Measuring the Outcomes of Stroke Rehabilitation

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					                                                 CANADIAN STROKE NETWORK




        Measuring the Outcomes of
        M     i th O t          f
          Stroke Rehabilitation
   Results of a Canadian Stroke Strategy/Heart and
    Stroke Foundation National Consensus Panel




 Objectives
By the end of this presentation should be able to:

  1. Identify three reasons for selecting a core set of
       rehabilitation outcome measures for Canada
  2. Name psychometric issues that must be considered
       when selecting responsive outcome measures
  3. Name some important consensus based measures of
       Stroke Rehabilitation outcomes using the International
       Classification of Functioning framework
  4. Recognize stroke rehabilitation system performance
       indicators that could be used at their organization




                          Page 1
                              CANADIAN STROKE NETWORK




Partners

 Canadian S
•C        Stroke Network
• Canadian Stroke Strategy
• Heart and Stroke Foundation of
  Ontario




Planning Group
• Mark Bayley        • Sharon Wood-
•   Patty Lindsay      Dauphinee
•   Nicol Korner     • Robert Teasell
    Bitensky         • Katherine Salter
•   Johanne          • Jeff Jutai
    Desrosiers
                     • Laurie Cameron
•   Alison MacDonald
                     • Nancy Deming



                Page 2
                                            CANADIAN STROKE NETWORK




Why an expert panel?
     de ce o       survey of de a ab ty          of
•Evidence from a su ey o wide variability in use o
outcome tools and assessment measures
•Stroke Rehabilitation Evidence Based Review has
identified a large number of assessment tools used in
stroke
•Canadian Stroke Strategy- Evaluation of the status of
st o e ca e Ca ada
stroke care in Canada
•Stroke Rehabilitation services could be enhanced by
use of standardized outcomes to identify professional
training needs, lack of resources and other systemic
issues.




   Objectives of the Consensus panel

   1. Using the International Classification of
      Functioning to prioritize a set of outcome
      measures in the domains of body structure
      and function, activity and participation that
      could be used to evaluate the outcomes of
      stroke rehabilitation in Canada
   2. Identify preliminary indicators of
      performance of of stroke rehabilitation
      process




                        Page 3
                                      CANADIAN STROKE NETWORK




  Background Information

  • Considerations for selecting Responsive
    Outcome Measures
  • International Classification of
    Functioning
  • Overview of Findings from Stroke
    Rehabilitation Evidence Based Review
  • Survey of Canadian Clinicians




Considerations for Selecting
Responsive and Interpretable
Outcome Measures
                              y
Your stroke team indicates they want to
measure the outcomes of their patients.
What are the considerations in selecting
measures?




                    Page 4
                                          CANADIAN STROKE NETWORK




   Ideal Measures for Outcomes
   You need a well developed evaluative
    measure with strong psychometric properties
    for use in clinical practice.

       - An evaluative measure assesses an
     individual or group at baseline and again at
     one or two points, usually to determine if
     change has occurred. It needs to be
     responsive to reflect change in patient
     status when it occurs.




   General Considerations
  Is th        t      i t d ith       f th         ?
• I there a cost associated with use of the measure?
• How long does it take to complete / administer the
  measure?
• How much equipment is required?
• Is the measure available in the language of the
  patient?
• Can it be completed by a proxy (family member,
  health professional)?




                      Page 5
                                               CANADIAN STROKE NETWORK




Consider the Content of the Measure

• On inspection, does the measure look as if it includes all
  important areas?
    - Determine how it was developed; who
  contributed?
• Do the items look appropriate for your patients and do
  you think that most patients will change on many
  items?
   - Check the response options: VASs; dichotomous;
  several ordinal categories. How many is enough?
  This has impact on reliability and responsiveness.




What are important
Psychometric properties of
P   h     ti       ti    f
Measures?




                        Page 6
                                              CANADIAN STROKE NETWORK




Reviewing Reliability

• Reliability: the degree to which –

    – A measure is free from random error

    – The observed score is different from the true score




Types of Reliability

• **Stability – test-retest (longitudinal)
• Inter- and Intra-rater
Assessed by correlation coefficients: Cronbach’s alpha,
  Intra-class Correlation Coefficient (ICC), Kappa or
  Weighted Kappa (K or WK) etc.




