Estimating the cost and value of functional changes in communication ability following telepractice treatment for aphasia.

CONTEXT: Aphasia is a post-stroke condition that can dramatically impact a person with aphasia's (PWA) communication abilities. To date, few if any studies have considered the cost and cost-effectiveness of functional change in aphasia nor considered measures of patient's value for aphasia treatment. OBJECTIVE: To assess the cost, cost-effectiveness, and perceived value associated with improved functional communication in individuals receiving telerehabilitation treatment for aphasia. DESIGN: Twenty PWA completed between 5 and 12 telehealth rehabilitation sessions of 45-60 minutes within a 6-week time frame using a Language-Oriented Treatment (LOT) designed to address a range of language issues among individuals with aphasia. National Outcomes Measures (NOMS) comprehension and verbal expression and the ASHA Quality of Communication Life (QCL) were completed prior to and at the completion of rehabilitation to obtain baseline and treatment measures. RESULTS: Age, education, and race are significantly correlated with improvement in the NOMS verbal expression. African Americans (OR = 2.0917) are twice as likely as Whites to experience improvement after treatment. The likelihood of improvement also increases with each additional year of education (OR = 1.002) but decrease with age (OR = 0.9463). A total of 15 PWA showed improvement in NOMS comprehension and nine patients showed improvement in NOMS verbal expression. Improving patients attended between five and 12 treatment sessions. The average cost of improvement in NOMS comprehension was $1,152 per patient and NOMS verbal expression was $1,128 per patient with individual treatment costs varying between $540 and $1,296. However, on average, the monetary equivalent in patient's improved QCL was between $1,790.39 to $3,912,54-far exceeding the financial cost of treatment. CONCLUSIONS: When measuring the functional improvement of patients with aphasia, patient's quality of communication life received from treatment exceeded financial cost of services provided.

Urban-Rural Differences in Service Utilization and Costs of Care for Racial-Ethnic Groups Hospitalized With Poststroke Aphasia.

OBJECTIVE: Although residence is a key contributor to cost and utilization in stroke patient care, its contribution to the care of persons with aphasia (PWA) is unknown. The objective of this study was to use discharge-level hospital inpatient data to examine the influence of patient residence (rural vs urban) and race-ethnicity on service utilization and cost of care among PWA. DESIGN: Cross-sectional. SETTING: Administrative data from acute care hospitals in the state of North Carolina. PARTICIPANTS: Individuals (N=4381) with poststroke aphasia. INTERVENTIONS: N/A. MAIN OUTCOME MEASURES: Length of stay (LOS), speech-language pathology (SLP) service utilization, costs of care. METHODS: The 2011-2012 Healthcare Cost and Utilization Project State Inpatient Database data were analyzed to examine the effect of rural or urban residence on LOS, SLP service utilization, as well as total inpatient and SLP service costs. These outcomes were further analyzed across both residence and racial groups (non-Hispanic white and non-Hispanic black). Outcomes were analyzed using generalized linear model. RESULTS: Both rural and urban black PWA experienced longer average LOS after controlling for demographics, illness severity, and the hospital where they received care. Rural blacks experienced longer LOS, received greater SLP services, and incurred greater average total hospital costs than their rural white counterparts after adjusting for differences in their demographics and stroke or illness severity. The differences were attenuated after controlling for the hospital where they received care. CONCLUSIONS: For PWA, race-ethnicity has a larger effect on average total medical costs, SLP service utilization, and LOS than residence. It is unclear how and why blacks with aphasia have greater service utilization and costs in acute care, yet their aphasia outcomes are worse. Future studies are required to explore potential factors such as quality of care.

Greater healthcare utilization and costs among Black persons compared to White persons with aphasia in the North Carolina stroke belt.

