! 國立台灣大學公共衛生學院流行病學與預防醫學研究所
碩士論文
Institute of Epidemiology and Preventive Medicine College of Public Health
National Taiwan University Master Thesis
以病患女兒數目預測腦中風急性期後
住院復健之返家障礙研究
Association between Number of Daughters and Failure of Home Discharge of Stroke Patients after Post-acute Inpatient Rehabilitation
謝曉芙
Shiau-Fu Hsieh
指導教授
簡國龍教授
Professor Kuo-Liong Chien
中華民國一〇三年六月June 2014
!
! 致謝
感謝指導教授簡國龍老師
感謝我的父母，謝豐舟先生與林季珍女士
!
Abstract
Background: Discharge disposition has been important for stroke patients after
post-acute inpatient rehabilitation. The rate of failure of home discharge in Taiwan
was still unknown. In addition, whether the number of daughters affected patients’
home discharge needs investigation.
Methods: We conducted a retrospective case-control study in a tertiary hospital
between July 2011 and Sep 2013, investigating stroke patients consecutively
discharged from post-acute rehabilitation. Factors regarding patient demographics,
family information, as well as disease and function information were collected. We
defined the outcome, failure of home discharge or home discharge, from the discharge
chart.
Results: One hundred and eighteen of 297 stroke patients (mean age 63 years, 37%
women) failed to discharge to home after post-acute inpatient rehabilitation, including
109 admitting to other rehabilitation hospitals and 9 to long-term care facilities.
Patients with more daughters tended to be older, female, married, to have ischemic
stroke, to receive fewer years of formal education, to have no job, to have homes
without stairs, and to have more sons and children. A trend existed between having
!more daughters and a lower risk of failure of home discharge: having three or more
daughters reduced 77 percent of the risk (odds ratio [OR] 0.23, 95% confidence
interval [CI] 0.07-0.72), compared with those without daughters (test for trend,
p=0.002). Other protective factors included a higher age (OR 0.97, 95%CI 0.95-0.99)
and a better function at discharge (OR 0.97, 95%CI 0.95-0.98).
Conclusion: The rate of failure of home discharge after post-acute inpatient rehabilitation was high in Taiwan and having more daughters lowered the risk.
Keywords: stroke, patient discharge, family support, social factor, daughter
! 摘要
背景： 出院安置對急性期後住院復健之腦中風病患是一重要健康問題。台灣目
前無相關資料，亦不清楚病患女兒數目是否影響病患返家安置之成功率。
方法：於2011 年 7 月至 2013 年 9 月間台灣一都會區醫院進行回溯性臨床研究，
追蹤所有於接受急性期後住院復健治療之腦中風病患。研究收集病人基本性質、
家屬狀況、疾病影響及功能狀況。主要結果為病患是否無法返家安置，資料來源
為病歷記錄。
結果：297 位病患，平均年齡 63 歲，37%為女性，其中 118 位無法返家安置，
包括109 名入住其他醫院復健科及 9 名至養護機構安置。女兒數目較多的病患，
相較於沒有或僅一個女兒者，其年齡較高，女性較多，已婚比例較高，梗塞性中 風較多，接受正式教育年數較短，無工作比例較高，居家有樓梯比例較高，同時
兒子數目較多，小孩數目也較多。 女兒數目較多的病患，無法返家安置的機會
較低：有三個女兒以上的病患，相較於沒有女兒者，無法返家安置的風險降低 77% (勝算比 0.23，95%信賴區間 0.07-0.72)。年齡較高與自理功能較佳者，無法
返家安置之風險亦較低（前者勝算比0.97，95%信賴區間 0.95-0.99，後者勝算比
0.97，95%信賴區間 0.95-0.98）。
結論：在台灣目前接受急性期後住院復健之腦中風病患中，有很高比例無法返 家安置。而其中如病患女兒數目較多，無法返家安置之風險顯著下降。
關鍵字：腦中風、出院安置、家庭支持、社會因素、女兒
!
6
Abbreviations
ADL Activity of daily life BI Barthel Index BMI Body mass index CI Confidence interval
ED-5Q EuroQol instruments for health-related quality of life FIM Functional Independence Measures
FIM-c The cognitive subscale of the FIM FIM-m The motor subscale of the FIM IQR Interquartile range
NA Not applicable/not available
NIHSS National Institute of Health Stroke Severity OR Odds ratio
SD Standard deviation
VS Versus
vi
!
viii
Contents
口試委員會審定書 i
致謝 ii
英文摘要 iii
中文摘要 v
Abbreviations vi
1. Introduction and literature review 1
1.1. Discharge disposition at the participation level of new health model 1
1.2. Failure of home discharge is the poor outcome for discharge disposition 2
1.3. Stroke and rehabilitation in the acute, post-acute, chronic stages 2
1.4. Post-acute inpatient stage, an important stage of stroke 4
1.5. The rate of failure of home discharge after post-acute stroke inpatient rehabilitation 5 1.6. Predictors for failure of home discharge after post-acute stroke inpatient rehabilitation 6
1.7. Social and environmental factors as predictors 6
1.8. Will number of daughters influence failure of home discharge? 7
1.9. Research gaps 7
2. Hypotheses and study aims 9
3. Materials and methods 10
3.1. Study design 10
3.2. Study participants 10
3.2.1. Inclusion criteria 10
3.2.2. Exclusion criteria 10
3.3. Study setting 11
3.4. Outcome variables 12
3.5. Predictors 12
3.5.1. Patient factors 13
3.5.2. Disease factors 13
3.5.3. Functional status 14
vi vii
!
