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Effect of Rehabilitation Intensity on Mortality Risk After Stroke

Published:November 03, 2017DOI:https://doi.org/10.1016/j.apmr.2017.10.011

      Abstract

      Objective

      To determine the relation between rehabilitation intensity and poststroke mortality.

      Design

      Retrospective cohort study.

      Setting

      Nationwide claims data.

      Participants

      From Taiwan's National Health Insurance claims databases, patients (N=6737; mean age, 66.9y; 40.3% women) hospitalized between 2001 and 2013 for a first-ever stroke who had mild to moderate stroke and survived the first 90 days of stroke were enrolled.

      Interventions

      The intensity of rehabilitation therapy within 90 days after stroke was categorized into low, medium, or high based on the tertile distribution of the number of rehabilitation sessions.

      Main Outcome Measures

      Long-term all-cause mortality. The Cox proportional hazard models with Bonferroni correction were used to assess the association between rehabilitation intensity and mortality, adjusting for age, comorbidities, stroke severity, and other covariates.

      Results

      Patients in the high-intensity group were younger but had a higher burden of comorbidities and greater stroke severity. During follow-up, the high-intensity group was associated with a significantly lower adjusted risk (hazard ratio [HR], .73; 95% confidence interval [CI], .63–.84) of mortality than the low-intensity group, whereas the medium-intensity group carried a similar risk of mortality (HR, 0.94; 95% CI, 0.84–1.06) compared with the low-intensity group. This association was not modified by stroke severity.

      Conclusions

      Among patients with mild to moderate stroke severity, high-intensity rehabilitation therapy within the first 90 days was associated with a lower mortality risk than low-intensity therapy. Efforts to promote high-intensity rehabilitation therapy for this group of patients with stroke should be encouraged.

      Keywords

      List of abbreviations:

      CCI (Charlson Comorbidity Index), ICD-9-CM (International Classification of Diseases–9th Revision–Clinical Modifications), LHID2000 (Longitudinal Health Insurance Database 2000), NHI (National Health Insurance), NIHSS (National Institutes of Health Stroke Scale), PAC (postacute care), SSI (stroke severity index)
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      References

