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Stroke Rehabilitation Robert Teasell MD FRCPC Professor and Chair-Chief Dept of Physical Medicine and Rehabilitation St. Josephs Health Care London Slide 2 Objectives 1.Appreciate that standards of stroke rehab care in Canada are no longer ideal 2.Provide evidence for those elements of stroke rehab necessary to produce optimal outcomes 3.Understand the magnitude of the changes necessary to implement best practices Slide 3 The Importance of Stroke Rehab Strokes are Increasing t-PA treats anywhere from 5-10% of strokes and benefits about 1 in 7 (significant impact on 1% of all strokes) Primary prevention is expensive and difficult First wave of baby boomers are now 60 years old and stroke is a disease of older people Demand for stroke rehabilitation services is going to dramatically increase Slide 4 The Need for Stroke Rehabilitation Once a stroke occurs specialized interdisciplinary rehab offers best opportunity for improving outcomes Animal and clinical evidence (>800 RCTs) have demonstrated the benefit of stroke rehab and are unravelling the blackbox of stroke rehab Evidence-based stroke rehab saves money and improves lives Estimate at least 30% of stroke patients admitted to acute inpatient care should get stroke rehab Slide 5 Basic Principles of Stroke Rehab Stroke patients often have a complex array of deficits and potential complications Best addressed by an interdisciplinary team of physicians, therapists and nursing staff Moderately severe stroke patients appear to benefit the most Very severe stroke patients represent greatest challenge Slide 6 Case Study 73 yo married male Lt MCA stroke, moderate size, Oct 1 Mon Seen by neurologist, imaged, Rx ASA Oct 4 Thurs consult to Rehab seen Oct 8 Mon, put on wait list 4 days later Oct 12 Fri admit to rehab unit (50% of time a general rehab unit) Seen for assessment Oct 15 and 16 and therapy initiated Oct 17 Wed Slide 7 Case Study Therapists on rehab unit decide when and how much they see the patient PT and OT schedule up to 1 hr of therapy each but patient often arrives late, therapy is cancelled for therapist illness, inservices or charting, patient complains of fatigue or is off having a test, no therapy on weekends or holidays actual therapy time averages 20-25 minutes per day per discipline Slide 8 Case Study At scheduled discharge there is concern that there is no speech therapy in outpatients so patient is kept an additional 2 wks Patient is discharged Dec 3 but waits 4 wks before outpt therapy is initiated because of cutbacks and holidays LOS = 51 days in rehab + 14 days in acute care = 65 days (Cost > $35,000 for inpatient care) Slide 9 Variable2003/20042005/2006 Stroke rehab admissions 2,8632,958 Mean LOS38.7 days33.5 days Total rehab bed days110,798 bed days 99,093 bed days Days from stroke onset to rehab admission 21.1 days18.3 days Admission FIM75.377.7 LTC Admissions2,2483,043 Reality Check: Trends in Ontario Slide 10 Ontario Stroke Rehab 2005/2006 16,068 strokes hospitalized to acute care 2005/2006 2,293 died and 13,775 alive at discharge from acute care 2,958 admitted to inpatient rehabilitation (21%) of all strokes discharged from acute care Mean FIM admission 78 (median 80) Mean FIM discharge 102 (median 109) Slide 11 Rehab in Canada Item Canada (CIHI 2003, n=1003) Mean Age 70.8 Lived alone Pre-Stroke 24.5% Mean Admission FIM 75.2 Mean/Median Stroke Onset to Rehab Admit (days) 26/14 Mean Rehab LOS (days) 38 Mean Discharge FIM 96.3 Mean Increase in FIM 21.1 FIM Efficiency (FIM gains/day) 0.56 Number of Patients Home 67.3% Slide 12 Can We Do Better? PSROP (Post-Stroke Rehabilitation Outcomes Project) Study of 7 stroke rehab centers (6 in United States, n=1161; 1 in New Zealand, n=130) Comprehensive study of stroke rehabilitation examining the black box Compare with CIHI Data of Canadian Centers (2003) PROSP study, Archives of PM&R Dec 2005 suppl Slide 13 Comparing US to Canada Item US PSROP (n=1161) Canada (CIHI 2003, n=1003) Mean Age 66.070.8 Lived alone Pre-Stroke 20.7%24.5% Mean Admission FIM 61.075.2 Median Stroke Onset to Rehab Admit (days) 714 Mean Rehab LOS (days) 18.638 Mean Discharge FIM 87.296.3 Mean Increase in FIM 26.221.1 FIM Efficiency (FIM gains/day) 1.40.6 Number of Patients Home 78.0%67.3% Slide 14 What do the PSROP (U.S.) Centers Do Differently? How do you get FIM efficiency of 1.4 (vs 0.6) or avg LOS of 25 days (vs. 52)? Apply Best Evidence and Do the Basics Well! 1.Pts get admitted to specialized inter-disciplinary stroke rehab units 2.Admitted earlier and more disabled 3.More intensive therapy (standardization of therapies, greater accountability, weekend therapy) 4.Move to high level tasks early 5.Well developed outpatient services Apply best-evidence to save money! Significant