3.6. Statistical analyses 16
3.6.1. Descriptive analyses 16
3.6.2. Correlations 16
3.6.3. Tests for trend 17
3.6.4. Simple logistic regressions 17
3.6.5. Multiple logistic regressions 17
3.7. Power calculation and sample size estimation 18
4. Results 19
5. Discussion 21
5.1. Main findings 21
5.2. Studies on the rate of failure of home discharge after post-acute inpatient rehabilitation 21
5.3. Previous findings on social factors 23
5.4. Number of daughters as a protecting factor for failure of home discharge 24
5.5. The different roles of daughters, sons, daughters-in-law and spouses 25
5.6. Other predictors for failure of home discharge after post-acute inpatient rehabilitation 27
5.7. The importance of a comprehensive framework for predictors 30
5.8. Strengths and limitations 31
5.9. Future implications 33
Conclusion 35
References 36
Tables and figures 40
Table 1. Literature review: the rate of home discharge from previous studies 41
Table 2. Literature review: important determinants from previous studies 42
Table 3. Literature review: systemic reviews and framework of predictors of discharge destination 43
Table 4. Characteristics of patients: based on number of daughters 45
Table 5. Distributions of patients’ daughters, sons, and children 46
Table 6. Correlations between continuous independent variables 47
Table 7. Correlations between binary independent variables 48
Table 8. Simple logistic regressions for predictors of failure of home discharge 50
!
Figure 1. Discharge disposition in the health model of World Health Organization 52
Figure 2. Stages of stroke rehabilitation 53
Figure 3. Structure of predictors for discharge disposition 54
Figure 4. Diagram of study setting 55
Figure 5. Diagram of data collection 56
Figure 6. Flowchart of patients 57
Figure 7. Trend test for number of daughters and rate of failure of home discharge 58
Figure 8. Trend test for number of sons and rate of failure of home discharge 59
Appendix 60
Appendix 1. The National Institute of Health Stroke Severity (NIHSS) Scale 60
Appendix 2. The Cog-4 Scale 65
Appendix 3. The Barthel Index 66
!1. Introduction and literature review
1.1. Discharge disposition at the participation level of new health model
Health models evolve as disease patterns change over time. As non-communicable
chronic diseases cause more and more health problems in both developed and
developing countries,1 in 2001, the World Health Organization proposed a new health
model, the International Classification of Functioning, Disability and Health model.2
This framework emphasized the “participation” level of health. Participation
describes how an individual interacts with the environmental and social contexts
under his/her body function impairment and functional disability. Only with good
interactions with one’s surrounding people and environment, this individual can
obtain more complete well-being (Figure 1).
Discharge disposition is a real-world challenge at such participation level. It is
defined as the further residential places where a patient reside in after being
discharged from inpatient medical service. Discharge disposition is also one of the
indicators of effectiveness of inpatient care.3, 4 In addition, discharge disposition is
important for medical care providers, public health workers and health policy
!administrators since poor discharge disposition leads to elevated medical and welfare
costs to compensate for individuals’ unmet needs in the long run.
1.2. Failure of home discharge is the poor outcome for discharge disposition
Home is the favored discharge destination because home provides familiar and
meticulous social and environmental supports. Whether the individual can return to
home affects the lives of patients and their families. On the contrary, failure of home
discharge impacts one’s health as the individual is separated from the original social
networks and has to adapt to the new environment, to build up new social networks
and to cope with the residual disabilities with less support. It is easy to understand
that discharge to places other than home is less desirable.
1.3. Stroke and rehabilitation in the acute, post-acute, chronic stages
Stroke results from disruption of sufficient perfusion of the brain. This hypoperfusion
may lead to ischemic penumbra to part of the brain tissue but other neurons may
suffer from irreversible damage. It mostly presents as one of the detrimental outcomes
of systemic atherosclerosis, or it can result from bleeding from anomalies of the
!vascular system or be caused by embolic events from the heart or great vessels.5
Stroke rehabilitation is an obligatory part of stroke care based on guidelines and
evidences.5, 6 It is designed based on the disease course and the special needs in
different stages (Figure 2).7-9 During the acute stage, rehabilitation aims to prevent
complications such as pressure sores by instructing patients and caregivers to perform
tolerated active and intensive passive limb mobilization. As medical conditions
stabilize, the post-acute stage starts, when multidisciplinary rehabilitation starts. The
goals are emphasizing secondary prevention of stroke, facilitating neurological
recovery, minimizing impairments and maximizing function. The multidisciplinary
care team consists of physiatrists, physical therapists, occupational therapists,
speech/swallowing therapists, nursing staff, social workers and other specialists. The
plan and goal of training are personalized. Studies have no consensus on the
definition of this time frame. Usually the stage starts as early as several hours after
stroke onset. Most studies define the post-acute stage can be no later than 3 months or
6 months from the onset of latest stroke. Training in post-acute stage can be either
hospital-based (the inpatient form) or home-based (the outpatient form). The chronic
!stage of stroke rehabilitation starts when the neurologic recovery reaches the plateau
or even its best possible level and when compensation skills of self-care are fully
acquired by the patient. Stroke rehabilitation in the chronic stage aims to maintain
patients’ self-care function, to prevent and solve late complications. Usually it is
defined to start sixth months after stroke onset. It is usually community- or
home-based.
