The percentage of Americans surviving a stroke is at an all-time high. But experts caution that for those who survive, more effective strategies are needed to help them recover — and avoid another stroke.
The most helpful intervention may be one delivered at an inpatient rehabilitation facility, according to new research presented this week at the American Stroke Association’s 2015 International Stroke Conference in Nashville.
The new study, led by researchers at the Duke Clinical Research Institute, involved nearly 70,000 stroke patients. The investigators found patients lived longer and were less likely to be rehospitalized if they received rehabilitation at an inpatient facility that offered more hands-on care and greater physician and nursing oversight.
One year after rehab, 82 percent of patients who had received inpatient care were still alive compared with 61 percent who had received care at a nursing facility, after adjusting for risks such as age. There were also fewer rehospitalizations or deaths from any cause in the inpatient rehab group: about 54 percent compared with about 68 percent in the nursing facility group.
Pamela Duncan, Ph.D., P.T., a professor of neurology at Wake Forest Baptist Medical Center and an investigator on the Duke study, said better implementation of clinical guidelines and quality indicators for stroke care have transformed acute care practices in the United States, where stroke has dropped from the No. 3 cause of death to No. 5 within the past several years.
“We need to bring similar efforts and resources to transforming post-acute stroke care,” said Duncan, also an American Heart Association volunteer.
About 795,000 Americans suffer a stroke each year, and many have problems walking, speaking or doing everyday tasks like getting dressed due to lost movement in an arm and hand. But as more people survive strokes, knowing which rehabilitation therapies work best to help survivors regain their independence, reduce disability and lower the risk for another stroke has become increasingly important.
In another study presented at the conference, researchers found that supplementing stroke rehabilitation in the outpatient setting offered little benefit.
In the study, dubbed ICARE, investigators found that 30 hours of a treatment that included task-based motor therapy training — an approach that involved challenging real-world tasks like handwriting or carrying groceries — was no better than 30 hours or much fewer hours of usual occupational therapy.
One year later, the three groups of stroke survivors had about the same improvement in motor performance and hand function. However, the task-based therapy group more quickly improved their perceived strength and function and had a faster return to a more normal life.
“In the end, basically everybody got to the same point, everybody improved,” said Carolee Winstein, Ph.D., P.T., lead investigator of the ICARE study and director of the Motor Behavior and Neurorehabilitation Laboratory at the University of Southern California. “So the question is, do you want to get there in an accelerated way, or are you happy to get there in a year.”
Outpatient therapy is one of a patient’s various rehab options, all of which vary in intensity, stroke expertise and cost. Yet healthcare providers may not be aware of the available options, Duncan said, or patients may be limited to the programs available in their communities.
Duncan also noted that although Medicare, Medicaid and private insurers cover the costs of acute care to save the lives of stroke patients, there is tremendous variability in the coverage for rehab.
For many patients, the cost of inpatient rehab is prohibitive, said Joel Stein, M.D., an AHA volunteer and chair of the department of rehabilitation and regenerative medicine at Columbia University’s College of Physicians and Surgeons in New York.
“Hospital-level rehabilitation care is the most effective, but expensive,” said Stein, who is also a co-investigator on the Duke study. That means many stroke survivors receive care in less costly skilled nursing facilities, he said.
Medicare’s cost for treating stroke patients in a skilled nursing facility for about five weeks averages about $11,000, according to an evaluation by RTI International. For patients treated at an inpatient rehab facility, Medicare spends about $16,000 for two weeks of care.
But the solution is not more inpatient rehabilitation facilities, Duncan said.
“If skilled nursing facilities are going to provide this level of care, then we need to set standards for processes of care in these places, just as we did in acute care, to guarantee the same high level of post-acute care at lower costs,” said Duncan.
She said providers and payers must also understand that successful rehabilitation includes more than just recovery of motor skills and activities of daily living.
“We can save their lives, but what’s the downstream outcome in terms of function beyond the acute hospital stay — their quality of life and their ability to self-manage their health and risk factors,” Duncan said. “Not until we get serious about those outcomes can we reform post-acute stroke care.”
Research like the rehabilitation studies presented at this week’s stroke conference are starting to create a body of evidence that can inform clinical guidelines for the long-term care of stroke patients, said Stein.
“We need to clarify which interventions are most effective and impact outcomes, and organize our care system to make these interventions more accessible,” Stein said. “That’s the current challenge.”