The Stroke unit Discharge Guideline,a prognostic framework for the discharge outcome from the hospital stroke unit. A prospective cohort study

Abstract

Objective: To investigate which factors during the subacute phase post stroke have predictive value for the discharge outcome from the hospital stroke unit.

Methods: In a prospective cohort of 338 patients admitted to a hospital stroke unit 26 potentially prognostic factors, arranged in clinical and social subdomains, were scored and analysed by binary logistic regression analysis. The outcome of the research consisted of the various discharge destinations.

Results: The overall predictive value of the discharge model is high (91%). Factors predictive of a poor discharge outcome are a low Barthel Index score (odds ratio (OR) 0.78 per point increase; p &lt 0.001), a poor sitting balance (OR 5.96; p &lt 0.001), a depression (OR 7.23; p &lt 0.001), poststroke cognitive disability (OR 3.51; p = 0.007) and older age (OR 1.05 per point increase; p = 0.008). If present, a personality disorder, premorbid cognitive disability and premorbid functional disability all show a tendency towards poor discharge outcome, but these factors did not reach statistical significance in this study, possibly due to their low prevalence. Readiness of the family circle to provide support was only significant in the univariate analysis.

Conclusions: Somatic, biological and psychological factors predict the discharge outcome. Functional and cognitive factors play a decisive role in the future ability to live independently after a stroke. The prognostic importance of social factors could not be demonstrated. Urinary incontinence did not emerge as a prognostic factor. This is in contrast to scientific findings till now, but in accordance with clinical experience.

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References

1 Scholte op Reimer WJM Long-term care after stroke. Studies on care utilisation, quality of care and burden of caregiving. Dissertation, Academic Medical Center/University of Amsterdam, The Netherlands, 1999.

2 Meijer R , Ihnenfeldt DS , Limbeek van J , Vermeulen M , Haan de RJ . Prognostic factors in the subacute phase after stroke for the future residence after one year. A systematic review of the literature. Clin Rehabil 2003; 17: 512-520.

3 Meijer R , Ihnenfeldt DS , Groot de IJM , Limbeek van J , Vermeulen M , Haan de RJ . Prognostic factors for ambulation and activities of daily living in the subacute phase after stroke. A systematic review of the literature. Clin Rehabil 2003; 17: 119-129.

4 Meijer R , Limbeek van J , Kriek B , Ihnenfeldt DS , Vermeulen M , Haan de R . Prognostic social factors in the subacute phase after a stroke for the discharge destination from the hospital stroke-unit. A systematic review of the literature. Disabil Rehabil 2004; 26: 191-197.

5 Meijer R , Ihnenfeldt DS , Vermeulen M , Haan de RJ , Limbeek van J . The use of a Modified Delphi procedure for the determination of 26 prognostic factors in the subacute stage of stroke. Int J Rehabil Res; 2003; 26: 265-271.

6 Bernstein SJ , Laouri M , Hilborne LH et al. Coronary angiography: a literature review and ratings of appropriateness and necessity. RAND, Report JRA, Santa Monica, CA.

7 Murphy MK , Black N , Lamping DL et al. Consensus development methods and their use in clinical guideline developoment. Health Technol Assess 1998; 2-2.

8 Black N , Murphy M , Lamping D et al. Consensus developoment methods: a review of best practice in creating clinical guidelines. J Health Serv Res Pol. 1999: 4: 236-248.

9 Wade DT , Langton Hewer R . Functional abilities after stroke: measurement, natural history and prognosis. J Neurol Neurosurg Psychiatry 1987; 50: 177-182.

10.

10 Friedman PJ . Stroke outcome in elderly people living alone. Disabil Rehabil 1995; 17:90-93.

11.

11 Jørgensen HS , Nakayama H , Raaschou HO et al. Outcome and time course of recovery in stroke. Part I: Outcome. The Copenhagen Stroke Study. Arch Phys Med Rehabil 1995; 76: 399-405.

12.

12 Geerts MJP , Witte de LP , Visser-Meily JMA , Tilli DJP , Lindeman E , Bakx WGM . Daily functioning during the first year after stroke: living arrangements and use of rehabilitation and other care facilities after discharge from hospital. J Rehabil Sci 1995; 8:39-45.