1.4. Post-acute inpatient stage, an important stage of stroke
Post-acute inpatient stroke rehabilitation is proved the most intensive form of
rehabilitation and most powerful in confining disability.6 Because post-acute inpatient
rehabilitation is costly, time-consuming and instructor intensive, in order to allocate
this limited resource, evidence-based guidance is required for clinicians and policy
makers. Patients who enter this training program are different from the rest of the
stroke rehabilitation population considering that they are carefully selected and they
receive special training programs.
!1.5. The rate of failure of home discharge after post-acute stroke inpatient
rehabilitation
When post-acute inpatient rehabilitation ends, patients face a difficult question, “can I
successfully return to home and care for myself safely?” The outcome affects the
whole family. For patients and their caregivers, knowing a realistic goal of discharge
disposition helps them to accept the goal and prepare themselves mentally and
physically for returning home or transferring to other accommodations. They can also
work on the modifiable factors early. For rehabilitation teams, they need to know the
overall picture and associated factors of discharge disposition to set goals and to
design trainings.
Discharge disposition have great variations in different health care systems, different
cultures and in different eras.10, 11 The rate of home discharge after post-acute
inpatient rehabilitation ranged from 45% in the United States to as high as 81.5% in
Spain (Table 1).12, 13
!1.6. Predictors for failure of home discharge after post-acute stroke inpatient
rehabilitation
Failure of home discharge is affected by various factors.14-16 A framework has been
proposed in 2003 to help categorize the predictors for discharge disposition in this
setting (Figure 3).15 Among the identified predictors for home discharge after
post-acute inpatient rehabilitation, some are more consistent throughout previous
studies: younger age 17-21 and better early physical functional ability 12, 13, 15, 17, 19-22.
Others are less consistent, including gender 16, 19-21, 23, etiology of stroke 16,
visuospatial disturbance 16, 21, communication ability 21, 24, urinary incontinence 16, 21,
cognitive function 14, 20, 21, independent sitting balance 21, comorbidities 13, 23, quality
of life 23, environmental factors 15 and more .
1.7. Social and environmental factors as predictors
Some studies revealed that “contextual factors”, including social and environmental
factors, play important roles in stroke patients’ discharge destination. Living with a
partner is shown most consistently protecting against failure of home discharge.14, 17,
18, 20, 21, 24 Being married and good social support are also protective (Table 2,3). 13, 14,
!
17, 19, 22
1.8. Will number of daughters influence failure of home discharge?
The common essence of three identified social protecting factors is having committed
caregivers at home. Female family members still take most responsibility to look after
their families who have chronic disabling diseases,25, 26 especially in the Asian
countries. By clinical observations and findings in previous studies, daughters of these
chronic patients are common caregivers while sons are not. We therefore were
interested in the association between numbers of daughters and patients’ failure of
home discharge. Currently no studies have investigated this topic.
1.9. Research gaps
! The rate of failure of home discharge in Taiwan after post-acute
inpatient stroke rehabilitation is unclear. Through careful literature review, we found that this rate can vary in different countries, different cultures and even in different eras. Therefore, an updated investigation regarding post-acute stroke rehabilitation in Taiwan is
! needed.
! The importance of number of daughters as a determinant for failure
of home discharge lacks previous evidence. Through careful literature review, we found that social determinants of post-acute discharge disposition lacks clear definition, were less understood and the results were controversial. The role of daughters, being common caregivers in families with stroke disabled patients, has not been studied before.
!2. Hypotheses and study aims
! We postulated that the rate of failure of home discharge after post-acute
inpatient stroke rehabilitation in Taiwan is higher than in other countries.
! We postulated that in Taiwan, number of daughters of patients
independently predicts failure of home discharge. A patient with more daughters has a lower risk for failure of home discharge compared with a patient with fewer daughters if other factors are comparable.
!3. Materials and methods
3.1. Study design A case-control study
3.2. Study participants
3.2.1. Inclusion criteria
Consecutive patients discharged from the rehabilitation ward between July 2011 and
December 2013 were evaluated. Patients had ischemic stroke or intracerebral
hemorrhage. These patients should be in the post-acute phase of the target stroke
onset, defined as less than 90 days.
3.2.2. Exclusion criteria
The patients with concomitant traumatic brain injury, subarachnoid hemorrhage,
subdural hemorrhage, brain tumor or other non-brain lesions were excluded. Also, if
patients were referred back to acute medical or neurologic services for recurrent
stroke or death happened during treatment, they were excluded.
!3.3. Study setting
We retrospectively collected data from a single-center database of Mackay Memorial
Hospital, Taipei, Taiwan. The study hospital was located in an urban area and was
equipped with a 20-bed multidisciplinary stroke rehabilitation unit. Diagnosis of
stroke, determination of stroke type and acute care were done by neurologists and
neurosurgeons based on guidelines.5 Brain imaging was used to help confirming
stroke etiology or exclusion criteria. Patients were referred to physiatrists from
neurologists and neurosurgeons. Physiatrists decided the eligibility of admission for
post-acute inpatient rehabilitation training (Figure 4).
An experienced multidisciplinary team provided stroke rehabilitation. Physiatrists
were in charge of goal setting, interdisciplinary communication and counseling for
discharge disposition. Structured physical, occupational, speech/swallowing therapies,
each 30 minutes a day, were provided in 2 to 5 days every week. Patients were
encouraged to do extra practice. Training goals were individualized. Length of stay
for inpatient rehabilitation was usually confined to around 30 days due to restrictions
from the government medical payment system (Figure 4).
