Transcript Blueprint for Transforming Stroke Rehabilitation Robert
Stroke Rehabilitation
Robert Teasell MD FRCPC Professor and Chair-Chief Dept of Physical Medicine and Rehabilitation St. Joseph’s Health Care London
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
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
• • • •
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
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
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
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
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)
Reality Check: Trends in Ontario
Variable 2003/2004 2005/2006
Stroke rehab admissions Mean LOS Total rehab bed days 2,863 38.7 days 110,798 bed days 21.1 days 2,958 33.5 days 99,093 bed days 18.3 days Days from stroke onset to rehab admission Admission FIM LTC Admissions 75.3
2,248 77.7
3,043
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)
Rehab in Canada Item Mean Age Lived alone Pre-Stroke Mean Admission FIM Mean/Median Stroke Onset to Rehab Admit (days) Mean Rehab LOS (days) Mean Discharge FIM Mean Increase in FIM FIM Efficiency (FIM gains/day) Number of Patients Home Canada (CIHI 2003, n=1003) 70.8
24.5% 75.2
26/14 38 96.3
21.1
0.56
67.3%
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
Comparing US to Canada Item Mean Age Lived alone Pre-Stroke Mean Admission FIM Median Stroke Onset to Rehab Admit (days) Mean Rehab LOS (days) Mean Discharge FIM Mean Increase in FIM FIM Efficiency (FIM gains/day) Number of Patients Home US PSROP (n=1161) 66.0
20.7% 61.0
7 18.6
87.2
26.2
1.4
78.0% Canada (CIHI 2003, n=1003) 70.8
24.5% 75.2
14 38 96.3
21.1
0.6
67.3%
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
The Importance of Stroke Rehab Units
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
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
Rønning & Guldvog (1998) Moderate to Severe Strokes Moderate to severe stroke (BI<50) (n=114):
• 62% CC vs 32% RU dead or dependent (p=.002) • 48% reduction in bad outcomes 100 75 Death Dependent Dependent or Dead Median BI 50 25 NS 0 RU CR
Norway: Combined acute-subacute stroke unit
• • •
Randomized 220 acute strokes to Stroke Unit or General Medical Unit Maintained treatment for 6 weeks Outcomes: home vs institution, mortality, Barthel index - at 6 and 52 weeks, 5 and 10 years
Indredavik et al. 1990
100
At 6 weeks
(Indredavik et al. 1990)
Dead Institution Home Barthel 75 50 25 0 SU MU
Significant benefit still seen at 10 years
The Impact of Stroke Unit Care on Combined Death/Dependency Post Stroke (Foley et al. 2007)
Stroke Rehabilitation Units
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Best Practice in Stroke Rehab involves specialized inter-disciplinary teams working in a highly coordinated manner to obtain best outcomes Stroke rehab is most effective for moderately severe stroke patients Rehabilitation therapies even account for benefit of acute stroke units
Specialized Rehab Care
Specialized Stroke Rehabilitation is the “gold standard” of care
Brain Reorganization
• •
The brain has significant capacity to reorganize itself to recover from loss of function following a stroke Reorganization depends on training or rehabilitation and will not occur spontaneously
Reorganization of Affected Hemisphere Post-Stroke Nudo RJ 1997 Post-stroke lesion in squirrel monkey, rehab results in expansion of hand representation; no rehab results in contraction
Brain Reorganization:Use It or Lose It Rehabilitation training (enriched environments with animals) increases brain reorganization with subsequent functional recovery In animal studies key factors promoting recovery include
increased activity and a complex, stimulating environment
Lack of rehab causes decline in cortical representation and delays recovery
Brain Reorganization
• • •
The brain has significant capacity to reorganize itself to recover from loss of function following a stroke Reorganization depends on training or rehabilitation and will not occur spontaneously Key elements of stroke rehab should be increased activity and a complex and stimulating environment
The Earlier the Better
The Earlier the Better
• • • •
Brain is “primed” to “recover” early in post-stroke period Animal studies suggest there is a time window when brain is “primed” for maximal response to rehab therapies Delays are detrimental to recovery Clinical association between early admission to rehab and better outcomes
Benefit of Early Therapy in Animals
• •
Methods:
Biernaskie et al. (2004) subjected rats to rehab x 5 weeks beginning at 5, 14 and 30 days post small strokes Control animals – social housing
Benefit of Early Therapy in Animals
• • • • •
Results:
All received 5 weeks of enriched environment Day 5 admission marked improvement Day 14 moderate improvement Day 30 no improvement vs. controls Corresponding cortical reorganization in brain around stroke
Therapy Intensity
Frontloading
• • • •
RCT of 146 “middle band” strokes to stroke unit (SU) or gen med (GM) unit Median BI = 4/20 initially in both Stroke Unit - BI = 15 after 6 wks; discharged at 6 wks General Medical Unit - BI = 12 after 12 wks; discharged at 20 wks
Kalra et al. 1994
Frontloading (Kalra et al. 1994) 20 18 16 14 12 10 8 SRU GMU 6 4 2 0 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Weeks
Frontloading (Kalra et al. 1994) 100 90 80 70 60 50 SRU GMU 40 30 20 10 0 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Weeks
Frontloading (Kalra et al. 1994)
Amount of Physiotherapy and Occupational Therapy
20 * OT PT 10 0 SRU GMW
20 * OT PT 10 0
Therapy Intensity: Front Loading
Kalra et al. 1994
SRU GMW 20 18 16 14 12 10 SRU GMU 8 6 4 2 0 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Weeks
100 90 80 70 60 50 SRU GMU 40 30 20 10 0 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Weeks
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
(Inactive and alone, Bernhardt et al, Stroke 2004)
Contrary to the evidence that increased activity and environmental stimulation is important to neurological recovery
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
Greater Accountabilities
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
Average daily direct therapy time
Hrs T herapy per day
3 2.5
2 1.5
1 0.5
0 1 UK 2 2.3
2.8
B elg ium S witz erland G ermany Hrs T herapy per day
European CERISE Trial
% Time Spent in Therapeutic Activities
European CERISE Trial
• •
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
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
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 don’t count (TR=OT sometimes) 55 min one-on-one therapy sessions with PT, OT, SLP daily and if pt can’t handle 55 min then 2x30 min is scheduled Patient: therapist ratio is 7:1 each day, supplemented with rehab techs (aids)
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
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
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 <20% of core therapies) which have better developed accountabilities Stroke rehab patient gets an average of a little over one hour of therapy per day
Where Did the Outpatients Go?
Outpatient Therapy
• • • • • •
Outpatient therapy improves short-term functional outcomes Hospital same as home-based Outpatient therapy is relatively inexpensive (1 PT/1 OT/0.5 SLP/0.5 SW = cost of 1 rehab inpt bed) Reduces rehospitalization and allows earlier discharge home Estimated savings is $2 for every $1 spent on outpatient therapies First thing cut with budget pressures
Cochrane Review of OutPt Rehab
• • • •
14 RCTs of 1,617 patients (Outpatient Trialists 2003) involved in home based, day hospital and outpatient clinic Therapy reduced the odds of a poor outcome (death, deterioration or dependency) (OR 0.72; 95% CI 0.57-0.92; p=0.009) Number needed to treat in order to spare one person from experiencing a poor outcome was 14 U.S. colleagues put a lot of emphasis on Outpatient Programs
Stroke Rehab: Structural Issues
• • • •
Only 21% of admitted stroke patients are admitted to rehabilitation in Ontario At least 50% of stroke rehabilitation patients are admitted to general rehabilitation units Decline in outpatient resources across Ontario due to budget cutbacks Health care authorities need to ensure appropriate structures in place – only partially successful and seems to be declining, albeit slowly
Stroke Rehab: Process Issues
• • • • •
Patients are still often admitted to rehabilitation after excessive delays The intensity of rehab therapies and the rehab experience remains deficient on most rehab units Accountabilities remain poor and “administrative creep” is a problem Maintenance care is declining or nonexistent Our processes remain provider-driven
Stroke Rehab in Canada
Admission to Rehab Intensity of Therapy Weekend Therapy and Statutory Holidays Therapy Time Regulation Rehab Length of Stay Rehab FIM Efficiency Outpatient Therapy System Designed for Who?
Canadian Stroke Rehab Proposed Goals
10-17 days post-stroke onset PT , OT or SLP average 20-25 minutes per day No therapy (sometimes weekend LOAs) Little or no regulation – therapists set their own times; accountabilities are often lax 35-45 days 0.6-0.8
Often wait list or not available 5-7 days post-stroke onset 3 hours of therapy per day extending to weekends Active therapy every day Carefully regulated – therapists’ time carefully accounted for; therapists replaced when off 25 days > 1.0
Well developed and readily available Provider-driven care Patient-driven care