Article Text

Original research
Assessment of rehabilitation following acute ischaemic stroke in China: a registry-based retrospective observational study
  1. Zhike Yin1,
  2. Yongmei Deng1,
  3. Zixiao Li1,
  4. Hongqiu Gu1,
  5. Qi Zhou2,3,
  6. Yongjun Wang4,
  7. Chunjuan Wang5,6
  8. on behalf of Chinese Stroke Center Alliance Investigators
  1. 1Beijing Tiantan Hospital, Beijing, China
  2. 2China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Beijing, China
  3. 3National Center for Healthcare Quality Management in Neurological Diseases, Beijing Tiantan Hospital, Beijing, China
  4. 4Neurology, Beijing Tiantan Hospital, Beijing, China
  5. 5Vascular Neurology Department of Neurology, Capital Medical University, Beijing, China
  6. 6Capital Medical University, Beijing, China
  1. Correspondence to Chunjuan Wang; wangchunjuan{at}ncrcnd.org.cn

Abstract

Objectives This study aimed to describe the frequency, determinants and outcomes for assessment of patients who had an acute ischaemic stroke (AIS) for rehabilitation during hospitalisation in China.

Design A registry-based retrospective observational study.

Study design and settings Data regarding assessment or rehabilitation were extracted from the Chinese Stroke Center Alliance database from 1 August 2015 to 31 July 2019. Univariate and multivariate analyses were conducted to identify patient and hospital characteristics associated with rehabilitation assessment during acute hospitalisation as well as discharge outcomes.

Study cohort We included 837 897 patients who had a stroke in this study with patient characteristics, admission location, medical history, hospital characteristics and hospital designation.

Primary and secondary outcome measures Rehabilitation assessment and discharge outcomes.

Results Among 837 897 patients who had a stroke admitted to 1473 hospitals, 615 991 (73.5%) underwent rehabilitation assessment. There were significant variations in the rates of rehabilitation assessment across hospitals (IQR 61.3% vs 92.9%). According to multivariate analysis, guideline recommended care delivery was associated with a higher rehabilitation assessment rate, whereas high/low body mass index, ambulation (OR 0.88; 95% CI 0.87 to 0.90), history of stroke (OR 0.94; 95% CI 0.93 to 0.95), coronary heart disease (OR 0.84; 95% CI 0.82 to 0.85) and atrial fibrillation (OR 0.91; 95% CI 0.89 to 0.94) were associated with a lower rate. Additionally, rehabilitation assessment during hospitalisation was significantly associated with lower in-hospital mortality (OR 0.38; 95% CI 0.35 to 0.41) and a higher probability of discharge to a rehabilitation centre (OR 2.66; 95% CI 2.5 to 2.82).

Conclusions Nearly one-quarter of patients who had an AIS do not undergo documented rehabilitation assessment and compliance across hospitals varies. Thus, it is necessary to improve adherence to rehabilitation assessment to improve the quality of medical care for patients who had an AIS.

  • stroke
  • rehabilitation medicine
  • China

Data availability statement

All data relevant to the study are included in the article or uploaded as online supplemental information.

http://creativecommons.org/licenses/by-nc/4.0/

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

Statistics from Altmetric.com

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.

STRENGTHS AND LIMITATIONS OF THIS STUDY

  • This is the largest study to describe the status of rehabilitation assessment in patients who had an acute ischaemic stroke in China.

  • This study involved various regions and category of hospitals, enhancing the representativeness and generalisability of the findings.

  • As this is a retrospective observational study, causal relationships can not be explored.

  • There were no data on Modified Rankin Scale scores and detailed dysfunction at admission in this study, although these factors affected rehabilitation assessment.

Introduction

Stroke is regarded as the leading cause of death and disability-adjusted life-year loss in adults in China,1 2 with 10 million stroke survivors, among which ischaemic stroke accounts for 78% of cases.3 Many acute ischaemic stroke (AIS) survivors have varying degrees of neurological impairment, resulting in a loss of 118.6 million disability-adjusted life-years.4 With the ageing of society, the stroke burden in China has exhibited an explosive growth trend.4

Rehabilitation is the most effective way to reduce disability and improve functionality in patients who had a stroke.5 6 A considerable body of evidence indicates when initiated early after stroke, rehabilitation can enhance the recovery process and lead to better clinical outcomes.7 Assessment is the first step in providing rehabilitation and is related to a greater chance of receiving rehabilitation services.8 Both international and Chinese guidelines recommend that the rehabilitation needs of patients with AIS should be assessed or initiated during acute hospitalisation.9 10 Indeed, rehabilitation assessment during acute hospitalisation has become a widely recognised indicator of stroke care quality,11 12 and it is also an indispensable key point in the organisational management of stroke.