!
3.4. Outcome variables
Data of discharge disposition was coded according to patients and families’ decision
recorded in the discharge chart. The failure of home discharge group included the
patients who went to other rehabilitation hospitals or wards and the patients admitted
to long-term care facilities after being discharge. The control group was the home
discharge group. During hospitalization, physiatrist provided counseling to patients
and family members who decided discharge disposition.
3.5. Predictors
Four categories of potential predictors were collected (Figure 5),15 including:
1) Patient factors: age, gender, length of stay
2) Disease factors: stroke type, stroke severity, with cognitive impairment or not,
having aphasia or not
3) Functional status: functional ability on admission and at discharge
4) Social and environmental factors: years of formal education, having a job or not,
needing financial support or not, having stairs at home or not, living with families or
!not, being married or not, having children or not, number of children, number of
daughters, number of sons.
3.5.1. Patient factors
Age at admission, male or female gender, length of stay, which was the number of
days between one’s admission and discharge of the rehabilitation ward, were
collected.
3.5.2. Disease factors
Stroke severity was assessed with the National Institute of Health Stroke Severity
(NIHSS) score by neurologist or neurosurgeons on they first evaluation of these
stroke patients.27 It is a validated, reliable tool which covers the influences of stroke
on consciousness, motor, sensory, coordination, cognitive, speech, visuospatial
functions. Item scores are 0, 1, 2 and in some items can be given a 3 or 4 point, with 0
meaning no symptoms and higher score meaning more severe symptoms. Total score
ranges from 0 to 42. We analyzed the NIHSS score as a continuous variable.
!The Cog-4 scale is a newly proposed composite score using four items (1b, 1c, 9, 11)
from the NIHSS.28 It is designed to evaluate patients’ cognitive function in acute
stroke setting. A 0 point means no cognitive disturbance and a maximum of 9 points
indicates severe cognitive impairment. The Cog-4 score was treated as a continuous
variable in the analysis. Presence of aphasia was recorded as positive based on
documentation in medical records.
3.5.3. Functional status
Functional status was scored using the Barthel index (BI) on the admission day and
before discharge.29 The BI is a widely used and validated scale for basic self-care
function, also in stroke rehabilitation setting. It is comprised of 10 items, including
feeding, grooming, dressing, toilet use, bathing, bladder control, bowel control,
transfers, flat surface mobility, stair climbing. Each item is given 0 to 10. Scores for
each item are summed into a total score for the BI, ranging from 0 (total dependence)
to 100 (basic independence). The BI score was treated as a continuous variable.
!3.5.4. Social and environmental factors
Social factors were recorded based on the interviews by nurses with patients or
families on admission. Education level was coded based on self-reported years of
formal education into none, 1-6, 7-9, 10-12, >12 years. Patients were inquired if they
have a job, if they need extra financial support, if they have stairs at home, if they live
with families, have current marriage, and if they have children. Numbers of patients’
children, daughters and sons were recorded. We further categorized patients into
groups, based on how many daughters they had: without daughters, having one
daughter, having two daughters and having three or more daughters. Similarly, based
on the number of sons we created four groups: patients without sons, having one son,
having two sons, having three or more sons.
!3.6. Statistical analysis
The statistical analyses were performed using SAS software 9.3 (SAS Institute, Inc.,
Cary, NC).
3.6.1. Descriptive analyses
All the data were descriptively presented using mean ± standard deviation (SD),
median, interquartile ranges (IQRs), and minimum-maximum for continuous data and
provided frequencies for categorical data, using the Chi-squared test or the Student’s t
test as appropriate. Descriptions of overall population and of patient groups according
to numbers of daughters were presented.
3.6.2. Correlations
We checked the correlations between dependent variables, using the Spearman’s
correlation for two continuous variables and the phi coefficient for two binary
variables, and the point-biserial correlation coefficient for one continuously measured
variable and another dichotomous variable.
!3.6.3. Tests for trend
We used the Cochran–Armitage test for trend to check the trend between increased
number of daughters or sons and the rate of failure to discharge to home. It was
calculated with the median value in each category based on numbers of daughters or
sons.
3.6.4. Simple logistic regressions
Simple logistic regression was performed with failure of home discharge as the
dependent factor and to estimate the odds ratios (ORs) and 95% confidence intervals
(CIs) for each independent factor.
3.6.5. Multiple logistic regressions
To see the independent associations between factors and outcome, we selected
potential confounders to be adjusted for based on prior study findings and results from
correlation tests and simple regressions and performed multiple logistic regressions.
Model 1 checked the association between number of daughters and failure of home
discharge adjusting for age and sex. In model 2, the association was adjusted for age,
!sex and function at discharge. In model 3, important factors from simple regression
and without strong correlations with other factors in model 2 were added, i.e. type of
stroke. All variables were entered as categorical variables except age, length of stay,
scores from the NIHSS scale, Cog-4 scale, BI, and numbers of daughters, sons and
children. P values < 0.05 were considered to be statistically significant.
