Role of caregiver factors in outpatient medical follow-up post-stroke: observational study in Singapore.

BACKGROUND: Outpatient medical follow-up post-stroke is not only crucial for secondary prevention but is also associated with a reduced risk of rehospitalization. However, being voluntary and non-urgent, it is potentially determined by both healthcare needs and the socio-demographic context of stroke survivor-caregiver dyads. Therefore, we aimed to examine the role of caregiver factors in outpatient medical follow-up (primary care (PC) and specialist outpatient care (SOC)) post-stroke. METHOD: Stroke survivors and caregivers from the Singapore Stroke Study, a prospective, yearlong, observational study, contributed to the study sample. Participants were interviewed 3-monthly for data collection. Counts of PC and SOC visits were extracted from the National Claims Database. Poisson modelling was used to explore the association of caregiver (and patient) factors with PC/SOC visits over 0-3 months (early) and 4-12 months (late) post-stroke. RESULTS: For the current analysis, 256 stroke survivors and caregivers were included. While caregiver-reported memory problems of a stroke survivor (IRR: 0.954; 95% CI: 0.919, 0.990) and caregiver burden (IRR: 0.976; 95% CI: 0.959, 0.993) were significantly associated with lower early post-stroke PC visits, co-residing caregiver (IRR: 1.576; 95% CI: 1.040, 2.389) and negative care management strategies (IRR: 1.033; 95% CI: 1.005, 1.061) were significantly associated with higher late post-stroke SOC visits. CONCLUSION: We demonstrated that the association of caregiver factors with outpatient medical follow-up varied by the type of service (i.e., PC versus SOC) and temporally. Our results support family-centred care provision by family physicians viewing caregivers not only as facilitators of care in the community but also as active members of the care team and as clients requiring care and regular assessments.

Dyadic approach to supervised community rehabilitation participation in an Asian setting post-stroke: exploring the role of caregiver and patient characteristics in a prospective cohort study.

OBJECTIVE: To study the association of caregiver factors and stroke survivor factors with supervised community rehabilitation (SCR) participation over the first 3 months and subsequent 3 to 12 months post-stroke in an Asian setting. DESIGN: Prospective cohort study. SETTING: Community setting. PARTICIPANTS: We recruited stroke survivors and their caregivers into our yearlong cohort. Caregiver and stroke survivor variables were collected over 3-monthly intervals. We performed logistic regression with the outcome variable being SCR participation post-stroke. OUTCOME MEASURES: SCR participation over the first 3 months and subsequent 3 to 12 months post-stroke RESULTS: 251 stroke survivor-caregiver dyads were available for the current analysis. The mean age of caregivers was 50.1 years, with the majority being female, married and co-residing with the stroke survivor. There were 61%, 28%, 4% and 7% of spousal, adult-child, sibling and other caregivers. The odds of SCR participation decreased by about 15% for every unit increase in caregiver-reported stroke survivor's disruptive behaviour score (OR: 0.845; 95% CI: 0.769 to 0.929). For every 1-unit increase in the caregiver's positive management strategy score, the odds of using SCR service increased by about 4% (OR: 1.039; 95% CI: 1.011 to 1.068). CONCLUSION: We established that SCR participation is jointly determined by both caregiver and stroke survivor factors, with factors varying over the early and late post-stroke period. Our results support the adoption of a dyadic or more inclusive approach for studying the utilisation of community rehabilitation services, giving due consideration to both the stroke survivors and their caregivers. Adopting a stroke survivor-caregiver dyadic approach in practice settings should include promotion of positive care management strategies, comprehensive caregiving training including both physical and behavioural dimensions, active engagement of caregivers in rehabilitation journey and conducting regular caregiver needs assessments in the community.

Dyadic approach to post-stroke hospitalizations: role of caregiver and patient characteristics.

