Use of Time by Stroke Patients
A Comparison of Four European Rehabilitation Centers
Background and Purpose— Differences exist between European countries in the proportion of patients who die or become dependent after stroke. The aim of the present study was to identify differences in the use of time by stroke patients in 4 rehabilitation centers in 4 European countries.
Methods— In each of the 4 centers, 60 randomly selected stroke patients were observed at 10-minute intervals using behavioral mapping. Observations took place on 30 weekdays selected at random, on equal numbers of morning, afternoon, and evening sessions. A logistic generalized estimating equation model with correction for differences in case mix and multiple testing was used for the analysis.
Results— Overall time available from different professions was the highest in the United Kingdom, but patients in the United Kingdom spent on average only 1 hour per day in therapy. This was significantly less than patients in Belgium and Germany, who spent ∼2 hours, and patients in Switzerland who spent ∼3 hours per day in therapy. In all centers, patients spent less than half their time in interactions and >72% of the time in nontherapeutic activities.
Conclusions— Important differences in the use of time were established, which appeared dependent on management decisions rather than the number of staff available. Patients in the Swiss and German centers spent more time in therapy, possibly because of the structured organization of rehabilitation. Further studies will verify whether this has an effect on outcome.
There is wide variation between European countries in the proportion of patients who die or become dependent within the first 6 months after stroke.1,2 Outcomes in the United Kingdom appear to be consistently worse than the rest of Europe.1,2
Beech et al3 found significant differences in length of stay and percentage of stroke patients receiving brain imaging and neurosurgery on admission. Also, the extent of rehabilitation varied significantly between European countries: the percentage of patients with an identified need who actually received therapy ranged from 44% to 90% for physiotherapy, 0% to 65% for occupational therapy, and 0% to 60% for speech therapy.3 Significant differences also existed in the amount of therapy stroke patients received. Two American studies found that patients spent 21% to 31% of the working day in therapeutic activities.4,5 In the United Kingdom, patients were engaged in therapy for <15% of the working day.6,7 Another study showed that Swiss stroke patients spent 45% of the working day in therapy, whereas Belgian patients spent 28%.8
These studies suggest large geographical variation in the amount of therapy stroke patients receive in rehabilitation centers. This is important because evidence suggests that more intensive rehabilitation produces a better functional outcome.9 Studies comparing the use of time by patients in rehabilitation centers in European countries are lacking.
The aim of the present study was to compare the way stroke patients spent their time while in a rehabilitation center in 4 European countries.
Subjects and Settings
The study was conducted in the following rehabilitation centers: University Hospital, Leuven, Belgium; City Hospital and Queens Medical Centre, Nottingham, UK; RehaClinic, Zurzach, Switzerland, and Fachklinik, Herzogenaurach, Germany. The centers were typical of established stroke rehabilitation services in each country.
Sixty stroke patients were monitored in each center. The inclusion criteria were: (1) first-ever stroke as defined by World Health Organization (WHO),10; (2) 40 to 85 years of age; and (3) score on Gross Motor Function of Rivermead Motor Assessment (RMA-GF)11 ≤11, score on leg and trunk function ≤8, or score on arm function ≤12 on admission to the rehabilitation center. The exclusion criteria were: (1) other neurological impairments with permanent damage; (2) stroke-like symptoms attributable to subdural hematoma, tumor, encephalitis, or trauma; (3) prestroke Barthel Index (BI)12 <50; (4) admitted to the rehabilitation center >6 weeks after stroke; and (5) no informed consent. The study was approved by the ethics committee for each center.
On admission, stroke severity was assessed with the National Institute of Health Stroke Scale (NIHSS),13 RMA-GF,11 and Barthel Index.12 Behavioral mapping was used to document patients’ activity, location, and interaction. Observations were made on 30 randomly selected days, equally distributed over the 5 weekdays to cover regular activities. Observations took place in 3 5-hour sessions: from 7 am until 12 pm, 12 pm until 5 pm, and 5 pm until 10 pm. Ten morning, 10 afternoon, and 10 evening sessions were conducted in each center. For each session, 2 patients were randomly selected and observed at intervals of 10 minutes. One of the 2 patients was observed every 5 minutes. In each center, there were 1800 observations.
The researchers were trained in the observation technique, and a manual was provided to ensure standardization. The project manager (L.D.W.) visited all centers 4× to recalibrate the researchers’ work. Rehabilitation staff were informed about the nature of the study but were not given advanced warning when the observations would take place.