                           Page 7
                                              CANADIAN STROKE NETWORK




Verifying Validity

• Validity: the extent to which a measure really measures
  what it claims to measure


• Reflects an absence of both random and systematic error
  (bias)


• Not an all or none property –rather a matter of degree




Types of Validity

• Content
• Criterion-Related
      - Concurrent (SIS; FIM, Barthel: SF-12; SF-36)
      - Predictive (BBS; falls)
• Construct
      - Convergent (RNL; QOL)
      - Discriminant (divergent) (Zung; MCS & PCS)
      - *Known Groups (discriminative)
      - *Longitudinal (correlate change scores)




                       Page 8
                                                           CANADIAN STROKE NETWORK




Responsiveness

• What is it? Unlike reliability and validity it is not a
  traditional psychometric property.
• How is it defined? Many ways / no consensus.
• How is it evaluated? Even more ways.
                   Terwee et al Qual Life Res 2003;12:349-62

  How should it b reported? Q
• H    h ld be                  tit ti l
                       t d? Quantitatively.
• How should it be interpreted? Two main approaches.




What are we trying to measure?
• Meaningful change – to patient, to health
  professional, to payer


• Minimal Clinically Important Difference
   (MCID) (MID)




                           Page 9
                                                               CANADIAN STROKE NETWORK




• Minimal Clinically Important Difference (MCID)
  (MID)
     - “the smallest difference in score in the domain of
  interest which patients perceive as
  beneficial………………..”.


       Jaeschke et al. Controll Clin Trials. 10:407-15, 1989




Interpretation of Change

• Interpretability means the capacity to assign a qualitative
  meaning to a quantitative score.
     Ware & Keller. Quality of life and Pharmacoeconomics in
      Clinical Trials, Lippencott Raven, 1996:445-60.


• This score can be at a single point in time or one that
  reflects change over time.




                             Page 10
                                                   CANADIAN STROKE NETWORK




     Today we have estimates of MCID values for many measures but
     few for stroke measures*

•   *Berg Balance Scale (0-56) 6 points
•   *2 minute Walk Test 19 m
•    Lower Ext. Functional Scale (0-80) 9 points
•   *Box and Block Test 7 blocks
•   *6 Minute Walk 54m (95% CI 33-71m)
•   *SF-36: 8 Scales (0-100) ~3-6 points
•   *Sickness Impact Profile (0-100) ~3-5 points
•   *Stroke Impact Scale (0-100) ~10-15 points




     Summary

     • Need to consider all the factors
        – Reliability
        – Validity
        – Responsiveness




                              Page 11
                                                                          CANADIAN STROKE NETWORK




  What domains should we
  measure in Stroke patients?




International Classification of Functioning
                      ( Health condition)


Body Functions                        Activity                        Participation
 & Structure



                Environmental                       Personal
                   Factors                          Factors

            WHO International Classification of Functioning and Disability, ICF
      (International Classification of Impairments, Disabilities and Handicaps, ICIDH)




                                   Page 12
                                                           CANADIAN STROKE NETWORK




ICF Brief Core Set for Stroke
• ICF component        ICF code         • ICF category title


• Body functions           b110         • Consciousness functions
                           86 b114      • Orientation functions
                           82 b730      • Muscle power functions
                           75 b167      • Mental functions of language
                           50 b140      • Attention functions
                           25 b144      • Memory functions
• Body Structures              s110     • Structure of brain
                               7 s730   • Structure of upper extremity
                                        • Structure of Lower extremity




ICF Brief Core Set for Stroke

Activities and participation            • Walking
                                        • Speaking
                                        • Toileting
                                        • Eating
                                        • Dressing
                                          Communicating-receiving
                                        • Communicating receiving
                                          spoken messages
Environmental Factors                   • Immediate Family
                                        • Health Care providers
                                        • Health Care System




                               Page 13
                                             CANADIAN STROKE NETWORK




What measures are commonly
      d i th lit     t   ?
   used in the literature?




Stroke Outcome measures in SREBR

• 1968-2004 Total number of outcome citations = 1105
• Large number of authors created own study specific
  outcomes = 175
• Physical assessments not using a single standardized
  scale = 178 citations
• Citations of previously published scales= 752
• Only 35 previously published assessment scales were
  cited 5 or more times




                      Page 14
                                                          CANADIAN STROKE NETWORK




Most often cited outcomes 1968 - 2004                No. of citations
BI                                                                98
Timed walk assessments (varying times & distances)                44
Fugl-Meyer Assessment of Stroke Recovery
Fugl Meyer                                                        38
FIM                                                               29
Modified Ashworth Scale                                           23
Nottingham EADL                                                   19
Nottingham Health Profile                                         16
MMSE                                                              15
Frenchay Activities Inventory                                     15
SF-36                                                             15
Motor Assessment Scale                                            14
HADS                                                              12
Action Reach Arm Test                                             12
Rankin Handicap/modified R ki /O f d H di
R ki H di        /   difi d Rankin/Oxford Handicap                11
GHQ-28                                                            10
Rivermead Mobility Inventory                                      10
Motricity Index                                                    9
HRSD                                                               9
PICA                                                               9
Berg Balance Scale                                                 9
9-hole peg test                                                    9
Scandinavian Stroke Scale                                          8
Brunnstrom scale                                                   7