PURPOSE: To examine racial differences in healthcare utilization and costs for persons with aphasia (PWA) being treated in acute care hospitals in North Carolina (NC). METHODS: NC Healthcare Cost and Utilization Project State Inpatient Database (HCUP-SID) data from 2011-2012 were analyzed to examine healthcare utilization and costs of care for stroke patients with aphasia. Analyses emphasized length of stay, charges and cost of general hospital services. Generalized linear models (GLM) were constructed to determine the impact of demographic characteristics, stroke/illness severity, and observed hospital characteristics on utilization and costs. Hospital fixed effects were included to yield within-hospital estimates of disparities. RESULTS: GLM models demonstrated that Blacks with aphasia experienced 1.9days longer lengths of stay compared to Whites with aphasia after controlling for demographic characteristics, 1.4days controlling for stroke/illness severity, 1.2days controlling for observed hospital characteristics, and ~1 extra day controlling for unobserved hospital characteristics. Similarly, Blacks accrued ~$2047 greater total costs compared to Whites after controlling for demographic characteristics, $1659 controlling for stroke/illness severity, $1338 controlling for observed hospital characteristics, and ~$1311 greater total costs after controlling for unobserved hospital characteristics. CONCLUSIONS: In the acute hospital setting, Blacks with aphasia utilize greater hospital services during longer hospitalizations and at substantially higher costs in the state of NC. A substantial portion of the adjusted difference was related to the hospital treating the patient. However, even after controlling for the hospital, the differences remained clinically and statistically significant.

Racial-Ethnic Differences in Word Fluency and Auditory Comprehension Among Persons With Poststroke Aphasia.

OBJECTIVES: To examine aphasia outcomes and to determine whether the observed language profiles vary by race-ethnicity. DESIGN: Retrospective cross-sectional study using a convenience sample of persons of with aphasia (PWA) obtained from AphasiaBank, a database designed for the study of aphasia outcomes. SETTING: Aphasia research laboratories. PARTICIPANTS: PWA (N=381; 339 white and 42 black individuals). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Western Aphasia Battery-Revised (WAB-R) total scale score (Aphasia Quotient) and subtest scores were analyzed for racial-ethnic differences. The WAB-R is a comprehensive assessment of communication function designed to evaluate PWA in the areas of spontaneous speech, auditory comprehension, repetition, and naming in addition to reading, writing, apraxia, and constructional, visuospatial, and calculation skills. RESULTS: In univariate comparisons, black PWA exhibited lower word fluency (5.7 vs 7.6; P=.004), auditory word comprehension (49.0 vs 53.0; P=.021), and comprehension of sequential commands (44.2 vs 52.2; P=.012) when compared with white PWA. In multivariate comparisons, adjusted for age and years of education, black PWA exhibited lower word fluency (5.5 vs 7.6; P=.015), auditory word recognition (49.3 vs 53.3; P=.02), and comprehension of sequential commands (43.7 vs 53.2; P=.017) when compared with white PWA. CONCLUSIONS: This study identified racial-ethnic differences in word fluency and auditory comprehension ability among PWA. Both skills are critical to effective communication, and racial-ethnic differences in outcomes must be considered in treatment approaches designed to improve overall communication ability.

A Taiwanese Mandarin Main Concept Analysis (TM-MCA) for quantification of aphasic oral discourse.