However, due to the limited availability of services, there are practice inequities in access to hospital rehabilitation.13 14 By comparing the findings from the China National Stroke Registry II (CNSR II) and the American Heart Association Get with the Guidelines-Stroke Programme, we found that almost 97.4% of patients with AIS at participating institutions in the USA had undergone documented assessment for rehabilitation but that less than 60% of patients in China received this service.15 16 To bridge these remarkable gaps between guideline recommendations and clinical practices, the Chinese Stroke Association (CSA) in 2015 initiated the Chinese Stroke Center Alliance (CSCA) to establish the national hospital-based stroke care quality assessment and improvement platform.12 Nevertheless, little is known about the current frequency, predictors and outcomes of patients with AIS who receive rehabilitation services during acute hospitalisation, creating an obstacle for improving the quality of stroke rehabilitation.

Using data from the CSCA, we aimed in this study to describe (1) the frequency of documented assessment for rehabilitation at relevant hospitals, (2) the patient and hospital characteristics that affect rehabilitation assessment and (3) the association between rehabilitation assessment and discharge outcomes among patients with AIS.

Materials and methods

Database description

The CSCA is a voluntary, national, continuous stroke quality improvement programme guided by the National Center of Neurological Diseases Care Management and initiated by the CSA in 2015. The details of this programme and its management have been published previously.12 Many secondary and tertiary hospitals in China were invited to participate in the programme and report data on eligible patients continuously. All data were derived from patient medical records during hospitalisation and reported through the web-based patient data collection and management tool (Medicine Innovation Research Center, Beijing, China). The completeness and quality of the data were evaluated through predefined logic features, range checks and structured reporting at the time of input. Data regarding hospital characteristics were also collected in this database. The China National Clinical Research Center for Neurological Diseases of Beijing Tiantan Hospital serves as the data coordination, abstraction and analysis centre of the CSCA. The participating hospitals were allowed to report data without the consent of the patient under the common rule or under a waiver of authorisation and exemption from their respective institutional review boards. Data supporting the findings of this study are available on reasonable request. Patients and the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

Study population and key variables

Our study population consisted of patients admitted to a CSCA participating hospital from 1 August 2015 to 31 July 2019, who met the following criteria: (1) aged 18 years or older and (2) a primary diagnosis of AIS confirmed by brain CT or MRI. The patient characteristics collected included demographics, body mass index (BMI), medical history of eight diseases and two lifestyle behaviours (smoking and alcoholism), arrival at emergency medical services, ambulation status within 48 hours after admission, in-hospital National Institutes of Health Stroke Scale (NIHSS) score and hospitalisation length of stay. The hospital characteristics compiled included geographical region and hospital category (secondary and tertiary grade). This study also explored six other evidenced-based care deliveries that have been reported to be associated with rehabilitation assessment.16 17

Outcome

Rehabilitation assessment was defined as a patient being assessed for or receiving rehabilitation services during acute hospitalisation. If medical records included the following information, the patient was considered to have received rehabilitation assessment: (1) an evaluation by rehabilitation members during hospitalisation; (2) receipt of rehabilitation services during hospitalisation; (3) transfer to a rehabilitation institution and (4) referral to rehabilitation services after discharge. Discharge outcomes associated with rehabilitation assessment, including disability (Modified Rankin Scale (MRS) 2–5), in-hospital mortality and discharge disposition (home or rehabilitation institution), were also collected for this study.

Statistical analysis

Continuous variables are described as means with SD or medians with IQRs. Categorical variables are presented as absolute numbers with percentages. Because of the large sample size, we used standardised differences to compare differences in variables of interest between groups. An absolute standardised difference of >10 indicated a significant difference.18 Multivariate logistic regression models were performed using the backward method to determine independent predictors, which are reported as ORs with 95% CIs. To assess the impact of stroke severity on rehabilitation assessment, a sensitivity analysis was conducted for a subset of the study population with initial NIHSS scores recorded (79.7% of the cases). Propensity matching (PSM) analysis was performed to adjust for confounding factors to analyse the relationship between rehabilitation assessment and discharge outcomes. The matching ratio was 1:1. All tests were two tailed, and a p<0.05 was considered statistically significant. All statistical analyses were performed by using SAS (SAS Institute), V.9.4.