AIM: To study the association of caregiver factors and stroke patient factors with rehospitalizations over the first 3 months and subsequent 3-12 months post-stroke in Singapore. METHODS: Patients with stroke and their caregivers were recruited in the Singapore Stroke Study, a prospective yearlong cohort. While caregiver and patient variables were taken from this study, hospitalization data were extracted from the national claims database. We used Poisson modelling to perform bivariate and multivariable analysis with counts of hospitalization as the outcome. RESULTS: Two hundred and fifty-six patient with stroke and caregiver dyads (N = 512) were analysed, with patients having spouse (60%), child (29%), sibling (4%) and other (7%) as their caregivers. Among all participants, 89% of index strokes were ischemic, 57% were mild in severity and more than half (59%) of the patients had moderate or severe disability post-stroke as measured on the Modified Rankin Scale. Having social support in the form of a foreign domestic worker for general help of caregiver reduced the hospitalization rate over 3 months post-stroke by 66% (IRR: 0.342; 95% CI: 0.180, 0.651). Compared to having a spousal caregiver, those with a child caregiver had an almost three times greater rate of hospitalizations over 3-12 months post-stroke (IRR: 2.896; 95% CI: 1.399, 5.992). Higher reported caregiving burden at the 3-month point was associated with the higher subsequent rate of hospitalization. CONCLUSION: Recommendations include the adoption of a dyadic or holistic approach to post-stroke care provision by healthcare practitioners, giving due importance to both patients with stroke and their caregivers, integrating caregivers in the healthcare system to extend the care continuum to include informal care in the community and provision of timely support for caregivers.

Healthcare utilization and cost trajectories post-stroke: role of caregiver and stroke factors.

BACKGROUND: It is essential to study post-stroke healthcare utilization trajectories from a stroke patient caregiver dyadic perspective to improve healthcare delivery, practices and eventually improve long-term outcomes for stroke patients. However, literature addressing this area is currently limited. Addressing this gap, our study described the trajectory of healthcare service utilization by stroke patients and associated costs over 1-year post-stroke and examined the association with caregiver identity and clinical stroke factors. METHODS: Patient and caregiver variables were obtained from a prospective cohort, while healthcare data was obtained from the national claims database. Generalized estimating equation approach was used to get the population average estimates of healthcare utilization and cost trend across 4 quarters post-stroke. RESULTS: Five hundred ninety-two stroke patient and caregiver dyads were available for current analysis. The highest utilization occurred in the first quarter post-stroke across all service types and decreased with time. The incidence rate ratio (IRR) of hospitalization decreased by 51, 40, 11 and 1% for patients having spouse, sibling, child and others as caregivers respectively when compared with not having a caregiver (p = 0.017). Disability level modified the specialist outpatient clinic usage trajectory with increasing difference between mildly and severely disabled sub-groups across quarters. Stroke type and severity modified the primary care cost trajectory with expected cost estimates differing across second to fourth quarters for moderately-severe ischemic (IRR: 1.67, 1.74, 1.64; p = 0.003), moderately-severe non-ischemic (IRR: 1.61, 3.15, 2.44; p = 0.001) and severe non-ischemic (IRR: 2.18, 4.92, 4.77; p = 0.032) subgroups respectively, compared to first quarter. CONCLUSION: Highlighting the quarterly variations, we reported distinct utilization trajectories across subgroups based on clinical characteristics. Caregiver availability reducing hospitalization supports revisiting caregiver's role as potential hidden workforce, incentivizing their efforts by designing socially inclusive bundled payment models for post-acute stroke care and adopting family-centered clinical care practices.

Can caregivers report their care recipients' post-stroke hospitalizations and outpatient visits accurately? Findings of an Asian prospective stroke cohort.

