Long-Term Outcomes after Acute Stroke Treatment Larry B. Goldstein, M.D. Professor of Medicine (Neurology) Center for Cerebrovascular Disease Center for Clinical Health Policy Research Duke University and Durham VA Medical Center Larry B. Goldstein, M.D. Professor of Medicine (Neurology) Center for Cerebrovascular Disease Center for Clinical Health Policy Research Duke University and Durham VA Medical Center Disclosures None relevant Disclosures None relevant

Quality of life Levels of Outcome Measurement World Health Organization Handicap Disability Impair-ment Quality of life Participation Dimension Activities Dimension BodyDimension

Level of Measurement Severity Comorbidity Disease Body Dimension Participation Dimension Activities Dimension Severity Comorbidity Severity Comorbidity Motivation Depression Social Sup. Severity Comorbidity Severity Comorbidity Motivation Depression Social Sup. Motivation Depression Social Sup. Education Occupation Access

Which Scales?  Reliable  Valid  Sensitive to change  Logistically feasible

Reliability (Precision)  Degree of agreement between or among observers  Inter-observer agreement  Degree of agreement between observations  Intra-observer agreement (t est-retest)

Validity (Accuracy)  Content validity  Does the scale includes all relevant dimensions of what is being measured?  Criterion validity  Concurrent validity - Does the scale produce the same result as a “gold standard?”  Predictive validity - Does scale predict future health status?  Construct validity  Discriminant validity - Do the results differ from measures of a different type of deficit?  Convergent validity - Is the scale responsive to change?

Stroke Scales Levels of Outcome Measurement Quality of life Participation Dimension Activities Dimension Body Dimension NIH Stroke Scale Canadian Stroke Scale European Stroke Scale Scandinavian Stroke Scale

Stroke Impairment Scales Reliability and Validity ScaleReliabilityValidity NIH++ Canadian NS++ European++ Scandinavian++ UFNSS+ND Copenhagen+ND Mathews+/-+ Toronto+/-+

Stroke Scales Levels of Outcome Measurement Quality of life Participation Dimension Activities Dimension Body Dimension Barthel Index Katz Kenny Functional Independence Measure IADL NIH Stroke Scale Canadian Stroke Scale European Stroke Scale Scandinavian Stroke Scale

Stroke ADL Scales DomainBIKatzKennyFIM Dressing++++ Gait++++ Bathing++++ Feeding++++ Transfer++++ Grooming+-++ Toileting++++ Wheelchair+-++ Continence++-+ Travel--++ Communic.---- Cognition---- Socialization----

Instrumental ADL Application to Stroke  No consensus for a clear definition of IADL  Measure ability to live independently in the home  Bridge delineation between disability and handicap  Core activities  Domestic chores  Household management  Outdoor activities  Transportation Chong Stroke 1995; 26: 1119

IADL Scales for Stroke Evidence for Reliability and Validity Chong Stroke 1995; 26: 1119 RivermeadHamrinFrencha y Nottingham Reliability IntraraterAbsent InterraterPresent Absent RetestWeakAbsent Present SensitivityAbsentPresentWeakAbsent Validity ConstructWeakAbsentWeakPresent ContentAbsent ConcurrentAbsent PredictiveAbsent

Stroke Scales Levels of Outcome Measurement Quality of life Participation Dimension Activities Dimension Body Dimension Rankin Index Glasgow Outcomes Scale Barthel Index Katz Kenny Functional Independence Measure IADL NIH Stroke Scale Canadian Stroke Scale European Stroke Scale Scandinavian Stroke Scale

Modified Rankin Score GradeDescription 1No significant disability 2Slight disability; unable to carry out some previous activities, but able to look after own affairs without assistance 3Moderate disability; requiring some help but able to walk without assistance 4Moderately severe disability; unable to walk and attend to own bodily needs without assistance 5Severe disability; bedridden requiring constant nursing care 6Dead

Stroke Scales Levels of Outcome Measurement Quality of life Participation Dimension Activities Dimension Body Dimension SF-36 Sickness Impact Profile Stroke Impact Scale Rankin Index Glasgow Outcomes Scale Barthel Index Katz Kenny Functional Independence Measure IADL NIH Stroke Scale Canadian Stroke Scale European Stroke Scale Scandinavian Stroke Scale

Quality Adjusted Life Years QALYS  Outcome of clinical trial  Assign QOL weights  Calculate QALY  Assumes QOL rating independent of time in that state  Implies 2 QALYs is twice as good as 1 QALY  1 person gaining 10 QALYs = 10 persons gaining 1 QALY  Estimate of costs for that state used for cost- effectiveness analysis

Stroke Scales Levels of Outcome Measurement Quality of life Participation Dimension Activities Dimension Body Dimension SF-36 Sickness Impact Profile Stroke Impact Scale Rankin Index Glasgow Outcomes Scale Barthel Index Katz Kenny Functional Independence Measure IADL NIH Stroke Scale Canadian Stroke Scale European Stroke Scale Scandinavian Stroke Scale

Effect of Comorbid Conditions Goldstein et al Stroke 2004; 35: 1941

Competing Events Cumulative Recurrence Rates Petty et al. Neurology 1998; 50: % of Strokes are recurrent events 30% of Strokes are recurrent events

Causes of Death After Stroke Hankey et al. Stroke 2000; 31: 2080

Motor Recovery After Stroke Durham County Stroke Study Duncan et al. Stroke 1992; 23: 1084

Long-Term Outcomes after Stroke Severity Comorbidity Disease Body Dimension Participation Dimension Activities Dimension Severity Comorbidity Severity Comorbidity Motivation Depression Social Sup. Severity Comorbidity Severity Comorbidity Motivation Depression Social Sup. Motivation Depression Social Sup. Education Occupation Access TIME