intra-observer agreement (test-retest)
Validity (Accuracy)
Content validity Does the scale includes all relevant dimensions of what is
being measured? Criterion validity
Concurrent validity - Does the scale produce the same result as a “gold standard?”
Predictive validity - Does scale predict future health status? Construct validity
Discriminant validity - Do the results differ from measures of a different type of deficit?
Convergent validity - Is the scale responsive to change?
Stroke ScalesLevels of Outcome Measurement
Quality of life
ParticipationDimension
Activities Dimension
BodyDimension
NIH Stroke ScaleCanadian Stroke ScaleEuropean Stroke ScaleScandinavian Stroke Scale
Stroke Impairment ScalesReliability and Validity
Scale Reliability ValidityNIH + +Canadian NS + +European + +Scandinavian + +UFNSS + NDCopenhagen + NDMathews +/- +Toronto +/- +
Stroke ScalesLevels of Outcome Measurement
Quality of life
ParticipationDimension
Activities Dimension
BodyDimension
Barthel IndexKatzKennyFunctional Independence MeasureIADLNIH Stroke ScaleCanadian Stroke ScaleEuropean Stroke ScaleScandinavian Stroke Scale
Stroke ADL Scales
Domain BI Katz Kenny FIMDressing + + + +Gait + + + +Bathing + + + +Feeding + + + +Transfer + + + +
Grooming + - + +Toileting + + + +Wheelchair + - + +Continence + + - +Travel - - + +Communic. - - - -Cognition - - - -Socialization - - - -
Instrumental ADLApplication to Stroke
No consensus for a clear definition of IADL Measure ability to live independently in the home Bridge delineation between disability and handicap Core activities
Domestic chores Household management Outdoor activities Transportation
Chong Stroke 1995; 26: 1119
IADL Scales for StrokeEvidence for Reliability and Validity
Chong Stroke 1995; 26: 1119
Rivermead Hamrin Frenchay
Nottingham
ReliabilityIntrarater Absent Absent Absent AbsentInterrater Present Present Absent AbsentRetest Weak Absent Absent PresentSensitivity Absent Present Weak AbsentValidityConstruct Weak Absent Weak PresentContent Absent Absent Absent AbsentConcurrent Absent Absent Absent AbsentPredictive Absent Absent Absent Absent
Stroke ScalesLevels of Outcome Measurement
Quality of life
ParticipationDimension
Activities Dimension
BodyDimension
Rankin IndexGlasgow Outcomes Scale
Barthel IndexKatzKennyFunctional Independence MeasureIADLNIH Stroke ScaleCanadian Stroke ScaleEuropean Stroke ScaleScandinavian Stroke Scale
Modified Rankin ScoreGrade Description
1 No significant disability
2 Slight disability; unable to carry out some previous activities, but able to look afterown affairs without assistance
3 Moderate disability; requiring some helpbut able to walk without assistance
4 Moderately severe disability; unable to walk and attend to own bodily needswithout assistance
5 Severe disability; bedridden requiring constant nursing care
6 Dead
Stroke ScalesLevels of Outcome Measurement
Quality of life
ParticipationDimension
Activities Dimension
BodyDimension
SF-36Sickness Impact ProfileStroke Impact ScaleRankin IndexGlasgow Outcomes Scale
Barthel IndexKatzKennyFunctional Independence MeasureIADLNIH Stroke ScaleCanadian Stroke ScaleEuropean Stroke ScaleScandinavian Stroke Scale
Quality Adjusted Life YearsQALYS
Outcome of clinical trial Assign QOL weights Calculate QALY
Assumes QOL rating independent of time in that state
Implies 2 QALYs is twice as good as 1 QALY 1 person gaining 10 QALYs = 10 persons gaining 1
QALY Estimate of costs for that state used for cost-
effectiveness analysis
Stroke ScalesLevels of Outcome Measurement
Quality of life
ParticipationDimension
Activities Dimension
BodyDimension
SF-36Sickness Impact ProfileStroke Impact ScaleRankin IndexGlasgow Outcomes Scale
Barthel IndexKatzKennyFunctional Independence MeasureIADLNIH Stroke ScaleCanadian Stroke ScaleEuropean Stroke ScaleScandinavian Stroke Scale
Effect of Comorbid Conditions
Outcome
Discharge Rankin ≤ 1 1 Year Mortality0
10
20
30
40
50Charlson≤ 1Charlson≥ 2
p<0.001 p<0.001
Goldstein et al Stroke 2004; 35: 1941
Competing EventsCumulative Recurrence Rates
Petty et al. Petty et al. NeurologyNeurology 1998; 50: 208 1998; 50: 208
30% of Strokes are recurrent events
Causes of Death After Stroke
Hankey et al. Hankey et al. StrokeStroke 2000; 31: 2080 2000; 31: 2080
Motor Recovery After StrokeDurham County Stroke Study
Duncan et al. Duncan et al. StrokeStroke 1992; 23: 1084 1992; 23: 1084
Long-Term Outcomes after Stroke
SeverityComorbidity
Disease BodyDimension
ParticipationDimension
ActivitiesDimension
SeverityComorbidity
MotivationDepressionSocial Sup.
SeverityComorbidity
MotivationDepressionSocial Sup.
EducationOccupationAccess
TIME