BACKGROUND: Various quantitative systems have been proposed to examine aphasic oral narratives in English. A clinical tool for assessing discourse produced by Cantonese-speaking persons with aphasia (PWA), namely Main Concept Analysis (MCA), was developed recently for quantifying the presence, accuracy and completeness of a narrative. Similar tools for Mandarin speakers are currently absent. AIMS: The first aim is to develop and establish the validity of the Taiwanese Mandarin Main Concept Analysis (TM-MCA) for the Mandarin-speaking population in Taiwan, given the paucity of related investigations. Another aim is to establish the influence of age and education level on Taiwanese Mandarin speakers' oral narrative abilities. The third purpose is to examine how well the TM-MCA could distinguish between native speakers with and without aphasia in Taiwan. The final aim is to examine the reliability and validity of the TM-MCA. METHODS & PROCEDURES: Eight speech-language pathologists (SLPs) and eight neurologically intact participants were involved to establish the TM-MCA main concepts. Another 36 neurologically intact participants and 10 PWA participated to validate the TM-MCA by contrasting their performance. OUTCOMES & RESULTS: Both age and educational level affected the oral discourse performance among the neurologically intact adults. Significant differences on the TM-MCA measures were noted between the control group and the group with aphasia. Moreover, the degree of aphasia significantly affected the oral discourse of PWA. CONCLUSIONS & IMPLICATIONS: The TM-MCA is a culturally appropriate quantitative system for the Taiwanese Mandarin population. It can be used to supplement standardized aphasia tests to help SLPs make more informative decisions not only on clinical diagnosis but also on treatment planning.

The use of interpretive description within Kaupapa Maori research.

Kaupapa Maori research (KMR) is an Indigenous research approach that is decolonizing and transformative. Interpretive description (ID) is a qualitative methodology used to generate knowledge relevant to the applied health disciplines. In this article, we discuss how we combined KMR and ID to investigate the experiences of Maori (the Indigenous peoples of New Zealand) with aphasia and their whanau (extended family). This is novel because it is the first time these two approaches have been combined. In the context of aphasia research, we discuss how they work together in theory, and the synergies that became apparent in practice. We conclude that the combination of KMR and ID enables clinicians and Maori with aphasia to learn from each other and work together, thereby generating knowledge that makes a difference for Maori with aphasia and their whanau.

Living with aphasia: three Indigenous Australian stories.

The incidence of cardiovascular disorders and stroke in Australian Aboriginal communities is more than twice as high as non-Indigenous Australians. Approximately 30% of people who survive stroke are left with some level of aphasia, and yet Indigenous Australians appear to be infrequent users of speech-language pathology services, and there is virtually no research literature about the experiences of aphasia for this group of people. This paper presents the stories of living with aphasia for three Indigenous Australian men living in Perth, Western Australia. Their narratives were collected by an Indigenous researcher through in-depth, supported interviews, and were explored using both within-case and cross-case analyses for common and recurring themes. It is argued that there is value for speech-language pathologists, and other health professionals, to be aware of the broad experiences of living with aphasia for Indigenous Australians because their stories are rarely heard and because, as with people with aphasia generally, they are at risk of social isolation and tend to lack visibility in the community. This study explores the key issues which emerge for these three men and highlights the need for further research in this area.

Speech-language assessment in a linguistically diverse setting: preliminary exploration of the possible impact of informal 'solutions' within the South African context.

Speech-language therapists (SLTs) working in the context of cultural and linguistic diversity face considerable challenges in providing equitable services to all clients. This is complicated by the fact that the majority ofSLTs in South Africa are English or Afrikaans speakers, while the majority of the population have a home language other than English/Afrikaans. Consequently, SLTs are often forced to call on untrained personnel to act as interpreters or translators, and to utilise informally translated materials in the assessment and management of clients with communication impairments. However, variations in translation have the potential to considerably alter intervention plans. This study explored whether the linguistic complexity conveyed in translation of the Western Aphasia Battery (WAB) test changed when translated from English to isiZulu by five different first-language IsiZulu speakers. A qualitative comparative research design was adopted and results were analysed using comparative data analysis. Results revealed notable differences in the translations, with most differences relating to vocabulary and semantics. This finding holds clinical implications for the use of informal translators as well as for the utilisation of translated material in the provision of speech-language therapy services in multilingual contexts. This study highlights the need for cautious use of translators and/or translated materials that are not appropriately and systematically adapted for local usage. Further recommendations include a call for intensified efforts in the transformation of the profession within the country, specifically by attracting greater numbers of students who are fluent in African languages.

Maori with aphasia: a people without a voice?