3.7. Power calculation and sample size estimation
The significance level was set at 0.05 and power set at 0.9. The effect size used for
calculation was derived from a study by Frank and colleagues.21 The study showed an
OR of 3.9 for patients with caregivers living together to return to home, compared
with patients without caregivers living together. The probability of having caregiver
living together was 0.46. The probability of outcome in those without caregiver at
home was 0.72. The result of sample size calculation was 202.30
!4. Results
One hundred and eighteen of 297 patients (39.7%) failed to discharge to home after
post-acute inpatient rehabilitation, including 109 subsequently admitting to other
rehabilitation hospitals or wards, and 9 admitting to long-term care facilities (Figure
6). The age of all patients was 63.1±13.4 years, with 37.4% of them were women. The
median of length of stay of post-acute inpatient rehabilitation was 35 days (IQR 28-44)
(Table 4). These patients’ social factors were distributed as following: 90.2% of them
lived with others; 70.4% of them were in a marriage and 86.5% had children (Table 4,
5).
Patients with more daughters were more likely to be older (p=0.001), women
(p=0.019), married (p=0.001), and were more likely to have ischemic stroke
(p=0.001), receive fewer years of formal education (p=0.001), have no job (p=0.001),
live in homes without stairs (p=0.007), and have more sons (p=0.001) and children
(p=0.001) (Table 8).
Some predictors had significant correlations, including the following pairs of
!predictors: numbers of sons/daughters/children, the NIHSS/Cog-4 scores, the BI
scores on admission/at discharge. Some correlations were observed between
age/number of sons, age/number of daughters, age/number of children, age/NIHSS
score, age/BI score on admission, and length of stay/NIHSS score (Table 6, 7).
A trend existed (Figure 7) between having more daughters and a lower risk of failure
of home discharge: having three or more daughters reduced 63 percent of the risk
(odds ratio [OR] 0.37, 95% confidence interval [CI] 0.15-0.91, p=0.014), compared
with those without daughters after adjusting for age and sex (test for trend, p=0.002)
(Table 8). Such trend was not seen between the number of sons and the risk of failure
of home discharge (p=0.06) (Figure 8). Having three or more daughters (OR 0.23,
95% CI 0.07-0.72, p=0.003) was significantly associated with failure of home
discharge after adjusting for age (OR 0.97, 95% CI 0.95-1.00, p=0.029), sex and
function at discharge (OR 0.97, 95% CI 0.95-0.98, p=0.001, for every 1 point increase
in the BI) (Table 9).
!5. Discussion
5.1. Main findings
Nearly forty percent of stroke patients failed to discharge to home after a 1-month
post-acute rehabilitation in a medical center in urban Taiwan. Having three or more
daughters was the most important protecting factor for this poor outcome in discharge
distribution. This protecting effect remained significant after adjusting for age, sex
and self-care function at discharge. An older age and a better self-care function were
also significant protecting factors.
5.2. Previous studies on the rate of failure of home discharge after post-acute inpatient rehabilitation
In previous studies, the rate of home discharge range between 62 to 82 percent.10, 13, 17,
19-24 The length of stay of the reported inpatient rehabilitation had a wide range, from
18 to 101 days. A US study by Sandstrom and colleages reported that 45% of their
stroke patients had home discharge after inpatient rehabilitation, with another 26% of
patients discharged to an affiliated subacute service and 28% discharged to a
long-term care facility.12 This exceptionally low rate of home discharge may be
!attributed to the inclusion criteria of severe stroke and to a shorter length of stay
(mean 24 days).
In our study, 39 percent of all patients failed to discharge to home after 37 days of
multidisciplinary inpatient rehabilitation. This rate of poor discharge distribution was
high compared with previous studies and noteworthy. Similar as in the study by
Sandstrom, our participants had a shorter length of stay. This high rate of poor
outcome was even more noteworthy because unlike the study by Sandstrom, our
participants had a wide range of stroke severity, including some with very mild stroke.
The BI score at discharge was 46 on average, indicating these patients had severe
dependence after inpatient rehabilitation.31 Moreover, according to the informal
interviews with some patients, some contextual factors might contribute to the
phenomenon of choosing rehabilitation hospitals as their discharge destination and a
higher rate of failure of home discharge. In Taiwan, the National Health Insurance
system covered the expanses of further hospital disposition. For inpatients, the
expenses for transportation and accommodation were saved. Meanwhile, some
patients with private medical insurance might have additional gains for being
!hospitalized. In contrast, if the patients return to home, they need to find appropriate
caregivers, overcome environmental obstacles at home, and arrange transportation to
the hospitals for outpatient rehabilitation without hospitalization compensation from
private medical insurance. Evidences from further qualitative researches and formal
interviews are warranted to support these explanations.
5.3. Previous findings on social factors
The importance of social factors on home discharge after post-acute inpatient
rehabilitation has been recognized. The significant protecting social domain factors
included being married (OR 4.1-9.7)13, 20 and having caregiver at home (OR 3.9-430.0)
18, 21 for home discharge. Koyama and colleagues found that for post-acute stroke
patients in Japan, those without a spouse at home and living in households with fewer
family members were more likely to fail to return to home after adjusting for the
influence of age and function.17 Of note, they found a negative association between
the number of patients’ children and home discharge. They explained that in the
setting of modern suburban Japan, the stroke patients’ married children commonly
live in separately from their patients and were less likely to take the caregiver roles
!for disabled parents. This phenomenon contributes to the children’s lack of impact on
parents’ discharge outcome.
5.4. Number of daughters as a protecting factor for failure of home discharge
Our study was the first to attempt to delineate the influences of patients’ daughters
and sons separately on the discharge outcome during post-acute stage of stroke. We
found that having more daughters was related to a lower rate of failure of home
discharge, while number of sons was not related to discharge outcome. Number of
daughters remained as an independent determinant for home discharge after adjusting
for age and self-care function. This protecting effect was most prominent when
patients had three or more daughters.