    What measures are Canadian Clinicians
    using?
    • Nicol Korner Bitensky et al surveyed about
      1800 rehabilitation clinicians in Canada by
      telephone
    • Asked to answer scenarios concerning
      typical stroke patients
    • Asked about what measures they used




                              Page 15
                                                                                                                                                        CANADIAN STROKE NETWORK




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Page 18
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                                                                                                                                                                                                                                                    CANADIAN STROKE NETWORK
                                      CANADIAN STROKE NETWORK




Summary of Survey findings

• Inconsistent use of measures
• Frequently used only at admission and not at
  discharge
• Not necessarily using measures tested for
     p
  responsiveness




Consensus Panel Principles for selection

• Tried to select measures that worked
  across the continuum
• Can be interprofessional administration
• Can be administered in reasonable time
  at beginning and end of Rehabilitation
• Minimize cost of training
• Ideally available in English and French.




                  Page 19
                                                    CANADIAN STROKE NETWORK




   Consensus Process
   • Divided panel into small groups
   • Technique de Recherche D’Information par Animation
     d’un Groupe D’experts (TRIAGE) by Desrosiers was used
   • all the proposed tools are written on cardboard cards
   • a number of headings are placed on the wall including
     MEMORY, CANDIDATES         BASKET
     MEMORY CANDIDATES,, WASTE BASKET,
     REFRIGERATOR, VETO AND SELECTION.
   • Sort the tools into the categories and narrow the
     selections




Summary of Body, Function and structure Tools
                                y
   • Measures of Stroke Severity-
      – Orpington or NIHSS
   • Medical Comorbidities
      – Charlson
   • Upper Extremity Structure and Function-
      – Chedoke McMaster Stroke Assessment
   • Lower extremity-
      – Chedoke McMaster Stroke Assessment
   • Spasticity –
      – Modified Ashworth Scale
      – Alternate use the spasticity subscale of CMSA




                           Page 20
                                                         CANADIAN STROKE NETWORK




Summary of Body, Function and structure Tools

                 p
   • Visual Perception-
      – Comb and Razor( interdisciplinary admin)
      – Behavioural Inattention Test ( Sunnybrook NAP)
      – Line Bisection ( Unilateral Spatial Neglect)
      – Alternates- Rivermead, OSOT and MVPT
   • Language
      – Screening in Acute and followup
          » Frenchay Aphasia Screening Test ( FAST)
      – Impairment
          » Boston Diagnostic Aphasia Assessment (homework)
   • Speech Intelligibility Tool- none used in the literature




Summary of Body, Function and structure Tools

     Cognition
   • Cognition-
      – Screening
         » SCORE team Recommended MMSE and Line
            Bisection + Semantic fluency but not useful in
            rehabilitation followup

           » Initial selection Cambridge (CAM-COG)




                              Page 21
                                              CANADIAN STROKE NETWORK




Summary of Body, Function and structure Tools

   Depression
   Depression-
         -Hospital Anxiety Depression Scale (SCORE
         Screening tool)
         -stroke Aphasic Depression Questionnaire
         Alternates
         -?Geriatric Depression Scale
         -? Beck Depression Scale
         -?PHQ-9




   Activity Assessment Scales
           Extremity-
   • Upper Extremity
      – Chedoke Arm and Hand Activity Inventory
      – Box and Block
      – Nine Hole peg test
   • Lower extremity-
      – Chedoke inventory
      – Timed up and Go
      – 6 minute Walk test
      – Alternate- Rivermead Mobility index
   • Balance-
      – Berg Balance Scale




                         Page 22
                                               CANADIAN STROKE NETWORK




Activity Assessment Scales

• Functional Communication-
   – Amsterdam(ANELT)
   – Alternate- ASHA-Functional Assessment of
     Communication of Activities of Daily Living (ASHA-
     FACS)
   – Consultation Required with Aphasia experts




Activity Assessment Scales
Activities of Daily Living-
  -Functional Independence Measure (FIM)
  - Request CIHI-NRS to calculate Barthel Index from the
  FIM for comparison with European research


Instrumental Activities of Daily Li i
I t      t l A ti iti    f D il Living-
  -Reintegration to Normal living Index (RNL)( self- report)
  -Life H-Leisure Section




                         Page 23
                                         CANADIAN STROKE NETWORK




Participation
-Stroke Impact Scale
- Reintegration to Normal Living Index




What is the difference between a
rehabilitation outcome measure
and a process indicator?
      p