AIM: This literature review aimed to investigate whether Maori with aphasia and their whanau are being included in research. A second aim was to identify what, if any, specific outcomes or concerns have been reported. Although the prevalence and incidence of aphasia in the Maori population is unknown, it is likely to be relatively high, given the high rate of stroke among Maori. METHODS: We provide a background to Maori health, stroke, aphasia and rehabilitation. A standard review of the literature was conducted in the online databases PsycINFO, ScienceDirect, PubMed, MEDLINE, CINAHL Plus, and Google Scholar. We searched "Maori" AND "aphasia" and "Maori" AND "dysphasia" as "anywhere in text" and as a keyword with no limits placed on publication dates. CONCLUSIONS: The search revealed no articles that involve Maori with aphasia and none that address aphasia in the Maori population. Four articles involved Maori participants with stroke or a condition linked to communication disorders and specifically addressed either culture or ethnicity in their observations or results. We consider possible explanations for this apparent lack of Maori with aphasia as participants in research, and conclude that the investigation of aphasia in Maori requires an approach that involves Maori with aphasia and their whanau, in a way that is culturally appropriate enabling them to have a voice.

The main concept analysis in cantonese aphasic oral discourse: external validation and monitoring chronic aphasia.

PURPOSE: The 1st aim of this study was to further establish the external validity of the main concept (MC) analysis by examining its relationship with the Cantonese Linguistic Communication Measure (CLCM; Kong, 2006; Kong & Law, 2004)-an established quantitative system for narrative production-and the Cantonese version of the Western Aphasia Battery (CAB; Yiu, 1992). The 2nd purpose of the study was to evaluate how well the MC analysis reflects the stability of discourse production among chronic Cantonese speakers with aphasia. METHOD: Sixteen participants with aphasia were evaluated on the MC analysis, CAB, and CLCM in the summer of 2008 and were subsequently reassessed in the summer of 2009. They encompassed a range of aphasia severity (with an Aphasia Quotient ranging between 30.2/100 and 94.8/100 at the time of the 1st evaluation). RESULTS: Significant associations were found between the MC measures and the corresponding CLCM indices and CAB performance scores that were relevant to the presence, accuracy, and completeness of content in oral narratives. Moreover, the MC analysis was found to yield comparable scores for chronic speakers on 2 occasions 1 year apart. CONCLUSION: The present study has further established the external validity of MC analysis in Cantonese. Future investigations involving more speakers with aphasia will allow adequate description of its psychometric properties.

Executive functions and aphasia treatment outcomes: data from an ortho-phonological cueing therapy for anomia in Chinese.

This study examined the existence of a possible relationship between anomic treatment outcomes and executive functions. An ortho-phonological cueing method was used to facilitate object naming in 12 Cantonese-speaking anomic individuals. Treatment effectiveness for each participant was quantified and correlated with the performance of executive functions and language tasks. It was found that 10 participants showed significant improvement in naming treated items. Eight of the participants were able to maintain treatment gains for at least 1 month. Phonological generalization effects were observed in two participants. Performance on the Test of Nonverbal Intelligence (TONI-3) was significantly correlated with effect sizes of treatment, treatment generalization and maintenance and the Attention Network Test (ANT) was significantly correlated with phonological generalization. The result of a simultaneous multiple regression suggested that the performance of the ANT played an important role in phonological generalization. The findings reinforce the current view about the role of executive functions in language rehabilitation. They also shed light on the effect of inhibitory control on treatment generalization.

Issues and principles in service delivery to communicatively impaired minority bilingual adults in neurorehabilitation.

