The Active Ingredient of Cognitive Restoration: A Multicenter Randomized Controlled Trial of Sequential Combination of Aerobic Exercise and Computer-Based Cognitive Training in Stroke Survivors With Cognitive Decline.

OBJECTIVE: To investigate the efficacy of a sequential combination of aerobic exercise and cognitive training on cognitive function and other health-related outcomes in stroke survivors with cognitive decline. DESIGN: Intervention study and randomized controlled trial. SETTING: Hospital-based rehabilitation units. PARTICIPANTS: Survivors of stroke with cognitive decline (N=30) were randomized to sequential combination training (SEQ) (n=15) or an active control (n=15) group. INTERVENTIONS: The SEQ group received 30 minutes of aerobic exercise, followed by 30 minutes of computerized cognitive training. The control group received 30 minutes of nonaerobic physical exercise, followed by 30 minutes of unstructured mental activities. MAIN OUTCOME MEASURES: The primary outcome measure was cognitive function. Secondary outcome measures included physical function, social participation, and quality of life. RESULTS: Compared with the control group, the SEQ group had significantly improved Montreal Cognitive Assessment scores (P=.03) and Wechsler Memory Scale span scores (P=.012) after training. The endurance and mobility level measured by the 6-minute walk test (P=.25) was also enhanced in the SEQ group relative to the control group. However, the transfer of sequential training to social participation (Community Integration Questionnaire) and quality of life (EuroQoL questionnaire) was limited (P>.05 for both). CONCLUSIONS: Aerobic exercise combined with computerized cognitive training has better effects on the cognitive functional status of survivors of stroke than an active control. The cognitive functional status of stroke survivors was better after participation in aerobic exercise combined with computerized training than after active control therapy, demonstrating the clinical significance of this combination therapy.

Synergistic effects of aerobic exercise and cognitive training on cognition, physiological markers, daily function, and quality of life in stroke survivors with cognitive decline: study protocol for a randomized controlled trial.

BACKGROUND: Aerobic exercise and cognitive training have been effective in improving cognitive functions; however, whether the combination of these two can further enhance cognition and clinical outcomes in stroke survivors with cognitive decline remains unknown. This study aimed to determine the treatment effects of a sequential combination of aerobic exercise and cognitive training on cognitive function and clinical outcomes. METHODS/DESIGN: Stroke survivors (n = 75) with cognitive decline will be recruited and randomly assigned to cognitive training, aerobic exercise, and sequential combination of aerobic exercise and cognitive training groups. All participants will receive training for 60 minutes per day, 3 days per week for 12 weeks. The aerobic exercise group will receive stationary bicycle training, the cognitive training group will receive cognitive-based training, and the sequential group will first receive 30 minutes of aerobic exercise, followed by 30 minutes of cognitive training. The outcome measures involve cognitive functions, physiological biomarkers, daily function and quality of life, physical functions, and social participation. Participants will be assessed before and immediately after the interventions, and 6 months after the interventions. Repeated measures of analysis of variance will be used to evaluate the changes in outcome measures at the three assessments. DISCUSSION: This trial aims to explore the benefits of innovative intervention approaches to improve the cognitive function, physiological markers, daily function, and quality of life in stroke survivors with cognitive decline. The findings will provide evidence to advance post-stroke cognitive rehabilitation. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02550990 . Registered on 6 September 2015.

Evolving methods to combine cognitive and physical training for individuals with mild cognitive impairment: study protocol for a randomized controlled study.

BACKGROUND: Nonpharmacologic interventions, such as cognitive training or physical exercise, are effective in improving cognitive functions for older adults with mild cognitive impairment (MCI). Some researchers have proposed that combining physical exercise with cognitive training may augment the benefits of cognition. However, strong evidence is lacking regarding whether a combined therapy is superior to a single type of training for older adults with MCI. Moreover, which combination approach - combining physical exercise with cognitive training sequentially or simultaneously - is more advantageous for cognitive improvement is not yet clear. This proposed study is designed to clarify these questions. METHODS/DESIGN: This study is a single-blinded, multicenter, randomized controlled trial. Eighty individuals with MCI will be recruited and randomly assigned to cognitive training (COG), physical exercise training (PE), sequential training (SEQ), and dual-task training (DUAL) groups. The intervention programs will be 90 min/day, 2-3 days/week, for a total of 36 training sessions. The participants in the SEQ group will first perform 45 min of physical exercise followed by 45 min of cognitive training, whereas those in the DUAL group will perform physical exercise and cognitive training simultaneously. Participants will be assessed at baseline, after the intervention, and at 6-month follow-up. The primary cognitive outcome tests will include the Montreal Cognitive Assessment and the color-naming Stroop test. Other outcomes will include assessments that evaluate the cognitive, physical, and daily functions of older adults with MCI. DISCUSSION: The results of this proposed study will provide important information regarding the feasibility and intervention effects of combining physical exercise and cognitive training for older individuals with MCI. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02512627 , registered on 20 July 2015.