BACKGROUND: Health services research aimed at understanding service use and improving resource allocation often relies on collecting subjectively reported or proxy-reported healthcare service utilization (HSU) data. It is important to know the discrepancies in such self or proxy reports, as they have significant financial and policy implications. In high-dependency populations, such as stroke survivors, with varying levels of cognitive impairment and dysphasia, caregivers are often potential sources of stroke survivors' HSU information. Most of the work conducted on agreement analysis to date has focused on validating different sources of self-reported data, with few studies exploring the validity of caregiver-reported data. Addressing this gap, our study aimed to quantify the agreement across the caregiver-reported and national claims-based HSU of stroke patients. METHODS: A prospective study comprising multi-ethnic stroke patient and caregiver dyads (N = 485) in Singapore was the basis of the current analysis, which used linked national claims records. Caregiver-reported health services data were collected via face-to-face and telephone interviews, and similar health services data were extracted from the national claims records. The main outcome variable was the modified intraclass correlation coefficient (ICC), which provided the level of agreement across both data sources. We further identified the amount of over- or under-reporting by caregivers across different service types. RESULTS: We observed variations in agreement for different health services, with agreement across caregiver reports and national claims records being the highest for outpatient visits (specialist and primary care), followed by hospitalizations and emergency department visits. Interestingly, caregivers over-reported hospitalizations by approximately 49% and under-reported specialist and primary care visits by approximately 20 to 30%. CONCLUSIONS: The accuracy of the caregiver-reported HSU of stroke patients varies across different service types. Relatively more objective data sources, such as national claims records, should be considered as a first choice for quantifying health care usage before considering caregiver-reported usage. Caregiver-reported outpatient service use was relatively more accurate than inpatient service use over shorter recall periods. Therefore, in situations where objective data sources are limited, caregiver-reported outpatient information can be considered for low volumes of healthcare consumption, using an appropriate correction to account for potential under-reporting.

Caregivers: Do They Make a Difference to Patient Recovery in Subacute Stroke?

OBJECTIVE: To evaluate the relationship between caregiver nature and availability, and rehabilitation outcomes in subacute stroke. DESIGN: Retrospective cohort study. SETTING: Four community rehabilitation hospitals. PARTICIPANTS: Patients with subacute, first-time stroke (N=4042; 48.5% men; mean age ± SD, 70.12±10.4y; 51.5% women; mean age ± SD, 72.54 ±10.0y). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Rehabilitation effectiveness, defined as the percentage of potential improvement eventually achieved with rehabilitation; and rehabilitation efficiency, defined as the rate of functional improvement during rehabilitation. RESULTS: In our cohort, 96.7% had available caregiver(s), of which 42.0% were primarily supported by foreign domestic workers (FDWs), 25.9% by spouses, 19.3% by first-degree relatives, 7.8% by other relatives, and 5.1% by other caregivers. Using quantile regression, we found that having a caregiver was independently associated with rehabilitation efficiency (ß=-3.83; 95% confidence interval [CI], -6.99 to -0.66; P=.018). The relationship between caregiver availability and rehabilitation effectiveness was modified by patient sex in that the negative association was significantly greater in men (ß=-22.81; 95% CI, -32.70 to -12.94; P<.001) than women (ß=-5.64; 95% CI, -14.72 to 3.44; P=.223). Having a FDW as a caregiver compared with a spousal caregiver was negatively associated with rehabilitation effectiveness (ß=-3.95; 95% CI, -6.94 to -0.95; P=.01) and rehabilitation efficiency (ß=-1.83; 95% CI, -3.14 to -0.53; P=.006). The number of potential caregivers was only significantly associated with rehabilitation effectiveness at the bivariate level (P=.006). CONCLUSIONS: Caregiver identity, and possibly availability, appears to negatively affect rehabilitation outcomes in subacute stroke. A better understanding of these relationships has potential implications on clinical practice and policy directions.

Rehabilitation Outcomes After Inpatient Rehabilitation for Lower Extremity Amputations in Patients With Diabetes.