Demographic and epidemiological trends coupled with health-care needs in minority populations highlight the imperative need to develop effective, culturally appropriate clinical approaches for minority adults with communication impairments. The steady increase in linguistic and cultural diversity in the country includes a large number of bilingual adults, which is estimated to continue. Because strokes are quite prevalent in racial/ethnic minorities, the number of bilingual adults with acquired communication disorders will similarly increase. However, members of minority groups presently confront disparities in health-care services compared with the general population that translates into reduced health outcomes. This article discusses the current clinical needs and complexities in service delivery to communicatively impaired minority adults, with a special focus on bilingual adults with aphasia.

Verb and sentence processing in Norwegian aphasic speakers compared to Dutch and English aphasic speakers: experimental evidence.

The article reports on a comparative study of the abilities of aphasic speakers and normal control subjects to comprehend and produce verbs and sentences. The analysis is based on test results obtained as part of the standardization procedure for a test battery originally developed for Dutch and since translated and adapted for English and Norwegian. With a few exceptions, there is extensive similarity in the test results between the different languages. The exceptions can be accounted for with reference both to structural differences between the languages and to coincidental aspects of informant selection and scoring procedures. The Norwegian version contains an additional sub-test on past tense inflection, which correlates significantly with at least two other sub-tests in the test battery.

Perspectives on public awareness of stroke and aphasia among Turkish patients in a neurology unit.

Recent studies on awareness have drawn attention to the fact that aphasia is a little known disorder to the public, in spite of all the publicity about this frequently occurring neurogenic language disorder. Being a very new concept, studies of awareness are rare in Turkey. This survey study assessed the extent of public awareness of neurological disorders, including aphasia, and information sources to answer questions about such disorders. A survey questionnaire consisting of 22 brief questions divided into three sections of awareness was administered to a convenience sample of 196 adults at a University Hospital in 2004. The results indicated that epilepsy and dementia are "the most well-known", and Multiple Sclerosis (MS) is "the least-known" among the surveyed diseases/disorders. Aphasia awareness was also low. The respondents preferred doctors as the most reliable information source. Speech and language therapists were found to be one of the information sources in advocating publicity as well. Most respondents expected to receive information from the doctors; who, in Turkey, are totally occupied with the physical aspects of health care provision. Neurologists, in collaboration with speech and language therapists, should be in a position to develop educational programmes to increase public awareness.

Rehabilitation of left brain-damaged ischemic stroke patients: the role of comprehension language deficits. A matched comparison.

BACKGROUND: Aphasia is considered a risk factor for disability after stroke. The aim of this study was to assess the specific influence of aphasia on rehabilitation results. METHOD: A case-control study in consecutive left brain-damaged stroke inpatients, enrolled in three homogeneous subgroups [nonaphasic (NA) patients, aphasic with comprehension deficit (CD), and without comprehension deficit (NCD)] matched for age and onset-admission interval. Rehabilitation results (gain, efficiency, effectiveness of treatment, percentage and odds ratio of dropouts and of each degree of therapeutic response, assessed by Barthel Index and Rivermead Mobility Index) were compared among the subgroups. RESULTS: Two hundred and forty patients with sequelae of a first stroke were enrolled. CD patients, as compared with NCD and NA ones, had a significantly more severe basal neurological and functional status at admission, minor effectiveness on ADL and mobility, a higher percentage of low responders on ADL and urinary incontinence at discharge, and a risk of low therapeutic response on ADL nearly 4 times higher than the other patients (OR = 4.22, 95% CI = 1.90-9.38). The rehabilitative behavior between NCD and NA was similar. However, all subgroups (NA, CD and NCD) showed a significant improvement (p < 0.001) between their basal and discharge score, both on BI and RMI. CONCLUSIONS: Comprehension language deficit was confirmed to be a strong negative rehabilitation prognostic factor despite the speech therapy done by all CD patients.

Disorganization of semantic memory underlies alogia in schizophrenia: an analysis of verbal fluency performance in Japanese subjects.

