Predictors of physical independence at discharge after stroke rehabilitation in a Dutch population.

The aim of this study was to identify predictors, available at admission, of physical independence at discharge from inpatient rehabilitation. Secondary aims were to identify predictors of functional gain and length of stay (LOS). We included 1310 adult stroke patients who were admitted for inpatient rehabilitation in five Dutch rehabilitation centres. Data on the Utrecht Scale for Evaluation of Clinical Rehabilitation at admission and discharge (physical and cognitive independence, mood, pain and fatigue), age, sex and in a subsample stroke characteristics as well were collected. A prediction model was created using random coefficient analysis. None of the stroke characteristics were independently associated with physical independence or functional gain at discharge, or LOS. Higher physical and cognitive independence scores and severe pain at admission were predictors of higher physical independence scores at discharge. Furthermore, lower physical independence scores, higher cognitive independence scores, less pain at admission and younger age predicted more functional gain. Finally, lower physical and cognitive independence scores at admission and younger age predicted longer LOS. Physical independence at admission was the most robust predictor for rehabilitation outcome in a Dutch rehabilitation setting. To a lesser extent, age, cognitive independence and pain predicted rehabilitation outcome after stroke. Treatment of cognition and pain should be taken into account during rehabilitation. Further work needs to be carried out to establish whether focusing on these factors improves outcome after rehabilitation.

Quality of Life during the First Two Years Post Stroke: The Restore4Stroke Cohort Study.

BACKGROUND: Little information is available about the course of quality of life (QoL) post stroke and how dependency on activities of daily living (ADL) influences this course. The aim of this study was therefore to describe the course of QoL from 2 months up to 2 years post stroke and to study the influence of ADL dependency in the first week post stroke. METHODS: This is a multicenter prospective longitudinal cohort study in which 368 stroke patients were included and data were collected at 1 week, 2 months, 6 months, 12 months and 24 months post stroke. QoL assessment included measures of health-related quality of life (HRQoL) (short stroke-specific Quality of Life Scale), emotional functioning (Hospital Anxiety and Depression Scale), participation (Utrecht Scale for Evaluation of Rehabilitation-Participation), and life satisfaction (2LS). Dependency on ADL was defined as having a Barthel Index score ≤ 17 four days post stroke. Generalized Estimating Equations analyses were performed to examine the course of the 4 domains of QoL. Furthermore, the possible confounding effect of age, gender, marital status, level of education and discharge destination was examined. RESULTS: Results showed that HRQoL, participation and life satisfaction improved during the first year post stroke, with most changes occurring in the first 6 months. Furthermore, patients dependent in ADL scored consistently lower on all 4 QoL domains and test occasions compared to ADL-independent patients. In both patient groups separately, no changes over time were found in emotional functioning. ADL-independent patients improved in HRQoL (p = 0.002), participation (p < 0.001) and life satisfaction (p = 0.020) between 2 and 6 months and in life satisfaction (p = 0.003) between 6 and 12 months also. ADL-dependent patients improved in HRQoL (p = 0.009) between 2 and 6 months and in participation between 2 and 6 months (p = 0.001) and between 6 and 12 months (p = 0.031). Furthermore, they experienced no changes in life satisfaction. No confounding effect was found after adding age, gender, marital status, level of education and discharge destination. CONCLUSIONS: Most improvement in QoL occurred up to 6 months post stroke and showed different patterns for specific domains of QoL and for patients with and without dependency in ADL in the first week post stroke. It is therefore important to differentiate between these different domains of QoL when the long-term perspective is considered. Furthermore, patients dependent in ADL consistently scored lower on all QoL domains and did not reach the level of QoL of patients independent of QoL.

Toward defining a cutoff score for elevated fear of hypoglycemia on the hypoglycemia fear survey worry subscale in patients with type 2 diabetes.

OBJECTIVE To determine a cutoff score for clinically meaningful fear of hypoglycemia (FoH) on the Hypoglycemia Fear Survey Worry subscale (HFS-W). RESEARCH DESIGN AND METHODS Data on the HFS-W, history of hypoglycemia, emotional well-being (World Health Organization-5 well-being index), and distress about diabetes symptoms (Diabetes Symptom Checklist-Revised) were available from Dutch patients with type 2 diabetes who were treated with oral medication or insulin (n = 1,530). Four criteria were applied to define a threshold for clinically meaningful FoH: 1) modal score distribution (MD criterion), 2) scores 2 SDs above the mean (SD criterion), 3) concurrent validity with severe hypoglycemia and suboptimal well-being (CV criterion), and 4) an elevated score (≥3) on more than one HFS-W item (elevated item endorsement [EI criterion]). Associations between the outcomes of these approaches and a history of severe hypoglycemia and suboptimal well-being were studied. RESULTS Of the 1,530 patients, 19% had a HFS-W score of 0 (MD criterion), and 5% reported elevated FoH (HFS-W ≥ mean + 2 SD; SD criterion). Patients with severe hypoglycemia reported higher HFS-W scores than those without (25 ± 20 vs. 15 ± 17; P < 0.001). Patients with suboptimal well-being reported higher HFS-W scores than those with satisfactory well-being (20 ± 18 vs. 13 ± 15; P < 0.001, CV criterion). Elevated FoH (defined by the EI criterion) was seen in 26% of patients. The SD and EI criteria were the strongest associated with history of severe hypoglycemia. The EI criterion was the strongest associated with suboptimal well-being. CONCLUSIONS Although no definite cutoff score has been determined, the EI criterion may be most indicative of clinically relevant FoH in this exploratory study. Further testing of the clinical relevance of this criterion is needed.