A devoted caregiver is crucial for home discharge of stroke patients in the post-acute
stage, and for their physical and mental health. Primary caregivers need to handle
patients’ care need and troubleshoot rehabilitation problems. According to a study by
Pinquart, Asian families depended more on informal caregiver forces.32 Female
family members, especially daughters, were more likely to become major caregivers,
!as shown by a study in Taiwan and another from South Korea.25,26 Daughters,
especially those unmarried, usually take the caregiver roles for parents. The study
from Wu had a similar setting as our study. It surveyed 80 primary caregivers of
post-acute stroke patients.25 These caregivers’ mean age was 51 years, with 55% of
them were female. A total of 71% was unmarried; 50% were patients’ daughters/sons.
5.5. The different roles of daughters, sons, daughters-in-law and spouses as caregivers for stroke or chronic disabled patients
The roles of daughters as caregivers compared with spouses, sons, daughters-in-law
are different.33 Stroke patients’ spouses, sons and their daughters-in-law might
probably share partial responsibility for caregiving but are less likely to be primary
caregivers, and therefore may have less influence on patients’ discharge distribution.
Some studies observed that spouses frequently became primary caregivers. However,
we observed that the patients’ spouses were elderlies themselves and might have less
capacity to take the caregiver responsibility alone. Sons sometimes serve as decision
makers for parent care but less often become household caregivers.18, 19, 34 Sons may
be unmarried. If they are married, their wives, the daughter-in-laws of stroke patients,
!can sometimes become household caregivers.34, 35 In modern urban areas in Taiwan,
sons and daughters-in-law commonly live separately from their parents and may be
less influential on patients’ discharge distribution than daughters.
We explained that daughters, being the younger female members in these families, are
more capable of providing physical aids to the patients than stroke patients’ spouses.
Some married daughters provide care for elderly parents and children simultaneously,
being recognized as the “Sandwich Generation”,36 while some unmarried daughters
live with their parents, having fewer obstacles to start caregiving. Besides caregiving,
some daughters in Taiwan can be decision makers and even sources of financial aids
for elderly parents’ care. We hypothesized that if any of patients’ daughters can take
such role, these stroke patients may have higher chances to return to home than those
without daughters and by this way, number of daughters is influential to parents’
chances to home discharge.
!5.6. Other predictors for failure of home discharge after post-acute inpatient
rehabilitation
The influence of self-care function on outcome
Stroke patients’ functional ability on admission to inpatient rehabilitation is proved to
be an important predictor.12, 13, 16, 17, 19-22 Pohl and colleagues reported that patients
with a FIM score lower than their population mean FIM score had an OR of 5.8 for
residential care discharge.19 Other studies using FIM presented ORs between 1 to 3
for the protecting effect of better self-care function against poor outcome of failure of
home discharge. The study by Pinedo reported that patients with BI scores between 0
and 20 had a 2.9 fold risk compared with those with higher BI scores to be discharge
to residential care.13 This study confirmed the influence of good patient function on
successful home discharge.
The tools of assessing self-care function
In this study, we used the BI to evaluate functional ability for basic activity of daily
life.29 The BI was the most frequently used tool and the FIM being the second.27 It has
strong psychometric properties and is more feasible from a practical standpoint.
!Therefore we chose the BI to measure patients’ functional ability in our study.
Despite that our study population in average had severe dependence on admission and
even after they finished the inpatient training, a 10-point BI gain we observed was
clinically important.31,37 This supported that our rehabilitation team in this study
setting provided post-acute stroke rehabilitation with desirable and comparable
effectiveness compared with other studies. Therefore, our study findings can be
reliably compared with the findings from previous studies.
The timing of assessing self-care function
Studies usually assessed patients’ function on their admissions since this assessment
can be performed in a package of other admission routines. Also an early acquisition
of functional information may help early prediction of rehabilitation outcomes.
Function at discharge is another popular choice, like we did in our study. It is not only
a convenient time point to assess in clinical practice but also a time point of greatest
relevance to discharge disposition. Function scores of the same individual measured
at different time points have high correlations, as we proved in this study. Therefore,
choosing function on admission or at discharge may probably yield similar results.
!Some studies tried to determine whether rehabilitation gain, which is the difference
between the function on admission and at discharge, predicts rehabilitation outcomes,
including discharge disposition.17, 23 This predictive value is not as established as
function on admission and at discharge.
The influence of age on outcome
An older age, in previous researches, is associated with higher risk of not discharging
to home.17-21 However, all reported ORs were around 1-1.5, except in the study by
Tanwir.20 In their study, stroke patients less than 65 years old had an OR of 2.8,
patients between 65 and 85 years old an OR of 1.7 for home discharge, compared
with patents older than 85 years old. In our study, however, an older age was related
with lower risk of failure of home discharge, although the OR was close to 1. One
possible explanation is that elderly disabled stroke patients and their family members
tend to set low goals for these patients’ future self-care abilities. These elder patients
also tend to have more prolonged cognitive confusion and more chance of depression
after stroke. When arranging for discharge disposition, their key decision makers may
choose to bring them home instead of arrange further hospitalization which requires
!complicated processes or arrange long-term care facilities admission which is not a
popular choice in Taiwan. On the contrary, young stroke survivors and their families
expect highly of the patient. So these young patients may tend to go for subsequent
inpatient rehabilitation in other hospitals.