OBJECTIVE: To identify factors associated with functional gain, discharge destination, and long-term survival after inpatient rehabilitation in patients with lower extremity amputation and diabetes. DESIGN: Retrospective medical records review. SETTING: All community hospitals. PARTICIPANTS: Patients with diabetes (N=256) admitted for inpatient rehabilitation after lower extremity amputation. INTERVENTIONS: Not applicable. MAIN OUTCOMES MEASURES: Absolute functional gain (AFG) using the Shah-modified Barthel Index, discharge destination, and long-term survival for each patient. RESULTS: Length of stay (B=.15; 95% confidence interval [CI], .08-.21; P<.001) and admission functional status (B=-.09; 95% CI, -.18 to -.01; P=.032) were significantly associated with AFG. Availability of caregiver (foreign domestic worker: odds ratio [OR], 16.39; 95% CI, 4.65-57.78; P<.001; child: OR, 3.82; 95% CI, 1.31-11.12; P=.014; spouse: OR, 2.82; 95% CI, 1.07-7.46; P=.037 vs none), Charlson Comorbidity Index of 1 (OR, 4.32; 95% CI, 1.34-13.93; P=.014 vs ≥4), and younger age (OR, .96; 95% CI, .93-.99; P=.02) were significantly associated with being discharged home. Admission functional status (hazard ratio [HR], .98; 95% CI, .97-.99; P<.001), AFG (HR, .99; 95% CI, 0.97-1.00; P=.058), Charlson Comorbidity Index (1 vs ≥4: HR, .42; 95% CI, .24-.77; P=.004), ischemic heart disease (HR, 2.25; 95% CI, 1.27-4.00; P=.006), discharge destination (other vs home: HR, 1.82; 95% CI, 1.02-3.23; P=.041), age (HR, 1.02; 95% CI, 1.00-1.03; P=.082), and ethnicity (Malay vs Chinese: HR, .37; 95% CI, .16-.87; P=.022) predicted survival postamputation. CONCLUSIONS: Admission functional status predicted both functional gain during rehabilitation and survival in these patients. We also found ethnic differences in outcomes, with Malays having better survival after amputation. Lastly, there appears to be greater reliance on foreign domestic workers as caregivers, with patients with foreign domestic workers as their primary caregiver having the highest odds of being discharged home.

The synergistic effect of functional status and comorbidity burden on mortality: a 16-year survival analysis.

OBJECTIVES: The relationship between disability and comorbidity on mortality is widely perceived as additive in clinical models of frailty. DESIGN: National data were retrospectively extracted from medical records of community hospital. DATA SOURCES: There were of 12,804 acutely-disabled patients admitted for inpatient rehabilitation in Singapore rehabilitation community hospitals from 1996 through 2005 were followed up for death till 31 December 2011. OUTCOME MEASURE: Cox proportional-hazards regression to assess the interaction of comorbidity and disability at discharge on all-cause mortality. RESULTS: During a median follow-up of 10.9 years, there were 8,565 deaths (66.9%). The mean age was 73.0 (standard deviation: 11.5) years. Independent risk factors of mortality were higher comorbidity (p<0.001), severity of disability at discharge (p<0.001), being widowed (adjusted hazard ratio [aHR]: 1.38, 95% confidence interval [CI]:1.25-1.53), low socioeconomic status (aHR:1.40, 95%CI:1.29-1.53), discharge to nursing home (aHR:1.14, 95%CI:1.05-1.22) and re-admission into acute care (aHR:1.54, 95%CI:1.45-1.65). In the main effects model, those with high comorbidity had an aHR = 2.41 (95%CI:2.13-2.72) whereas those with total disability had an aHR = 2.28 (95%CI:2.12-2.46). In the interaction model, synergistic interaction existed between comorbidity and disability (p<0.001) where those with high comorbidity and total disability had much higher aHR = 6.57 (95%CI:5.15-8.37). CONCLUSIONS: Patients with greater comorbidity and disability at discharge, discharge to nursing home or re-admission into acute care, lower socioeconomic status and being widowed had higher mortality risk. Our results identified predictive variables of mortality that map well onto the frailty cascade model. Increasing comorbidity and disability interacted synergistically to increase mortality risk.

Factors and trade-offs with rehabilitation effectiveness and efficiency in newly disabled older persons.

