Burden of informal care in stroke survivors and its determinants: a prospective observational study in an Asian setting.

BACKGROUND: Informal caregiving is an integral part of post-stroke recovery with strenuous caregiving demands often resulting in caregiving burden, threatening sustainability of caregiving and potentially impacting stroke survivor's outcomes. Our study aimed to examine and quantify objective and subjective informal care burden after stroke; and to explore the factors associated with informal care burden in Singapore. METHODS: Stroke patients and their informal caregivers were recruited from all five tertiary hospitals in Singapore from December 2010 to September 2013. Informal care comprised of assistance provided by informal caregivers with any of the activities of daily living. Informal care burden was measured by patients' likelihood of requiring informal care, hours of informal care required, and informal caregivers' Zarit's Burden Score. We examined informal care burden at 3-months and 12-months post-stroke. Generalized linear regressions were applied with control variables including patients' and informal caregivers' demographic characteristics, arrangement of informal care, and patients' health status including stroke severity (measured using National Institute of Health Stroke Scale), functional status (measured using Modified Rankin Scale), self-reported depression, and common comorbidities. RESULTS: Three hundred and five patients and 263 patients were examined at 3-months and 12-months. Around 35% were female and 60% were Chinese. Sixty three percent and 49% of the patients required informal care at 3-months and 12-months point, respectively. Among those who required informal care, average hours required per week were 64.3 h at 3-months and 76.6 h at 12-months point. Patients with higher functional dependency were more likely to require informal care at both time points, and required more hours of informal care at 3-months point. Female informal caregivers and those caring for patients with higher functional dependency reported higher Zarit's Burden. While informal caregivers who worked full-time reported higher burden, those caring for married stroke patients reported lower burden at 3-months point. Informal caregivers who co-cared with foreign domestic workers, i.e.: stay-in migrant female waged domestic workers, reported lower burden. CONCLUSIONS: Informal care burden remains high up to 12-months post-stroke. Factors such as functional dependency, stroke severity, informal caregiver gender and co-caring with foreign domestic workers were associated with informal care burden.

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.

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.

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.