Patients with schizophrenia exhibit impaired semantic memory as well as deficits in a wide range of language-related functions, such as verbal fluency, comprehension and production of complex sentences. Since language and memory disturbances may underlie some of the psychotic symptoms of schizophrenia, the present study investigated the specific association between alogia (i.e. poverty of speech, poverty of content of speech, blocking, and increased latency of response) and semantic memory organization using the category fluency task (CFT) as a measure of verbal fluency. Thirty-eight patients with schizophrenia and an equal number of normal controls entered the study. Semantic structure was derived from multidimensional scaling analysis using sequential word outputs from the CFT. Patients with schizophrenia revealed disorganized semantic structure (e.g. irregular association of category members) compared with controls, consistent with previous reports. The patients were then divided into two groups, i.e. alogia- and non-alogia subjects, based on the Alogia scores from the Scale for the Assessment of Negative Symptoms (SANS). The symptom-based analysis showed that the semantic structure for the alogia group (Alogia score < or =2) was more disorganized than that for the non-alogia group (Alogia score <1) although the number of words produced did not differ between the two groups. The results of cluster analysis revealed the presence of bizarre coherence specifically in the alogia group. These results indicate that semantic memory disorganization may contribute to the symptom of alogia in schizophrenia. In addition, this is one of the few studies that examined verbal fluency in Japanese patients with schizophrenia and suggest that the language abnormalities in schizophrenia are universal.

The Thai version of the German Aachen Aphasia Test (AAT): description of the test and performance in normal subjects.

The Aachen Aphasia Test (AAT), originally developed as a test for aphasia language disorders in Germany, consists of six spontaneous speech rating scales and five subtests: Token Test, Repetition, Written Language, Confronting Naming and Comprehension. The study aimed to describe the linguistic properties of the AAT Thai version and to investigate the test performances of the normal subjects. In this study some problems of linguistic changes in the construction of the Thai version were discussed. The results revealed that the normal subjects' performances on the test were independent of age, sex and education level. Therefore, the Thai version of AAT is applicable to the differential diagnosis of the communicative abilities of Thai aphasic patients.

The Peyote way: implications for Culture Care theory.

The development and provision of culturally sensitive and meaningful nursing care is a challenging yet essential element in our rapidly changing health care environment. This article describes the use of the theory of Culture Care to assess, understand, and plan care for an aphasic Navajo man who followed very traditional ways. It is an example of how nursing praxis can be applied to a clinical setting. A description of a Navajo peyote ceremony serves to illustrate the importance of incorporating traditional healing practices into nursing and collaborative care for individuals from diverse culture backgrounds. It also describes how the participation in the Native American Church benefitted the client and his family. By using the Culture Care theory, the authors were able to make predictions about the influences of a culture specific expression, the peyote ceremony, had on the client's care.

Crossed aphasia in Chinese: a clinical survey.

According to our clinical observations from various aspects of stroke patients, such as the total incidence of aphasia, the incidence of aphasia after left brain damage of the dextrals, the aphasia that occurs in patients without hemiplegia, and the types of aphasia, a much higher incidence of crossed aphasia is seen among the stroke patients of the Han (the largest ethnic group in China) as compared with the Uighur-Kazaks (U-K) in China and the Occidentals documented in the literature. Motor aphasia is most common and pure sensory or posterior aphasia is rarely seen in Han patients. The distinct features of the Chinese language is a possible explanation for this difference. We suspect that language function of the Han is not localized in the left brain but in the right or both hemispheres. There is no definite Wernicke's area in the left brain of the Chinese people and the neural pathway of the language function in the brain of the Chinese people is not similar to people who speak phonetic languages. Consequently the universal applicability of the theories of cerebral laterality of the language function and dominant hemisphere established by Dax and Broca are questioned in this paper.

Transcortical sensory aphasia in China.

Three cases of transcortical sensory aphasia in Chinese speakers were associated with left parieto-temporal junction strokes. The possibility that this relatively rare aphasia syndrome is more common in the Chinese is raised and a theoretical explanation based on differences in Oriental written language is presented.