OBJECTIVE: To determine the factors for rehabilitation effectiveness (REs) and rehabilitation efficiency (REy) among newly disabled older persons and if there is any trade-off between REs and REy. DESIGN: Retrospective cohort study. SETTING: Rehabilitation hospitals. PARTICIPANTS: Patients (N=8828) aged ≥65 years admitted for inpatient rehabilitation from 1996 to 2005. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Independent factors affecting REs and REy were determined. The median rank ratios of REs to REy for each admission Barthel Index (BI) unit and number of days of stay were generated. The ideal ranges of admission BI score and length of stay (LOS) that corresponded to the REs to REy median rank ratio of 1 (both REs and REy optimized) were identified. RESULTS: Factors associated with poorer REs and REy were older age, Malay ethnicity, delayed admission, admission diagnosis of amputation, and comorbidities of dementia and stroke. An increase of 10 in admission BI score was associated with an increase of 3.47% in REs but a decrease of 1.1 per 30 days in REy; and an increase in LOS of 2.7 days was associated with an increase of 28% in REs but a decrease of 5.2 per 30 days in REy. A trade-off relation between REs and REy with respect to admission functional status and LOS was observed. The range, which optimized both REs and REy, was 50 to 59 units for admission BI score and 37 to 46 days for LOS. CONCLUSIONS: There are trade-offs between REs and REy with respect to admission functional status and LOS. Clinicians, policymakers, patients, and other stakeholders should be aware of such trade-offs when they make joint policy decisions about rehabilitation services.

Factors associated with nursing home placement of all patients admitted for inpatient rehabilitation in Singapore community hospitals from 1996 to 2005: a disease stratified analysis.

OBJECTIVES: To (1) identify social and rehabilitation predictors of nursing home placement, (2) investigate the association between effectiveness and efficiency in rehabilitation and nursing home placement of patients admitted for inpatient rehabilitation from 1996 to 2005 by disease in Singapore. DESIGN: National data were retrospectively extracted from medical records of community hospital. DATA SOURCES: There were 12,506 first admissions for rehabilitation in four community hospitals. Of which, 8,594 (90.3%) patients were discharged home and 924 (9.7%) patients were discharged to a nursing home. Other discharge destinations such as sheltered home (n = 37), other community hospital (n = 31), death in community hospital (n = 12), acute hospital (n = 1,182) and discharge against doctor's advice (n = 24) were excluded. OUTCOME MEASURE: Nursing home placement. RESULTS: Those who were discharged to nursing home had 33% lower median rehabilitation effectiveness and 29% lower median rehabilitation efficiency compared to those who were discharged to nursing homes. Patients discharged to nursing homes were significantly older (mean age: 77 vs. 73 years), had lower mean Bathel Index scores (40 vs. 48), a longer median length of stay (40 vs. 33 days) and a longer time to rehabilitation (19 vs. 15 days), had a higher proportion without a caregiver (28 vs. 7%), being single (21 vs. 7%) and had dementia (23 vs. 10%). Patients admitted for lower limb amputation or falls had an increased odds of being discharged to a nursing home by 175% (p<0.001) and 65% (p = 0.043) respectively compared to stroke patients. CONCLUSIONS: In our study, the odds of nursing home placement was found to be increased in Chinese, males, single or widowed or separated/divorced, patients in high subsidy wards for hospital care, patients with dementia, without caregivers, lower functional scores at admission, lower rehabilitation effectiveness or efficiency at discharge and primary diagnosis groups such as fractures, lower limb amputation and falls in comparison to strokes.

Trends in length of stay, functional outcomes, and discharge destination stratified by disease type for inpatient rehabilitation in Singapore community hospitals from 1996 to 2005.