Results

Rate of rehabilitation assessment

The final study sample was 837 897 patients with AIS from 1473 hospitals (figure 1). Among them, 615 991 (73.5%) received assessment for rehabilitation, and the median rate of rehabilitation assessment among participating hospitals was 81.2% (IQR 61.3%–92.9%). There were significant variations in assessment for rehabilitation, with 0% at 3 hospitals and 100% at 54 hospitals. In 2015, when CSCA was launched, there were fewer hospitals participated in the programme, so fewer data were available. Patient enrolment ended on 31 July 2019, so data for 2019 were less than for 2016–2018. Our analysis of data from 2016 to 2018 found an upward trend in stroke rehabilitation assessment rates across regions and categories of hospitals (online supplemental table 1).

Figure 1

Flow chart of study participants. CSCA, Chinese Stroke Center Alliance; TIA, transient cerebral ischaemia; ICH, intracranial hemorrhage; SAH, subarachnoid hemorrhage.

Predictors of rehabilitation assessment

The baseline characteristics of the entire sample and comparison of patients with and without rehabilitation assessment are provided in table 1. Compared with patients who did not receive rehabilitation assessment, those who did undergo assessment had higher in-hospital NIHSS scores (3 vs 2), longer hospitalisation stays (12 vs 10.4) and lower proportions of ambulation within 48 hours of admission (66.6% vs 72.9%). In addition, a higher proportion of patients who underwent rehabilitation assessment received evidence-based care.

Table 1

Univariate analysis of characteristics associated with rehabilitation assessment during acute hospitalisation among patients with AIS

Multivariate analyses showed that several factors independently increased the likelihood of rehabilitation assessment (table 2), including evidenced-based care and longer hospitalisation stay (OR 1.04; 95% CI 1.04 to 1.04). In contrast, abnormal BMI, ambulation within 48 hours of admission (OR 0.88; 95% CI 0.87 to 0.90), medical history of stroke (OR 0.94; 95% CI 0.93 to 0.95), coronary heart disease (CHD) (OR 0.84; 95% CI 0.82 to 0.85) and atrial fibrillation (OR 0.91; 95% CI 0.89 to 0.94) decreased the likelihood of assessment for rehabilitation. In sensitivity analysis, there was little change in the direction or magnitude of the variables, except for ambulatory status and receipt of thrombolysis, which were no longer significant. Moreover, patients with a higher NIHSS score were likely to be assessed for rehabilitation (OR 1.02 per point; 95% CI 1.02 to 1.02).

Table 2

Multivariate models of factors associated with documentation of rehabilitation assessment during acute hospitalisation among patients who had an AIS

Discharge outcomes

The comparison of discharge outcomes between patients with and without rehabilitation assessment is given in table 3. Patients with rehabilitation assessment had a higher risk of disability at discharge (38.9% vs 30.8%) and a higher probability of discharge to the rehabilitation centre (2.2% vs 0.6%) than those without assessment. In multivariate analysis (table 4), rehabilitation assessment during hospitalisation was independently associated with a lower in-hospital mortality (OR 0.38; 95% CI 0.35 to 0.41). Furthermore, patients who underwent assessment were more likely to be discharged to rehabilitation institutions (OR 2.66; 95% CI 2.5 to 2.82). Patient characteristics after PSM are given in online supplemental table 2. There was little change in the results of PSM (online supplemental tables 3 and 4).

Table 3

Univariate analysis of outcomes of patients with AIS with and without rehabilitation assessment during acute hospitalisation

Table 4

Multivariate analysis of outcomes of patients who had an AIS with and without rehabilitation assessment during acute hospitalisation

Discussion

It is guideline-recommended care to assess patients who had an AIS for rehabilitation during the acute phase. The CSCA provides a platform for medical quality auditing, feedback and continuous improvement to participating hospitals, which may lead to high compliance with guideline recommendations in practice. From 2016 to 2018, the rehabilitation assessment rate among patients with AIS in all regions and categories of hospitals increased year by year (online supplemental table 1). Previous studies conducted in the USA, Australia and Germany have reported that 90% of patients who had a stroke are assessed for or receive rehabilitation services.8 17 19 In comparison, the percentage of patients assessed for rehabilitation was 15% lower in our study, and significant interhospital variation was detected. The CSCA programme should be further promoted to eliminate interhospital variation and improve medical quality homogeneously.

We identified a number of patient and hospital characteristics that influence rehabilitation assessment. Indeed, rehabilitation assessment, thrombolytic therapy, documented NIHSS, dysphagia screening, deep vein thrombosis prevention and vascular evaluation are all key performance indicators of guidelines that reflect the quality of medical care after stroke and are also important components of stroke unit construction. Furthermore, the positive associations between stroke unit care, provision of other evidenced-based stroke care and receipt of rehabilitation assessment were consistent with the results of CNSR II,16 the Get With The Guidelines-Stroke Programme17 and Australian National Stroke Audit.8 These findings suggest that more attention should be given to the construction of stroke units and improvement of the overall quality of medical care for patients who had a stroke.