13.

13 Pedersen PM , Jørgensen HS , Nakayama H , Raaschou HO , Olsen TS . Orientation in the acute and chronic stroke patient: impact on ADL and social activities. The Copenhagen Stroke Study. Arch Phys Med Rehabil 1996; 77: 336-339.

14.

14 Thommessen B , Bautz-Holter E , Laake K . Predictors of outcome of rehabilitation of elderly stroke patients in a geriatric ward. Clin Rehabil 1999; 13: 123-128.

15.

15 Sanchez-Blanco I , Ochoa-Sangrador C , Lopez-Munain L , Izquierdo S, M , Fermoso-Garcia J . Predictive model of functional independence in stroke patients admitted to a rehabilitation programme. Clin Rehabil 1999; 13: 464-475.

16.

16 Henon H , Lebert F , Durieu I et al. Confusional state in stroke - relation to preexisting dementia, patient characteristics, and outcome. Stroke 1999; 30: 773-779.

17.

17 Jørgensen HS , Nakayama H , Raaschou HO , Olsen TS . Intracerebral hemorrhage versus infarction: a comparison of stroke severity, risk factors and prognosis. Ann Neurol 1995; 38:45-50.

18.

18 Taub NA , Wolfe CD , Richardson E , Burney PG . Predicting the disability of first-time stroke sufferers at 1 year. 12-month follow-up of a population-based cohort in southeast England. Stroke 1994; 25:2-7.

19.

19 Pedersen PM , Jørgensen HS , Nakayama H , Raaschou HO , Olsen TS . The impact of aphasia on ADL and social activities after stroke: the Copenhagen Stroke Study. J Neurol Rehabil 1996; 10:91-96.

20.

20 Wyller TB , Sodring KM , Sveen U , Ljunggren AE , Bautz-Holter E . Are there gender differences in functional outcome after stroke? Clin Rehabil 1997; 11: 171-179.

21.

21 Steube D , Wietholter S , Correll C . Prognostic value of lower limb motor evoked potentials for motor impairment and disability after 8 weeks of stroke rehabilitation - a prospective investigation of 100 patients. Electromyogr Clin Neurophysiol 2001; 41: 463-469.

22.

22 Tzvetanov PI , Rousseff RT , Milanov I . Lower limb SSEP changes in stroke - predictive values regarding functional recovery. Clin Neurol Neurosurg 2003; 105: 121-127.

23.

23 Hendricks HT. Motor Evoked Potentials in predicting motor and functional outcome after stroke. Dissertation. University of Nijmegen, the Netherlands, 2003.

24.

24 Duncan PW , Goldstein LB , Matchar D , Divine GW , Feussner J . Measurement of motor recovery after stroke: outcome assessment and sample size requirements. Stroke 1992; 23: 1084-1089.

25.

25 Kwakkel G , Kollen BJ , Grond Jvd , Prevo AJH . Probability of regaining dexterity in the flaccid upper limb. Impact of severity of paresis and time since onset in acute stroke. Stroke 2003; 34: 2181-2186.

26.

26 Jørgensen HS , Nakayama H , Raaschou HO , Olsen TS . Recovery of walking function in stroke patients: the Copenhagen Stroke Study. Arch Phys Med Rehabil 1995; 76:27-32

27.

27 Motto C , Ciccone A , Aritzu E et al. Hemorrhage after an acute ischemic stroke. Stroke 1999; 30: 761-764.

28.

28 Lin HJ , Wolf PA , Kelly-Hayes M et al. Stroke severity in atrial fibrillation. The Framingham Study. Stroke 1996; 27: 1760-1764.

29.

29 Samuelsson M , Soderfeldt B , Olsson GB . Functional outcome in patients with lacunar infarction. Stroke 1996; 27: 842-846.

30.

30 Hendricks HT , Zwarts MJ , Plat EF , Van Limbeek J . Systematic review for the early prediction of motor and functional outcome after stroke by using motor-evoked potentials. Arch Phys Med Rehabil 2002; 83: 1303-1308.