The correlations between predicting factors
Functional ability is highly correlated with stroke severity, cognitive impairment,
aphasia and age in our study. Therefore, we only adjusted for age and functional
status into the proposed models and left the other factors out. Age and functional
status, remained statistically significant after adjusting for confounding factors.
5.7. The importance of a comprehensive framework for predictors
Meijer in 2003 proposed a comprehensive framework for predicting discharge
destination 6 to 12 months after stroke onset. Twenty-six selected prognostic factors
were categorized into clinical and social sub-domains and then prioritized (Figure5)
(Table3).15 Each of these 26 factors was given clear definition. The social sub-domain
was further divided into home front, social situation and residence. In authors’
!opinion, this comprehensive framework is of great value for future researches to
generate comparable results for subacute prognostic factors especially the poorly
defined social factors. However, we didn’t identify any relevant study to use this
structure except three other studies from the same group of exports and one European
research regarding admission criteria for inpatient stroke rehabilitation.4, 14, 16, 38
5.8. Strengths and limitations
Our study had several strengths. First, it provided an overview for an increasingly
important health issue, discharge disposition. Second, this was the first study to
address the role of daughters in predicting failure of home discharge. Third, our study
design had a low change of selection bias since we collected data of all consecutive
patients admitted for rehabilitation. Last, low rates of missing data and loss to
follow-up made the findings less biased.
The study limitations included: first, data of the primary outcome was from chart
reviewing instead of directly acquiring from post-discharge follow-up. Therefore,
patients might be misclassified if they changed their discharge dispositions. The
!proportion of such patients was estimated to be small because any non-scheduled
change in destination or caregiver arrangement is not cost-effective to patients and
families and therefore is avoided if possible. Although the timing of our outcome
retrieval was early compared with previous studies which obtained discharge
destination 6 to 12 months after patients’ discharge, by this setting we not only
incorporated data collection in clinical practice, decreased the rate of missing data,
but also provided clinically relevant information. Second, demographic data of
patients’ family members were lacking. Therefore, the explanation that more
daughters supported stroke patients’ home discharge by acting as primary caregivers
may require evidence from prospective cohort studies or by obtaining recall data to
support. The third possible limitation was that some known confounding factors were
not collected or were collected with suboptimal quality due to the retrospective nature
of this study. The methods to record data of aphasia, cognitive impairment, depression,
premorbid function and places of residence, comorbidities in clinical and research
settings may be improved and updated. Moreover, we didn’t analyze socioeconomic
factors in depth. Researches regarding socioeconomic status and discharge disposition
of stroke patients are few and of insufficient quality.4 Future works are warranted.
!Last, the single-center setting may limit external generalizability. However, through
literature review, we found many shared elements for failure of home discharge in
studies with different settings and from studies worldwide. We believed our findings
could be generalized to some other countries. Multi-center studies and studies from
more countries are needed to reflect a global picture.
5.9. Future implications
Regarding discharge disposition or other topics in the post-acute inpatient
rehabilitation setting, future studies should report the admission criteria used, the
duration between stroke onset and admission, the length of stay, and the guideline or
considerations they use to advice about discharge disposition. Cost-effective analyses
in patients point-of-view may help delineating their decision making process on
discharge disposition. In our future studies, we will perform caregiver interviews and
collect caregiver demographics in detail.
Our study had the following clinical implications. First, rehabilitation teams should
provide counseling of discharge disposition to stroke patients’ and their caregivers
!early during hospitalization. Second, at clinical level and in policy making, efforts
need to made to provide support for informal caregivers especially patients’ daughters
during post-acute inpatient stage and other stages of stroke. For those patients’ with
poor social networks, we should provide them with formal caregiver resources. In the
long run, public health workers and policy makers should work on a community
model which provides high-quality rehabilitation service for post-acute and chronic
stage stroke patients to facilitate their home discharge and reintegration into society.
!
Conclusion
The rate of failure of home discharge after post-acute inpatient rehabilitation was high
in Taiwan and having more daughters was associated with a lower risk.
!
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14. Meijer R, Ihnenfeldt D, van Limbeek J, Kriek B, Vermeulen M and de Haan R.
Prognostic social factors in the subacute phase after a stroke for the discharge destination from the hospital stroke-unit. A systematic review of the literature.
Disability and rehabilitation. 2004;26:191-7.
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39.
!
Tables and figures
Table 1. Literature review: the rate of home discharge from previous studies
Table 2. Literature review: important determinants from previous studies
Abbreviations: ADL, activity of daily life; BMI, body mass index; ED-‐5Q, EuroQol instruments for health-‐related quality of life; FIM, Functional Independence Measures; FIM-‐m, the motor subsacale of the FIM; FIM-‐c, the cognitive subscale of the FIM; NA, not applicable/not available; vs, versus; OR, odds ratio.
Table 3. Literature review: systemic reviews and framework construction regarding predictors of discharge
destination
!