The average time available per patient per week was calculated for each professional group in each center using the formula: number of full-time equivalent staff×working hours per week/number of beds.
The observation methods used were based on 2 previous studies.5,8 De Weerdt et al8 verified the interobserver agreement of the 3 categories used in this study. Cohen’s κ was high for: (1) activities (κ=0.967); (2) locations (κ=0.986); and (3) interactions (κ=0.958). On the basis of direct observation, the category “activities” was scored into 9 therapeutic or 8 nontherapeutic subcategories. Location and interaction were scored in 8 and 7 subcategories, respectively (see Table 3).
The characteristics of patients were compared between centers using χ2, ANOVA, or a Kruskal–Wallis test, as appropriate. Frequencies of observations were calculated to determine the use of time by stroke patients in the centers. The total therapy time in the evening sessions was minimal (8.5 minutes average, of which 60% was nursing care). Therefore, the statistical analysis was based on the observations between 7 am and 5 pm.
The consecutive observations on patients were dependent. Therefore, the probability of therapy was modeled by fitting a logistic generalized estimating equation (GEE)14 model accounting for the serial dependency and controlling for confounders and effect modifiers. Confounders are variables having a significant influence on the amount of therapy patients receive. Effect modifiers are confounders with a significant but different influence in each center. Stroke severity, time in the center, age, and time of observation (morning or afternoon) were investigated as confounders and effect modifiers. Stroke severity was based on the RMA-GF,11 the BI,12 and the NIHSS13 on admission to the rehabilitation center. The influence of stroke severity and time in the center was explored because both determine the amount of therapy a patient receives.15,16 The influence of age was assessed because this differed between centers. The influence of the time of observation was evaluated to determine whether morning and afternoon observations could be combined.
The GEE model compared the centers on the probability of time use for each activity, location, and interaction. Some categories needed regrouping because they contained too few observations for statistical analysis. The Bonferroni–Holm correction17 was used to correct for multiple testing for pair-wise differences between the centers. The level of significance was 0.05. All statistical analyses were performed using SAS version 8.2.
Patients in the UK and Swiss centers were significantly older compared with those in Belgium and Germany (Table 1). Patients in the Swiss and German centers had less severe strokes compared with the other 2 centers. No significant differences were found for gender or time between admission and day of observation.
Taking into account the staffing levels and number of working hours per week, most time per patient was available for physiotherapy, occupational therapy, speech therapy, and neuropsychological training in Switzerland (Table 2). The United Kingdom had the most overall time available and the most time for medical and especially nursing care. Most time for “other therapy” was available in Germany.
Confounders and Effect Modifiers
Significant confounders were the RMA-GF squared score, BI score, and age. Consequently, they were included in the model. Age was also an effect modifier, but this effect occurred mainly in age groups containing very few patients and was very small in the other age groups. Therefore, age was not included as an effect modifier.
Comparison Between Centers
Time in Therapeutic and Nontherapeutic Activities Between 7 am and 5 pm
Table 3 shows percentage time, and the Figure (a and b) shows absolute time. The time spent in therapeutic and nontherapeutic activities differed between the centers. Patients in Switzerland spent more time in therapy (2 hours and 46 minutes) compared with those in Germany (2 hours and 20 minutes), Belgium (1 hour and 59 minutes), or the United Kingdom (1 hour and 0 minutes). In all centers, physiotherapy comprised ∼40% of therapeutic time. Except for the United Kingdom, the second most frequent therapy was occupational therapy. More than 35% of therapy time in the United Kingdom consisted of nursing care, compared with 10% in Belgium and ∼5% in Switzerland and Germany. In Germany, ∼10% of therapy time was spent in neuropsychological training; this was 6.3% in Belgium, 3.6% in Switzerland, and was never observed in the United Kingdom. In Switzerland and Germany, ∼6% of therapy time consisted of medical care, which was more than in Belgium (0.8%) or the United Kingdom (2.5%). Speech therapy, sports-related activities, and autonomous exercising accounted for little therapy time in all centers.
Much time was spent sitting, lying, or sleeping. In Belgium and the United Kingdom, patients spent >2 hours per day lying or sleeping. This was more than in Switzerland (1 hour and 26 minutes) or Germany (49 minutes). Leisure and communication were also common nontherapeutic activities. Eating and dressing/hygiene took ∼17% of nontherapeutic time. UK patients spent the least time moving or being transported from place to place (11.5 minutes). Compared with the other centers, patients in Germany spent more time in leisure activities.