Additionally, this study showed that not all patients have equal opportunities to receive rehabilitation services. Patients with moderately severe stroke (NIHSS score 5–14) tended to be assessed, whereas those with mild stroke and those who were ambulatory after stroke tended to be overlooked. These findings are in line with previous research.20 21 Such findings can be explained by a patient’s potential for functional improvement. Even in high-income countries, such as the USA and Australia, the availability of rehabilitation services is reported to be limited, and the patients most likely to benefit are prioritised for rehabilitation services.22 Similarly, patients with a history of stroke, atrial fibrillation or CHD were less likely to receive rehabilitation assessments, because these medical histories were associated with an unfavourable prognosis following stroke.23 Regardless, rehabilitation services are equally important for functional improvement in these patients, and efforts are needed to optimise rehabilitation care for these people to improve the quality of acute care services.

Organisational factors will also affect the performance of rehabilitation assessments. The rate of rehabilitation assessment in tertiary hospitals was higher than that in secondary hospitals, and the gap increased with the increase of stroke severity (online supplemental table 5 and figure 1). As with many developing countries, China faces a severe shortage and uneven distribution of health workers,24 and the ageing population further increases the pressure on the Chinese health system. The allocation of medical resources in tertiary hospitals is better than that in secondary hospitals, especially in the treatment of severe patients. In addition, patients with longer hospitalisation stays are likely to receive rehabilitation assessments. Indeed, there is a serious imbalance between the supply and demand of hospital beds, and hospital stays are often shortened to provide necessary medical services to more patients. It is not feasible to extend the length of hospital stay for all patients who had a stroke to provide inpatient rehabilitation services. Some patients are transferred to rehabilitation centres for further rehabilitation services. According to this study, the assessment of rehabilitation during acute hospitalisation increases the likelihood of being transferred to a rehabilitation centre after discharge by 2.66 times. However, only 1.7% of the patients receive postdischarge rehabilitation services from a rehabilitation centre. With the resources available, standard assessment establishment and rehabilitation service referral are needed to overcome the problems associated with inadequate rehabilitation services.

Strengths and limitations

With over 800 000 data points from 1473 hospitals nationwide, this study is the largest to describe the status of AIS patient assessment for rehabilitation in China. However, there are several limitations. First, hospitals participating in the CSCA programme have a strong willingness to improve their quality of stroke care. Therefore, the rate of rehabilitation assessment may be overestimated. Second, several factors associated with rehabilitation services were not considered in this study, such as prestroke MRS score, detailed functional disability at admission and the number of stroke beds. Additionally, the reasons why patients were not assessed for rehabilitation were not recorded. These are important areas for further investigation. Third, it cannot be ignored that a high rate of missing NIHSS scores limited our ability to adjust for confounding by stroke severity.

Conclusions

Compliance with rehabilitation assessment in clinical practice is suboptimal, and inequities in access to rehabilitation assessment exist. Patients with mild stroke, high/low BMI, the ability to ambulate after stroke, a history of stroke and atrial fibrillation are likely to be overlooked. More research is needed to establish standard rehabilitation assessments and referral strategies to ensure equitable access to rehabilitation for all patients.

Data availability statement

All data relevant to the study are included in the article or uploaded as online supplemental information.

Ethics statements

Patient consent for publication

Ethics approval

This study was approved by the Institutional Review Board/Ethics Committee of Beijing Tiantan Hospital, Capital Medical University (ID: KY 2018-061-02). Participating hospitals received research approval to collect data in CSCA without requiring individual patient informed consent under the common rule or a waiver of authorisation and exemption from their Institutional Review Board.

Acknowledgments

We thank the CSCA collaborating centres, members and volunteers for their hard work and efforts. We thank every participant who contributed important and invaluable data to the CSCA.

References

Supplementary materials

Footnotes

  • Contributors All authors contributed to the conception, design, analysis and interpretation of the study. ZY designed and wrote the manuscript. HG and QZ performed data analysis. YD, ZL and YW contributed to the conception and design, drafting of the manuscript or revising it. CW was responsible for supervision of all activities. All authors commented on manuscript drafts and gave their approval for the final version to be published. CW is the guarantor of the article.

  • Funding Ministry of Science and Technology of the People’s Republic of China (National Key R&D Programme of China, 2017YFC1310901, 2016YFC0901002, 2017YFC1307905, 2015BAI12B00), National Natural Science Foundation of China (No. 81801152), Beijing Talents Project (2018A13, 2018000021223ZK03) and Youth Programme (QML20180501).

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.