Favorable circulatory system outcomes as adjuvant traditional Chinese medicine (TCM) treatment for cerebrovascular diseases in Taiwan.

BACKGROUND: This study searches the National Health Insurance Research Database (NHIRD) used in a previous project, aiming for reconstructing possible cerebrovascular disease-related groups (DRG),and estimating the costs between cerebrovascular disease and related diseases. METHODS AND MATERIALS: We conducted a nationwide retrospective cohort study in stroke inpatients, we examined the overall costs in 3 municipalities in Taiwan, by evaluating the possible costs of the expecting diagnosis related group (DRG) by using the international classification of diseases version-9 (ICD-9) system, and the overall analysis of the re-admission population that received traditional Chinese medicine (TCM) treatment and those who did not. RESULTS: The trend demonstrated that the non-participant costs were consistent with the ICD-9 categories (430 to 437) because similarities existed between years 2006 to 2007. Among the TCM patients, a wide variation and additional costs were found compared to non-TCM patients during these 2 years. The average re-admission duration was significantly shorter for TCM patients, especially those initially diagnosed with ICD 434 during the first admission. In addition, TCM patients demonstrated more severe general symptoms, which incurred high conventional treatment costs, and could result in re-admission for numerous reasons. However, in Disease 7 of ICD-9 category, representing the circulatory system was most prevalent in non-TCM inpatients, which was the leading cause of re-admission. CONCLUSION: We concluded that favorable circulatory system outcomes were in adjuvant TCM treatment inpatients, there were less re-admission for circulatory system events and a two-third reduction of re-admission within ICD-9 code 430 to 437, compared to non-TCM ones. However, there were shorter re-admission duration other than circulatory system events by means of unfavorable baseline condition.

Readmission, mortality, and first-year medical costs after stroke.

BACKGROUND: Stroke is the leading cause of adult disability and mortality in Taiwan, resulting in a tremendous burden on the healthcare system. The purpose of this study was to characterize disease burden by evaluating readmissions, mortality, and medical cost during the first year after acute stroke under the National Health Insurance (NHI) program. METHODS: This retrospective cohort study extracted information about patients hospitalized with acute stroke from claims data of 200,000 randomly sampled NHI enrollees in Taiwan, with a 1-year follow-up duration. The incidence of the first-year adverse events (AEs) indicated by readmissions or mortality, and the amount of the first-year medical cost (FYMC) were assessed with predictive factors explored. Additionally, we also estimated the cost per life and life-year saved. RESULTS: There were 2368 first-ever stroke patients in our study, including those with subarachnoid hemorrhage (SAH) 3.3%, intracerebral hemorrhage (ICH) 17.9%, ischemic stroke (IS) 49.8%, and transient ischemic attack/other ill-defined cerebrovascular diseases (TIA/unspecified) 29.0%; each stroke type was identified with an all-cause AE of 59.0%, 63.0%, 48.6%, and 46.8%, respectively. Readmissions were mainly because of acute recurrent stroke or the late effects of previous stroke, respiratory disease/infections, heart/circulatory disease, and diseases of the digestive system. Advanced age, hemorrhagic stroke type, respiratory distress/infections, and greater comorbidities were predictive of increased AE risk. Admission to neurology/rehabilitation wards, undertaking neurosurgery, or use of inpatient/outpatient rehabilitation was less likely to incur AEs. Initial hospitalization, readmission, and ambulatory care constituted 44%, 29%, and 27%, respectively, of FYMC with the initial length of stay being the most reliable predictor. The FYMCs were NT $217,959, $246,358, $168,003, and $122,084 for SAH, ICH, IS, and TIA/unspecified, respectively. The cost per life saved were estimated to be NT $435,919, $384,028, $196,281, and $138,888, whereas cost per life-year saved were estimated to be NT$43,926, $48,019, $97,830, and $188,770 for SAH, ICH, IS, and TIA/unspecified, respectively. CONCLUSION: Half of the patients encountered readmission or death during the first year after stroke. Patients with advanced age, more complications, or comorbidities during initial stay tended to be highly vulnerable to AE occurrence, whereas TIA/unspecified stroke carried no less risk for AEs. FYMC or estimated cost per life saved for IS or TIA/unspecified was lower relative to SAH or ICH; however, their estimated cost per life-year saved became higher because of reduced life expectancy.