After adjusting for confounders and correcting for multiple testing (Table 4), patients in the United Kingdom were significantly less likely to be in therapy than patients in Germany, Belgium, or Switzerland. Patients in the United Kingdom were significantly less likely to receive occupational therapy compared with Switzerland and other therapy compared with Germany. For nontherapeutic activities, the only significant differences were found for transport: patients in United Kingdom were significantly less likely to be transported from place to place compared with the other 3 centers.
Time in Locations Between 7 am and 5 pm
Table 3 shows percentage time and the Figure (c) shows absolute time. Large differences emerged between centers in the time spent in patients’ and therapy room. Patients in the United Kingdom spent most time in their rooms (69%) and the least time in the therapy room (6%). Patients in the Swiss center spent 34% of the time in their rooms and 20% of the time in the therapy room.
After adjusting for confounders and correcting for multiple testing (Table 4), patients in the United Kingdom were significantly more likely to be in their rooms and less likely to be in the therapy room compared with Germany or Switzerland. Also, patients in Germany and Belgium were significantly more likely to be in their rooms than those in Switzerland. Patients in Germany, Belgium, and Switzerland spent significantly more time in the corridor than patients in the United Kingdom. Patients in Germany spent significantly less time in the dining/day room compared with patients in Belgium or Switzerland. Patients in Belgium spent significantly less time in the toilet/bathroom than patients in the United Kingdom or Switzerland.
Time in Interactions Between 7 am and 5 pm
Table 3 shows percentage time, and the Figure (d) shows absolute time. Patients were not involved in any interaction for more than half of their time. In the United Kingdom, patients were not interacting at all for 65% of the time. Interaction occurred most often with therapists in Belgium and Switzerland (14.3% and 21.6%, respectively), with nurses (11.3%) in the United Kingdom, and with other patients (13.3%) and therapists (13.0%) in Germany. Interaction with visitors was most often observed in the United Kingdom (10.2%). The remaining categories were <10%.
After adjusting for confounders and correcting for multiple testing (Table 4), patients in the United Kingdom spent significantly more time alone compared with patients in Switzerland and interacted less with other patients compared with patients in Germany. Patients in Switzerland spent significantly more time with professionals than those in the other centers.
The present study compared the activity patterns of stroke patients between 4 European centers. In previous studies, except Pound et al,18 only 1 or 2 centers were documented, and observations were treated as if they were independent. Also, the influence of case mix was not considered.6–8 There was statistical correction for both in this study.
The main significant finding was the large difference in the amount of time spent in therapy. This ranged from 1 hour per day in the United Kingdom to ∼3 hours in Switzerland. The UK results are consistent with previous work.6 The lack of therapy in the United Kingdom is in contrast to the time available from all professional groups. A possible explanation is the division of tasks. Participant observations (K.P.) indicate that professionals in the UK center spent more time in legally required administration, leaving less time for patient care. Taking into consideration the health economic conditions, the German center used the human resources most efficiently to provide therapy time.
In all 4 centers, physiotherapy and occupational therapy together accounted for more than half the total therapy time, in line with a previous study.8 Compared with the other centers, patients in the United Kingdom spent less time in occupational therapy but received more nursing. This may be explained by the high availability of nurses, which is in line with a previous UK study.19 Also in the United Kingdom, patients were in bays with 4 to 6 beds with open curtains. Therefore, nurses were more likely to offer help than in centers where the patients were in single rooms. In the United Kingdom, patients were less involved in other therapies compared with the other countries. In the German and Swiss centers, massage and electrotherapy were offered by professional groups that did not exist in Belgium or the United Kingdom. Consistent with a previous study,8 sports-related activities and autonomous exercising were rarely observed. These findings suggest that there is a potential for self-directed remedial therapy.
In line with previous European studies,6–8 sitting and lying or sleeping accounted for between a third and half the day. Patients in United Kingdom and Belgium were lying down or sleeping >2 hours per day. This raises the question whether spending such a long time inactive is of benefit to patients’ recovery.