incentives to be efficient and evidence-based Slide 15 The Importance of Stroke Rehab Units Slide 16 Ronning and Guldvog 1998 (Subacute Rehab Unit) Randomized Controlled Trial n = 251 stroke patients Acute stay 10 days randomized to treatment (inpatient rehab) or control (ad hoc community care) Rehab Unit LOS = 27.8 days Community Care - 40% nursing home, 30% outpt therapy, 30% no formal rehab treatment Slide 17 Ronning and Guldvog 1998 Results: 7 month follow-up for all stroke patients Dependent (BI < 75) or dead - 23% RU vs 38% CC (p=.01) 39% reduction in worse outcomes with stroke rehab Slide 18 Rnning & Guldvog (1998) Moderate to Severe Strokes Moderate to severe stroke (BI Inactive and Alone In a therapeutic day >50% time in bed 28% sitting out of bed 13% in therapeutic activities Alone for 60% of the time Contrary to the evidence that increased activity and environmental stimulation is important to neurological recovery (Inactive and alone, Bernhardt et al, Stroke 2004) Slide 40 Conclusions on Therapy Intensity More therapy results in improved outcomes Actual direct therapist-patient time and time spent in activation activities is important Rehab in Canada has traditionally struggled providing adequate therapy time Slide 41 Greater Accountabilities Slide 42 Collaborative Evaluation of Rehabilitation in Stroke Across Europe (CERISE) Trial Study compared motor and functional recovery after stroke between 4 European Rehab Centers Gross motor and functional recovery was better in Swiss and German than UK center with Belgian center in middle Time sampling study showed avg. daily direct therapy time of 60 min in UK, 120 min in Belgian, 140 min in German and 166 min in Swiss centers Differences in therapy time not attributed to differences in patient/staff ratio (similar staffing) De Wit et al. Stroke 2007:38:2101-2107 Slide 43 Average daily direct therapy time Slide 44 % Time Spent in Therapeutic Activities European CERISE Trial Slide 45 In German and Swiss centers, the rehabilitation programs were strictly timed (therapists had less freedom), while in UK and Belgian centers they were organized on an ad hoc basis (therapists had more freedom to decide)! No differences were found in the content of physiotherapy and occupational therapy More formal management in the German center may have resulted in the most efficient use of human resources, which may have resulted in more therapy time for the patients De Wit et al. Stroke 2007:38:2101-2107 Slide 46 PSROP Center (courtesy of Brendan Conroy at NIH) U.S. Inpatient Stroke Rehabilitation is driven by Medicare which expects: 1.Participation (the 3 Hour Rule) 2.Progress (FIM Gain of 1-1.5/day) 3.Expedited Discharge Home or to SNF if progress is too slow or family unwilling/unable to take home Slide 47 Participation Expectations in U.S. Centers The 3 Hour Rule 3 hours/day of PT, OT & SLP 5-6 days/wk Psychol, RN, VR, TR dont count (TR=OT sometimes) 55 min one-on-one therapy sessions with PT, OT, SLP daily and if pt cant handle 55 min then 2x30 min is scheduled Patient: therapist ratio is 7:1 each day, supplemented with rehab techs (aids) Slide 48 Participation Expectations in U.S. In Addition 1-2 hrs daily of OT +/or PT group sessions Weekly Speech/Cognitive group therapy sessions TR, VR, Psychology, RD, RN education Family are engaged very early in the process with caregiver training Slide 49 Participation Accountabilities Therapist must record face-to-face interactions with pt in 15 min increments Manager responsible at end of day to ensure patient received their full 3 hrs of therapy Any missed therapy must have a strong medical justification documented by MD and therapist Failure to deliver enough time means loss of payment Slide 50 Reality Check: Therapy is Cheap; LOS is Not Therapists are not replaced when sick or absent Laissez-faire attitude towards rehab therapies even though it is what we are supposed to be doing At least 60% of stroke rehab budget costs are nursing (versus Stroke Rehab in Canada Canadian Stroke RehabProposed Goals Admission to Rehab10-17 days post-stroke onset5-7 days post-stroke onset Intensity of TherapyPT, OT or SLP average 20-25 minutes per day 3 hours of therapy per day extending to weekends Weekend Therapy and Statutory Holidays No therapy (sometimes weekend LOAs) Active therapy every day Therapy Time RegulationLittle or no regulation therapists set their own times; accountabilities are often lax Carefully regulated therapists time carefully accounted for; therapists replaced when off Rehab Length of Stay35-45 days25 days Rehab FIM Efficiency0.6-0.8> 1.0 Outpatient TherapyOften wait list or not availableWell developed and readily available System Designed for Who? Provider-driven carePatient-driven care Slide 57 The End www.ebrsr.com www.ebrsr.com