Cost-effectiveness analysis of stroke management under a universal health insurance system.

OBJECTIVE: Cost-effectiveness analysis (CEA) of stroke management was evaluated in three care models: Neurology/Rehabilitation wards (NW), Neurosurgery wards (NS), and General/miscellaneous wards (GW) under a universal health insurance system. METHODS: From 1997 to 2002, subjects with first-ever acute stroke were sampled from claims data of a nationally representative cohort in Taiwan, categorized as hemorrhage stroke (HS) including subarachnoid hemorrhage (SAH) and intracerebral hemorrhage (ICH); or, ischemic stroke (IS), including cerebral infarction (CI), transient ischemic attack/ unspecified stroke (TIA/unspecified); with mild-moderate and severe severity. All-cause readmissions or mortality (AE) and direct medical cost during first-year (FYMC) after stroke were explored. CEA was performed by incremental cost-effectiveness ratios. RESULTS: 2368 first-ever stroke subjects including SAH 3.3%, ICH 17.9%, CI 49.8%, and TIA/unspecified 29.0% were identified with AE 59.0%, 63.0%, 48.6%, 46.8%, respectively. There were 50.8%, 13.5%, 35.6% of stroke patients served by NW, NS and GW with AE 44.9%, 60.6%, 56.0%, and medical costs of US$ 5,031, US$ 8,235, US$ 4,350, respectively. NW was cost-effective for both mild-moderate and severe IS. NS was the dominant care model in mild-moderate HS, while NW appeared to be a cost-minimization model for severe HS. CONCLUSIONS: TIA/unspecified stroke carried substantial risk of AE. NS performed better in serving mild-moderate HS, whereas NW was the optimal care model in management of IS.

Inpatient rehabilitation utilization for acute stroke under a universal health insurance system.

OBJECTIVE: To explore the population-level utilization and factors associated with the use of inpatient stroke rehabilitation services under a single-payer government-based National Health Insurance (NHI) program in Taiwan. STUDY DESIGN: Retrospective cohort study based on claims data. METHODS: Inpatients with stroke were sampled from a nationally representative cohort of 200,000 NHI program enrollees. Multiple inpatient claims for individuals were merged to create a patient-level file; the first-ever admission was considered the index stroke. Proxy indicators to represent stroke severity, comorbidity, and complications were constructed. Predisposing, need, and enabling characteristics associated with rehabilitation use were explored. RESULTS: Among 2639 identified patients with stroke from January 1, 1997, to December 31, 2002, the overall inpatient rehabilitation utilization was 34.0% (33.0% for physical therapy, 19.6% for occupational therapy, and 5.3% for speech therapy). Stroke type and stroke severity were immediate causes of rehabilitation use. Except in neurology wards, rehabilitation use was unaffected by physician or facility characteristics. Among 898 patients receiving rehabilitation services, the median number of treatment sessions was 8 (interquartile range, 4-19), and the total rehabilitation costs were US $114.00 (interquartile range, $47.80-$258.30), with a mean (SD) length of stay of 22.2 (21.8) days. CONCLUSIONS: In a setting in which ability to pay is neutralized, inpatient stroke rehabilitation service in this universal NHI program was equitable but inadequate relative to use elsewhere or estimated need. Less severe case mix and financial or human resources constraints might partially account for the low utilization. Further studies measuring stroke severity and functional status are needed to clarify the actual utilization, requirements, and cost-effectiveness of inpatient stroke rehabilitation services.