A new approach to analyse longitudinal epidemiological data with an excess of zeros.

BACKGROUND: Within longitudinal epidemiological research, 'count' outcome variables with an excess of zeros frequently occur. Although these outcomes are frequently analysed with a linear mixed model, or a Poisson mixed model, a two-part mixed model would be better in analysing outcome variables with an excess of zeros. Therefore, objective of this paper was to introduce the relatively 'new' method of two-part joint regression modelling in longitudinal data analysis for outcome variables with an excess of zeros, and to compare the performance of this method to current approaches. METHODS: Within an observational longitudinal dataset, we compared three techniques; two 'standard' approaches (a linear mixed model, and a Poisson mixed model), and a two-part joint mixed model (a binomial/Poisson mixed distribution model), including random intercepts and random slopes. Model fit indicators, and differences between predicted and observed values were used for comparisons. The analyses were performed with STATA using the GLLAMM procedure. RESULTS: Regarding the random intercept models, the two-part joint mixed model (binomial/Poisson) performed best. Adding random slopes for time to the models changed the sign of the regression coefficient for both the Poisson mixed model and the two-part joint mixed model (binomial/Poisson) and resulted into a much better fit. CONCLUSION: This paper showed that a two-part joint mixed model is a more appropriate method to analyse longitudinal data with an excess of zeros compared to a linear mixed model and a Poisson mixed model. However, in a model with random slopes for time a Poisson mixed model also performed remarkably well.

Are patients with type 2 diabetes reluctant to start insulin therapy? An examination of the scope and underpinnings of psychological insulin resistance in a large, international population.

OBJECTIVE: To examine the scope and underpinnings of psychological insulin resistance (PIR) across eight Western nations, with special attention to the potential influence of beliefs about insulin and broader patient beliefs regarding medications and diabetes. METHODS: A total of 1400 subjects with insulin-naïve, type 2 diabetes across eight nations completed an online survey. The survey assessed willingness to start insulin, beliefs about insulin and current medications, and diabetes-related emotional distress. RESULTS: The majority of respondents were male (59.3%), mean age was 51.6 years and mean diabetes duration was 6.1 years. A total of 17.2% reported they would be unwilling to start insulin (the PIR group), while 34.7% were ambivalent and 48.1% indicated they would be willing to do so. Marked differences by country were apparent, with PIR ranging from 5.9% (Spain) to 37.3% (Italy). Both unwilling and ambivalent patients reported significantly more negative (p < 0.001; p < 0.05) and fewer positive beliefs (p < 0.001; p < 0.01) about starting insulin, more negative feelings about their current medications (p < 0.01, p < 0.001), and more diabetes-related distress (p < 0.001; p < 0.05) than willing patients. Unwilling patients also reported significantly more negative (p < 0.05) and fewer positive beliefs (p < 0.001) about starting insulin than ambivalent patients. CONCLUSION: These are the first data demonstrating the prevalence of PIR across Western nations. PIR is strongly linked to positive and negative insulin beliefs, and may also reflect a broader discomfort with medications and with diabetes in general. Of note, however, PIR is a marker of behavioral intent only; it is not known whether this predicts actual behavior at the time when insulin is prescribed. When addressing patients who are reluctant to initiate insulin therapy, clinicians may find it valuable to inquire about their beliefs about insulin and their current medications.

Do physicians understand Type 2 diabetes patients' perceptions of seriousness; the emotional impact and needs for care improvement? A cross-national survey.

OBJECTIVE: To explore across countries the extent to which physicians understand Type 2 diabetes patients' perceptions of seriousness, worries about complications, emotional distress, and needs for care improvement. METHODS: Cross-sectional data were collected in a multinational survey (SHARED). Type 2 diabetes patients (n=1609), general practitioners (n=818) and diabetes specialists (n=697) from eight countries were included. Data were gathered online and via telephone interviews. Responses from patients and professionals were compared using descriptive statistics and multilevel analyses. RESULTS: Patients generally perceived diabetes as a serious condition and reported moderate distress. Physicians tended to underestimate patients' perceived seriousness, while overestimating their level of distress. Physicians had difficulty estimating which diabetes complications concerned patients most, and what they needed to feel more confident about their diabetes. Patients did not wish for more consultation time, but rather active involvement, information and easy access to their physician. CONCLUSION: Results of this large survey highlight the importance of patient involvement and shared decision making. PRACTICE IMPLICATIONS: Further improvement of patient-provider communication as a basis for shared responsibilities and achieving optimal treatment outcomes is needed. With the growing numbers of diabetes patients worldwide, task delegation should be considered, in the framework of a multidisciplinary diabetes care model.