        • Bettger J.P.
        • Thomas L.
        • Liang L.
        • et al.
        Hospital variation in functional recovery after stroke.
        Circ Cardiovasc Qual Outcomes. 2017; 10: e002391
        • Lang C.E.
        • Lohse K.R.
        • Birkenmeier R.L.
        Dose and timing in neurorehabilitation: prescribing motor therapy after stroke.
        Curr Opin Neurol. 2015; 28: 549-555
        • Winstein C.J.
        • Stein J.
        • Arena R.
        • et al.
        Guidelines for adult stroke rehabilitation and recovery: a guideline for healthcare professionals from the American Heart Association/American Stroke Association.
        Stroke. 2016; 47: e98-e169
        • Huang H.C.
        • Chung K.C.
        • Lai D.C.
        • Sung S.F.
        The impact of timing and dose of rehabilitation delivery on functional recovery of stroke patients.
        J Chin Med Assoc. 2009; 72: 257-264
        • Andrews A.W.
        • Li D.
        • Freburger J.K.
        Association of rehabilitation intensity for stroke and risk of hospital readmission.
        Phys Ther. 2015; 95: 1660-1667
        • Hu G.C.
        • Hsu C.Y.
        • Yu H.K.
        • Chen J.P.
        • Chang Y.J.
        • Chien K.L.
        Association between the volume of inpatient rehabilitation therapy and the risk of all-cause and cardiovascular mortality in patients with ischemic stroke.
        Arch Phys Med Rehabil. 2014; 95: 269-275
        • Yu A.Y.
        • Holodinsky J.K.
        • Zerna C.
        • et al.
        Use and utility of administrative health data for stroke research and surveillance.
        Stroke. 2016; 47: 1946-1952
        • Sung S.F.
        • Hsieh C.Y.
        • Kao Yang Y.H.
        • et al.
        Developing a stroke severity index based on administrative data was feasible using data mining techniques.
        J Clin Epidemiol. 2015; 68: 1292-1300
        • Sung S.F.
        • Hsieh C.Y.
        • Lin H.J.
        • et al.
        Validity of a stroke severity index for administrative claims data research: a retrospective cohort study.
        BMC Health Serv Res. 2016; 16: 509
        • Hung L.C.
        • Sung S.F.
        • Hsieh C.Y.
        • et al.
        Validation of a novel claims-based stroke severity index in patients with intracerebral hemorrhage.
        J Epidemiol. 2017; 27: 24-29
        • Chen C.M.
        • Yang Y.H.
        • Chang C.H.
        • Chen P.C.
        Effects of transferring to the rehabilitation ward on long-term mortality rate of first-time stroke survivors: a population-based study.
        Arch Phys Med Rehabil. 2017; 98: 2399-2407
        • National Health Insurance
        2016–2017 annual report.
        (Available at:)
        • Cheng C.L.
        • Kao Y.H.
        • Lin S.J.
        • Lee C.H.
        • Lai M.L.
        Validation of the National Health Insurance Research Database with ischemic stroke cases in Taiwan.
        Pharmacoepidemiol Drug Saf. 2011; 20: 236-242
        • Hsieh C.Y.
        • Chen C.H.
        • Li C.Y.
        • Lai M.L.
        Validating the diagnosis of acute ischemic stroke in a National Health Insurance claims database.
        J Formos Med Assoc. 2015; 114: 254-259
        • Cramer S.C.
        Repairing the human brain after stroke: I. Mechanisms of spontaneous recovery.
        Ann Neurol. 2008; 63: 272-287
        • Hsieh C.Y.
        • Lee T.H.
        • Chang K.C.
        • Taiwan Stroke Society
        A nationwide plan for postacute care of stroke in Taiwan.
        Int J Stroke. 2014; 9: E3
        • Schlegel D.
        • Kolb S.J.
        • Luciano J.M.
        • et al.
        Utility of the NIH Stroke Scale as a predictor of hospital disposition.
        Stroke. 2003; 34: 134-137
        • Lee H.C.
        • Chang K.C.
        • Huang Y.C.
        • Lan C.F.
        • Chen J.J.
        • Wei S.H.
        Inpatient rehabilitation utilization for acute stroke under a universal health insurance system.
        Am J Manag Care. 2010; 16: e67-e74
        • Liu C.Y.
        • Hung Y.T.
        • Chuang Y.L.
        • Chen Y.J.
        • Weng W.S.
        Incorporating development stratification of Taiwan townships into sampling design of large scale health interview survey.
        J Health Manag. 2006; 4: 1-22
        • Sung S.F.
        • Hsieh C.Y.
        • Lin H.J.
        • Chen Y.W.
        • Yang Y.H.
        • Li C.Y.
        Validation of algorithms to identify stroke risk factors in patients with acute ischemic stroke, transient ischemic attack, or intracerebral hemorrhage in an administrative claims database.
        Int J Cardiol. 2016; 215: 277-282
        • Deyo R.A.
        • Cherkin D.C.
        • Ciol M.A.
        Adapting a clinical comorbidity index for use with ICD-9-CM administrative databases.
        J Clin Epidemiol. 1992; 45: 613-619
        • Hou W.H.
        • Ni C.H.
        • Li C.Y.
        • Tsai P.S.
        • Lin L.F.
        • Shen H.N.
        Stroke rehabilitation and risk of mortality: a population-based cohort study stratified by age and gender.
        J Stroke Cerebrovasc Dis. 2015; 24: 1414-1422
        • Cheng C.L.
        • Chien H.C.
        • Lee C.H.
        • Lin S.J.
        • Yang Y.H.
        Validity of in-hospital mortality data among patients with acute myocardial infarction or stroke in National Health Insurance Research Database in Taiwan.
        Int J Cardiol. 2015; 201: 96-101
        • Sung S.F.
        • Chen S.C.
        • Hsieh C.Y.
        • Li C.Y.
        • Lai E.C.
        • Hu Y.H.
        A comparison of stroke severity proxy measures for claims data research: a population-based cohort study.
        Pharmacoepidemiol Drug Saf. 2016; 25: 438-443
        • Lohse K.R.
        • Lang C.E.
        • Boyd L.A.
        Is more better? Using metadata to explore dose-response relationships in stroke rehabilitation.
        Stroke. 2014; 45: 2053-2058
        • Nudo R.J.
        Recovery after brain injury: mechanisms and principles.
        Front Hum Neurosci. 2013; 7: 887
        • Chiu H.T.
        • Wang Y.H.
        • Jeng J.S.
        • Chen B.B.
        • Pan S.L.
        Effect of functional status on survival in patients with stroke: is independent ambulation a key determinant?.
        Arch Phys Med Rehabil. 2012; 93: 527-531
        • Foley N.
        • Teasell R.
        • Salter K.
        • Kruger E.
        • Martino R.
        Dysphagia treatment post stroke: a systematic review of randomised controlled trials.
        Age Ageing. 2008; 37: 258-264
        • Donovan N.J.
        • Daniels S.K.
        • Edmiaston J.
        • et al.
        Dysphagia screening: state of the art: invitational conference proceeding from the State-of-the-Art Nursing Symposium, International Stroke Conference 2012.
        Stroke. 2013; 44: e24-e31
        • Hafer-Macko C.E.
        • Ryan A.S.
        • Ivey F.M.
        • Macko R.F.
        Skeletal muscle changes after hemiparetic stroke and potential beneficial effects of exercise intervention strategies.
        J Rehabil Res Dev. 2008; 45: 261-272
        • Arango-Lopera V.E.
        • Arroyo P.
        • Gutiérrez-Robledo L.M.
        • Pérez-Zepeda M.U.
        • Cesari M.
        Mortality as an adverse outcome of sarcopenia.
        J Nutr Health Aging. 2013; 17: 259-262
        • Hsieh C.Y.
        • Wu D.P.
        • Sung S.F.
        Trends in vascular risk factors, stroke performance measures, and outcomes in patients with first-ever ischemic stroke in Taiwan between 2000 and 2012.
        J Neurol Sci. 2017; 378: 80-84
        • Mirer A.G.
        • Peppard P.E.
        • Palta M.
        • Benca R.M.
        • Rasmuson A.
        • Young T.
        Menopausal hormone therapy and sleep-disordered breathing: evidence for a healthy user bias.
        Ann Epidemiol. 2015; 25: 779-784.e1