OBJECTIVE: To determine the trends in length of stay (LOS), rehabilitation functional outcome, and discharge destination of patients admitted for inpatient rehabilitation from 1996 to 2005 and stratified by disease in Singapore. DESIGN: Retrospective national data were extracted from medical records of community-based inpatient rehabilitation admissions in Singapore from 1996 to 2005. SETTING: Four community hospitals. PARTICIPANTS: There were 12,506 first admissions for rehabilitation; 40.6% were for stroke, 30.4% for fracture, 2.9% for lower limb (LL) joint replacement, 2.3% for LL amputation, 1.9% for cancer, 1.8% for falls, 1.6% for pneumonia, and 18.5% for other illnesses. The overall mean age ± SD was 73.2±11.5 years. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: LOS, rehabilitation outcomes (rehabilitation effectiveness [R-effectiveness], rehabilitation efficiency [R-efficiency], relative functional efficiency [Relative-FE]), and discharge destination. RESULTS: The overall median LOS for all disease groups decreased by 16.2% (37 to 31d) from 1996 to 2005. The sharpest decline in LOS among the 8 disease groups was observed in the LL amputation group. The overall mean ± SD admission and discharge activities of daily living scores were 45.6±25.7 and 60.3±28.9, respectively; median R-effectiveness was 28.8%, median R-efficiency was 12.9/30d, and median Relative-FE was 27.7%/30d. From 1996 to 2005, mean R-effectiveness increased by 184% (14% to 40%), R-efficiency increased by 104% (9 to 19 units/30d), and Relative-FE increased by 145% (21% to 51%/30d). Among all inpatient admissions, most were discharged home (78.2%), 10.9% were discharged to an acute hospital, and 9.8% were discharged to nursing or sheltered homes, with no significant change during the 10-year period. CONCLUSIONS: Rehabilitation outcomes of patients admitted to Singapore's community hospitals have improved between 1996 and 2005 despite a decreasing LOS. Discharge destinations have largely remained unchanged over this period.

Socio-demographic and clinical profile of admissions to community hospitals in Singapore from 1996 to 2005: a descriptive study.

INTRODUCTION: Little data is available on community hospital admissions. We examined the differences between community hospitals and the annual trends in sociodemographic characteristics of all patient admissions in Singaporean community hospitals over a 10- year period from 1996 to 2005. MATERIALS AND METHODS: Data were manually extracted from medical records of 4 community hospitals existent in Singapore from 1996 to 2005. Nineteen thousand and three hundred and sixty patient records were examined. Chisquare test was used for univariate analysis of categorical variables by type of community hospitals. For annual trends, test for linear by linear association was used. ANOVA was used to generate beta coefficients for continuous variables. RESULTS: Mean age of all patient admissions has increased from 72.8 years in 1996 to 74.8 years in 2005. The majority was Chinese (88.4%), and female (58.1%) and admissions were mainly for rehabilitation (88.0%). Almost one third had foreign domestic workers as primary caregivers and most (73.5%) were discharged to their own home. There were significant differences in socio-demographic profile of admissions between hospitals with one hospital having more patients with poor social support. Over the 10-year period, the geometric mean length of stay decreased from 29.7 days (95% CI, 6.4 to 138.0) to 26.7 days (95% CI, 7.5 to 94.2), and both mean admission and discharge Barthel Index scores increased from 41.0 (SD = 24.9) and 51.8 (SD = 30.0), respectively in 1996 to 48.4 (SD = 24.5) and 64.2 (SD = 27.3) respectively in 2005. CONCLUSION: There are significant differences in socio-demographic characteristics and clinical profile of admissions between various community hospitals and across time. Understanding these differences and trends in admission profiles may help in projecting future healthcare service needs.

Concerns and preparedness for an avian influenza pandemic: a comparison between community hospital and tertiary hospital healthcare workers.

Little is known about differences in levels of concerns or preparedness for an avian influenza (AI) pandemic among healthcare workers (HCWs) in different types of hospitals. We compared these concerns and preparedness between 326 HCWs of two community hospitals (CHs) and 908 HCWs from a tertiary hospital (TH) using a self-administered questionnaire between March-June 2006. Response rates were 84.2% and 80.0% from the CHs and TH. Most HCWs (71.6%) felt prepared for an AI outbreak and had significant concerns. They perceive an AI pandemic having adverse impacts on their personal life and work, such as people avoiding them (57.1%). A greater percentage of TH compared to CH HCWs expressed concerns such as feeling their jobs put them at great AI exposure (78.3% vs 67.5%, p=0.012). TH HCWs were more likely to report participating in readiness preparation activities, such as training for infection control (90.0% vs 82.2%, p=0.014) and feel that they (74.1% vs 64.7%, p=0.045) and their hospital (86.8% vs 71.8%, p=0.000) were prepared for an outbreak. Healthcare institutions need to include personal, psychological and family concerns on the agenda and increase participation in readiness preparation activities among HCWs to help prepare for such future crises.