                       Page 24
                                                   CANADIAN STROKE NETWORK




Components of Rehab for Evaluation


   • Process measures explored for:
        – Acute care
        – Inpatient rehab
        – Day hospital
        – Ambulatory setting
        – Home-based care
        – Community programs




   Process Measures

 Some Common Indicators of Access
• Days waiting to enter stroke rehabilitation program – all
  settings
• Days waiting for access to outpatient and community services
  by provider type
• Types of therapy services and providers
   ypes o t e apy se ces a d p o de s
• Duration and intensity of services by provider type
• ALC Days waiting to be discharged from inpatient rehab
• Distribution of rehab patients by FRG
• Length of stay in rehab setting




                          Page 25
                                                  CANADIAN STROKE NETWORK




   Acute Care
• Rehab provided in inpatient acute care setting during early
  days after admission
   – Time to assessments for rehab potential and needs
   – Intensity and duration of rehab services by provider type
   – Standardized tool scores for assessment and functional
     outcomes
   – Time between referral for rehab and transfer to rehab
     services
   – Referral rates for community-based rehab




   Inpatient Rehabilitation


• Intensity and duration of rehab services by provider type
• Stroke unit – number of patients treated on stroke rehab
  units
• Documentation of rehab plan e.g. task specific therapy
• Details about environment
• Patient education




                          Page 26
                                                        CANADIAN STROKE NETWORK




    Rehab provided in day hospitals, outpatient
    ambulatory, and other community settings
•   Time to assessments for rehab potential and needs
•   Time from referral to commencement of therapy
•   Intensity and duration of rehab services by provider type
•   Standardized tool scores for assessment and outcomes
•   Details about environment
•   Patient education
•   Social support
•   Primary care utilization
•   Fitness to drive
•   Caregiver burden
•   Vocational assessments




    Some Cautionary Tales
    • Electronic stroke Referral service used in acute care for
      referral to rehab the
       – Alpha FIM
       – Charlson Comorbidities
       – Chedoke
       Challenges in training all staff, staff turnover, trusting the
         measure
    • SCORE project uses five outcome measures
       – FIM , Box and Block, 6 minute Walk test, Chedoke
         arm and Hand inventory, Chedoke McMaster Stroke
         Assessment and Euroqol-5D
       – Challenges in completion.




                             Page 27
                                                 CANADIAN STROKE NETWORK




Some Thoughts on Choosing Outcomes
• Less is More – avoid the temptation to want to answer all
  the questions on your first attempt
• Consider the time in administration
• Consider the time to train people
• Consider how much equipment is needed
  Consider whether it will change your practice
• C   id    h th       ill h               ti




Some Thoughts on Choosing Outcomes
• Pick tools that are transdisciplinary if possible
• Think about who is going to use the Results of all your
  work in collecting outcomes
   – Is this for you as a clinician to plan your practice?
   – Do you want to show those administration people that
     you make a difference?
     y
   – Do you want to show the fundors that you make a
     difference
   – ( What do you think they are interested in?)




                        Page 28
                                                 CANADIAN STROKE NETWORK




  Clinical vs Process measures
  • Do you want to measure team or program operations or
    are you interested in patient recovery
  • Is there an efficiency issue that needs to be measured




 Objectives
By the end of this presentation should be able to:

  1. Identify three reasons for selecting a core set of
       rehabilitation outcome measures for Canada
  2. Name psychometric issues that must be considered
       when selecting responsive outcome measures
  3. Name some important consensus based measures of
       Stroke Rehabilitation outcomes using the International
       Classification of Functioning framework
  4. Recognize stroke rehabilitation system performance
       indicators that could be used at their organization




                         Page 29
                                                CANADIAN STROKE NETWORK




Conclusions
1. A core set of rehabilitation outcome measures for
  Canada is required as there is variability in current
  practice, need to consistently evaluate system and
  compare across provinces in Canadian Stroke Strategy
2. issues that must be considered when selecting
  responsive outcome measures
  include the reliability, validity and responsiveness of the
  measure. These properties can now be estimated
  quantitatively




Conclusions
3. Good quality Stroke Rehabilitation outcomes can be
    identified for all aspects of the the International
    Classification of Functioning i.e. Body Structures and
    Function, Activity and Participation
4. System performance indicators are measures of how
   groups of patients are managed and involve measures
   of quality and efficiency of care




                        Page 30
                                             CANADIAN STROKE NETWORK




Next Steps
• Dissemination through the Canadian stroke Strategy and
  Ontario Stroke System
• Discussions with CIHI National Rehabilitation Recording
  System to adopt measures




                      Page 31