Multidisciplinary Care after Acute Care for Stroke: A Prospective Comparison between a Multidisciplinary Post-Acute Care Group and a Standard Group Matched by Propensity Score.

Chong-Chi Chiu,Sheng-Li Tung,Hong-Hsi Hsien,Kuo-Wei Hung,Hon-Yi Shi,Hong-Tai Chang,Ching-Huang Lin,Hsiu-Fen Lin

doi:10.3390/ijerph18147696

Abstract

In this large-scale prospective cohort study, a propensity score matching method was applied in a natural experimental design to investigate how post-acute care (PAC) after stroke affects functional status and to identify predictors of functional status. The main objective of this study was to examine longitudinal changes in various measures of functional status in stroke patients and predictors of scores for these measures before and after PAC. A group of patients who had received PAC for stroke at one of two medical centers (PAC group, n = 273) was compared with a group who had received standard care for stroke at one of four hospitals (three regional hospital and one district hospital; non-PAC group, n = 273) in Taiwan from March, 2014, to October, 2018. The patients completed the functional status measures before rehabilitation, the 12th week and the 1st year after rehabilitation. Generalized estimating equations were used to estimate differences-in-differences models for examining the effects of PAC. The average age was 68.0 (SD = 8.1) years, and males accounted for 57.9%. During the follow-up period, significant risk factors for poor functional outcomes were advanced age, hemorrhagic stroke, and poor function scores before rehabilitation (p < 0.05). Between-group comparisons at subsequent time points revealed significantly higher functional status scores in the PAC group versus the non-PAC group (p < 0.001). Notably, for all functional status measures, between-group differences in total scores significantly increased over time from baseline to 1 year post-rehabilitation (p < 0.001). The contribution of this study is its further elucidation of the clinical implications and health policy implications of rehabilitative care after stroke. Specifically, it improves understanding of the effects of PAC in stroke patients at different follow-up times. Therefore, a policy implication of this study is that standard care for stroke should include intensive rehabilitative PAC to maximize recovery of overall function.

Highlights

Stroke causes a wide range of neurologic deficits and is the leading cause of functionality loss worldwide [1]
A current literature review indicates that this work is the first large cohort study to investigate the role of post-acute care (PAC) in the functional status of patients with stroke by applying the propensity score matching (PSM) method in a natural experimental design [7,9]
This study is the first to use a generalized estimating equations (GEE) model for examining longitudinal changes in the total score for each functional status measure and the first to explore how these changes are related to effective predictors of functional status after stroke

Summary

Introduction

Stroke causes a wide range of neurologic deficits and is the leading cause of functionality loss (disability and mobility) worldwide [1]. Stroke can be divided into two types: intracerebral hemorrhagic (ICH) stroke and ischemic (IS) stroke. 10–24% of all strokes and is associated with increased mortality [2,3,4]. Previous studies show that patients with ICH type have a worse functional outcome compared to their. IS counterparts, but the difference decreases over time and becomes non-significant after several years [3,4]. Post-acute care (PAC) plans have demonstrated effectiveness in helping patients return home after stroke and in improving and accelerating recovery of function [5]. In Taiwan, the National Health Insurance Administration implemented the Post-acute

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