Patients were not involved in any social interaction for more than half the time. Despite the open access setting, patients in the United Kingdom interacted only 11 minutes per day with other patients. In Germany, patients interacted >1 hour per day. This may be because of the transport service, infrastructure, and type of therapy. Patients in Germany are transported from 1 location to another on a strict schedule. Several patients spent time talking while waiting for therapy. From participant observations (K.P.), we noticed that if there was a table in a patient’s room, other patients tended to sit and interact at that table. Also, group therapy stimulated interaction.
In summary, patients in Belgium and the United Kingdom spent more time in passive behavior, in their rooms, and without any interaction compared with patients in Germany and Switzerland. The latter centers had a more structured rehabilitation program. This may have resulted in more therapy time and a more challenging environment for the patients, physically and mentally.
There are some limitations to the study. Because only 1 center in each country participated, generalization of results to the country may not be justified. The presence of the observer may have affected the behaviors under observation. Severity of stroke was based on assessment on admission and not at the time of observation. However, the number of days between admission and observation were not significantly different between centers. Therefore, it is likely that the differences in case mix will be comparable between admission and observation. Also, staffing levels were recorded retrospectively on the basis of overall figures.
This study revealed that in the participating centers, stroke patients spent a large amount of the day in their rooms, inactive, and without any interaction. The evidence that more intensive rehabilitation improves outcome after stroke9 is not reflected in the rehabilitation practice observed. Providing therapy time seems to be more dependent on the management style than on the number of staff available. Further studies are under way to examine the effect of this on recovery.
This study was performed with financial support from “Bondesambt für Bildung und Wissenschaft” (C.H.) and from the Commission of the European Communities, specific RTD programme, “Quality of Life and Management of Living Resources,” QLK6-CT-2001-00170, Collaborative Evaluation of Rehabilitation in Stroke across Europe (CERISE). It does not necessarily reflect its views and in no way anticipates the future policy of the commission in this area.
- Received March 31, 2005.
- Revision received May 23, 2005.
- Accepted June 13, 2005.
Weir NU, Sandercock PAG, Lewis SC, Signorini DF, Warlow CP; on behalf of the IST Collaborative Group. Variations between countries in outcome after stroke in the International Stroke Trial (IST). Stroke. 2001; 32: 1370–1377.
Wolfe CDA, Tilling K, Beech R, Rudd AG; for the European BIOMED Study of Stroke Care Group. Variations in case fatality and dependency from stroke in Western and Central Europe. Stroke. 1999; 30: 350–356.
Beech R, Ratcliffe M, Tilling K, Wolfe CDA; on behalf of the participants of the European Study of Stroke Care. Hospital services for stroke care. A European perspective. Stroke. 1996; 27: 1958–1964.
Keith RA. Activity patterns of a stroke rehabilitation unit. Soc Sci Med. 1980; 14A: 575–580.
Newall JT, Wood VA, Hewer RL, Tinson DJ. Development of a neurological rehabilitation environment: an observational study. Clin Rehabil. 1997; 11: 146–155.
Lincoln NB, Willis D, Philips SA, Juby LC, Berman P. Comparison of rehabilitation practice on hospital wards for stroke patients. Stroke. 1997; 28: 543–549.
Kwakkel G, van Peppen R, Wagenaar RC, Dauphinee SW, Richards C, Ashburn A, Miller K, Lincoln N, Partridge C, Wellwood I, Langhorne P. Effects of augmented exercise therapy time after stroke. A meta-analysis. Stroke. 2004; 35: 2529–2536.
Lincoln N, Leadbitter D. Assessment of motor function in stroke patients. Physiotherapy. 1979; 62: 48–51.
Brott T, Adams HP, Olinger CP, Marler JR, Barsan WG, Biller J, Spilker J, Holleran R, Eberle R, Hertzberg V, Rorick M, Moomaw CJ, Walker M. Measurements of acute cerebral infarction: a clinical examination scale. Stroke. 1989; 20: 864–870.
Liang KY, Zeger SL. Longitudinal data analysis using generalized linear models. Biometrika. 1986; 73: 13–22.
Holm S. A simple sequentially rejective Bonferroni test procedure. Scand J Stat. 1979; 6: 65–70.
Pound P, Sabin C, Ebrahim S. Observing the process of care: a stroke unit, elderly care unit and general medical ward compared. Age Ageing. 1999; 28: 433–440.
Langhorne P, Pollock A; in conjunction with the Stroke Unit Trialists’ Collaboration. What are the components of effective stroke care? Age Ageing. 2002; 31: 365–371.