Cost-effectiveness analysis of tissue plasminogen activator for acute ischemic stroke: a comparative review.

PURPOSE: This work was undertaken to review current evidence of cost-effectiveness analysis (CEA) on thrombolysis for acute ischemic stroke. METHODS: An electronic search via PubMed, from 1995 until May 2004, was performed. The methods undertaken by these studies were examined with particular attention to their modeling assumptions, sources of data, and outcome measures. RESULTS: Three comprehensive CEAs of rtPA (recombinant tissue plasminogen activator) for acute ischemic stroke were reviewed. These studies were from the United States, Canada, and the United Kingdom. All these studies employed the perspective of a healthcare system and used a Markov decision-analytic modelling approach. Estimates of effectiveness of rtPA were based on the National Institute of Neurological Disorders and Stroke (NINDS) rtPA Stroke Trial, literature-derived values or a stroke registry. In each study, functional outcome measured by the modified Rankin Scale was used to represent health states, and quality-adjusted life year gained was the health outcome summary measure. The cost-effectiveness of rtPA therapy varied in magnitude, but seemingly with same positive implications. CONCLUSIONS: Cost-effectiveness analysis requires information on an intervention's effectiveness and country-specific sources of epidemiological and resource utilization data, most of which are not yet available in Taiwan. Despite the limitations, CEA is essential if a healthcare system would like to contain costs while maintaining, or improving, quality of care.

Costs of acute care of first-ever ischemic stroke in Taiwan.

BACKGROUND AND PURPOSE: We sought to investigate the direct costs of acute hospitalization for patients with first-ever ischemic stroke in Taiwan. METHODS: Data were prospectively collected from 360 first-ever ischemic stroke patients. Hospital charges were used for analysis. Multiple linear regression analysis was used to identify the main factors influencing costs. RESULTS: Mean age was 64.9 years (median, 67.0 years), and 58% were male. Mean National Institutes of Health Stroke Scale (NIHSS) score at admission was 9.4 (median, 6.0). Mean initial score of modified Barthel Index was 10.7 (median, 12.0). Median length of stay was 7 days (range, 1 to 122 days). In-hospital mortality was 8%. Overall, median cost per patient was 26 326 New Taiwan dollars (NTD) (original currency) or 841 dollars; median cost per day was 3777 NTD or 121 dollars. Median costs for patients with initial NIHSS score 0 to 6, 7 to 15, and 16 to 38 were 20 365 NTD (650 dollars), 31 954 NTD (1020 dollars), and 62 653 NTD (2000 dollars), respectively. Daily component (physician and ward charges) accounted for approximately 38% of total costs. Initial NIHSS score, small-vessel occlusion, admission to intensive care unit, sex, and smoking had significant impacts on costs. CONCLUSIONS: Apart from providing cost estimates, we note that stroke severity strongly affects costs.

Prediction of length of stay of first-ever ischemic stroke.

BACKGROUND AND PURPOSE: Accurate information about hospital resource utilization is necessary for management of healthcare service. The purpose of this study was to determine the demographic and clinical predictors of length of hospital stay (LOS) of acute care hospitalization for first-ever ischemic stroke patients. METHODS: A group of 330 patients who suffered from first-ever ischemic stroke and were consecutively admitted to a medical center in southern Taiwan were followed prospectively. Because our intention was to identify the major predictors of LOS from the information available at admission, we evaluated only those factors that could be assessed at the time of admission. Univariate analysis and multiple regression analysis were used to identify the main predictors of LOS. RESULTS: The median LOS was 7 days (mean, 11 days; range, 1 to 122 days). Among the prespecified demographic and clinical characteristics, National Institutes of Health Stroke Scale (NIHSS) score at admission, the quadratic term of the initial NIHSS score, modified Barthel Index score at admission, small-vessel occlusion stroke, sex, and smoking were the main explanatory factors for LOS. In particular, for each 1-point increase in the total score of NIHSS, LOS increased approximately 1 day for patients with mild or moderate (score 0 to 15 points) neurological impairments, while LOS decreased approximately 1 day for patients with severe (score >15 points) neurological impairments. CONCLUSIONS: The severity of stroke, as rated by the total score on NIHSS, is an important factor that influences LOS after acute stroke hospitalization.