!
daughters: none, one, two, and more than three
Abbreviations; BI, Barthel Index; NIHSS: National Institute of Health Stroke Scale
Table 5. Distributions of patients’ daughters, sons, and children
Mean Standard
deviation
Median Minim
um
First
quartile Third
quartile
Maximu
m
Number of daughters 1.3 1.3 1 0 0 2 7
Number of sons 1.5 1.1 1 0 1 2 6
Number of children 2.8 1.8 3 0 2 4 9
Table 6. Correlations between continuous independent variables
Number s of sons
Numbers of daughters
Numbers of children
NIHSS score
Cog-4 score
BI on admission
BI at discharge
BI difference
Age Length of stay Numbers of sons 1.00 0.13 0.68 -0.07 0.13 -0.22 -0.18 0.06 0.55 -0.01 0.16 <0.01 0.49 0.15 0.02 0.05 0.50 <0.01 0.89 Numbers of daughters 1.00 0.82 0.00 0.04 -0.16 -0.07 0.20 0.33 0.10
<0.01 0.99 0.70 0.08 0.44 0.03 <0.01 0.28
Numbers of children 1.00 -0.04 0.11 -0.25 -0.16 0.19 0.56 0.07
0.69 0.26 0.01 0.09 0.05 <0.01 0.48
NIHSS score 1.00 0.80 -0.38 -0.41 -0.09 -0.20 0.24
<0.01 <0.01 <0.01 0.34 0.03 0.01
Cog-4 score 1.00 -0.38 -0.41 -0.10 -0.05 0.15
<0.01 <0.01 0.29 0.61 0.10
BI on admission 1.00 0.91 -0.15 -0.19 -0.08
<0.01 0.11 0.04 0.42
BI at discharge 1.00 0.28 -0.18 -0.14
<0.01 0.06 0.14
BI difference 1.00 0.02 -0.15
0.80 0.10
Age 1.00 0.03
0.74
Length of stay 1.00
Abbreviations: BI, Barthel Index; NIHSS, National Institute of Health Stroke Severity.
Table 7. Correlations between binary independent variables
Sex Type Aphasia Educatio n
Employm ent
Financial aid
Barrier Living with others
Being married
Having children
Number of
daughters
Number of sons
Sex
1.00 -0.12 -0.05 0.32 0.26 0.12 0.04 -0.04 0.08 -0.14 0.18 0.23
Type
1.00 -0.13 0.29 0.29 0.13 -0.04 0.08 0.08 0.22 0.27 0.12
Aphasia
1.00 0.13 0.04 0.10 0.01 0.11 0.03 0.03 0.10 0.09
Education
1.00 0.42 0.17 0.09 0.12 0.05 0.34 0.47 0.47
Employment
1.00 0.14 0.10 0.09 0.10 0.22 0.28 0.24
Financial aid
1.00 0.10 0.13 0.17 0.07 0.15 0.20
Barrier
1.00 0.07 -0.03 -0.08 0.20 0.15
Living with others
1.00 0.36 0.20 0.15 0.18
Being married
1.00 0.46 0.31 0.32
Having children
1.00 0.64 0.74
Number of
daughters
1.00 0.43
Number of sons
1.00
!
!
discharge
Abbreviations; BI, Barthel Index; NIHSS: National Institute of Health Stroke Scale
!
discharge
Abbreviations; BI, Barthel Index; NIHSS: National Institute of Health Stroke Scale
!
Organization
Participation Discharge Disposition
Reference: WHO I. International Classification of Functioning. Disability and Health, Geneva, Switzerland: World Health Organization. 2001.
http://www.who.int/classifications/icf/en/
!
Acute stage Post-‐acute stage
Chronic stage Premorbid
status
Hospital
Discharge disposition
Home
Other places
!
Figure 3. Structure of predictors for discharge disposition
Reference: Meijer R, Ihnenfeldt D, Vermeulen M, De Haan R and Van Limbeek J. The use of a modified Delphi procedure for the determination of 26 prognostic factors in the sub-‐acute stage of stroke. International journal of rehabilitation research Internationale Zeitschrift fur Rehabilitationsforschung Revue internationale de recherches de readaptation. 2003;26:265-‐70.
!
Figure 4. Diagram of study setting
!
!
!
home discharge
!
discharge
!
Appendix
Appendix 1. The National Institute of Health Stroke Severity (NIHSS) Scale
The National Institute of Health Stroke Severity (NIHSS) Scale
! Assessing consciousness, motor, sensory, coordination, cognitive, speech, visuospatial functions
! Measuring during the first visit of neurologists
! Good validity, reliability and prognostic value
! With 11 items
! Item scored 0 (no symptoms) - 4 (severe); total score 0 – 42
! 0: No symptoms, 1-4: minor stroke;
5-15: moderate; 16-20: moderate to severe; 21-42: severe
Reference:
Meijer R, Ihnenfeldt D, Vermeulen M, De Haan R and Van Limbeek J. The use of a modified Delphi procedure for the determination of 26 prognostic factors in the sub-acute stage of stroke. International journal of rehabilitation research Internationale Zeitschrift fur Rehabilitationsforschung Revue internationale de recherches de readaptation. 2003;26:265-70. 27
http://www.ninds.nih.gov/doctors/NIH_Stroke_Scale.pdf
!
!
!
!
!
The Cog-4 Scale
! A composite scale from 4 items of NIHSS: 1b, 1c, 9, 11 (0-2, 0-2, 0-3, 0-2)
! An indicator for cognitive impairment of acute stroke patients
! Total score 0-9
Reference:
Meijer R, Ihnenfeldt D, Vermeulen M, De Haan R and Van Limbeek J. The use of a modified Delphi procedure for the determination of 26 prognostic factors in the sub-acute stage of stroke. International journal of rehabilitation research Internationale Zeitschrift fur Rehabilitationsforschung Revue internationale de recherches de readaptation. 2003;26:265-70. 28
