No abstract

Relatively poor quality of care for patients with AMI was provided by rural hospitals where greater opportunity for improvement exists.

In order to measure disability in a randomised controlled trial of different intensities of rehabilitation following stroke, a modification of existing methods has been developed; it makes use of 17 items of activities of daily living (ADL) which are rated on a three-point scale, and it has been subjected to tests of repeatability and validity. While some activities (e.g. use of taps, ascending or descending stairs) are either redundant or repetitive, others provide independent measures of disability. There was no significant inter-observer variability; the assessors disagreed on 78 (3.7%) out of a total of 2,125 paired observations. In a study of short-term within-patient variability, different scores were assigned on 49 (14.4%) out of a total of 340 observations made on two separate occasions. Minor differences (mainly in activities involving equipment e.g. cookers) emerged when scores obtained in hospital were compared with those obtained at home, but the two sets of scores were still highly correlated (r = 0.962. There was, however, considerable discrepancy between the hospital scores and those derived from the patients' own estimates of their activities at home, the latter falling below actual capabilities as indicated by the hospital scores. A clinical validation of the index showed a significant association between the hospital ADL scores and the extent of cerebral lesions determined by the number of neurological deficits. This modified ADL index is sufficiently repeatable and valid for the assessment of patients with moderate disability as a result of stroke and other chronic diseases; in most circumstances, it can probably be simplified to include only five or six items.

Of 1094 patients with a confirmed stroke admitted to Northwick Park, a district general hospital, 364 (33%) died while in hospital, 215 (20%) were fully recovered when discharged, and 329 (30%) were too frail or too ill from diseases other than stroke to be considered for active rehabilitation. Only 121 (11%) were suitable for intensive treatment. They and 12 patients referred direct to outpatients were allocated at random to one of three different courses of rehabilitation. Intensive was compared with conventional rehabilitation and with a third regimen which included no routine rehabilitation, but under which patients were encouraged to continue with exercises taught while in hospital and were regularly seen at home by a health visitor. Progress at three months and 12 months was measured by an index of activities of daily living. Improvement was greatest in those receiving intensive treatment, intermediate in those receiving conventional treatment, and least in those receiving no routine treatment. Decreasing intensity of treatment was associated with a significant increase in the proportions of patients who deteriorated and in the extent to which they deteriorated.Probably only a few stroke patients, mostly men, are suitable for intensive outpatient rehabilitation, but for those patients the treatment is effective and realistic. IntroductionRemedial therapists spend much of their time' rehabilitating patients disabled by strokes, though this has not been convincingly shown to improve chances of recovery. If rehabilitation is ineffective therapists' efforts are wasted and patients inconvenienced. If, on the other hand, rehabilitation is effective more investment in it might be justified.Three randomised controlled trials2-4 on the effectiveness of rehabilitation after stroke have been inconclusive, possibly because of their small numbers. Garraway et a15 have recently shown that patients admitted to a special stroke unit fared better than those admitted to medical units, but their trial was concerned largely with the effects of inpatient management, and the advantage was not sustained on longer follow-up.6 This paper compares the effectiveness of three intensities of outpatient rehabilitation. Patients and methodsAll 1094 patients with a recent confirmed stroke who were admitted to Northwick Park Hospital from October 1972 to September 1978 were considered for the trial. Of these, 364 (33%) died while in hospital and 215 patients (20%) made a full recovery while in hospital, in terms not only of day-to-day activities but also of limb function and speech. The remaining 515 patients were considered for the trial. The main criterion for entry was that the patient should BRITISH MEDICAL JOURNAL VOLUME 282 be able to manage the most intensive of the three regimens, even if they were eventually allocated to one of the other regimens. A further 329 patients (30%) were excluded by this criterion: most of these were elderly patients, predominantly women, who were either too old or too frail for intensive reh...

Abstract-The 1994 to 1997 administrative data on 40 450 elderly Medicare beneficiaries and general population of 2 states were used to measure "case mortality" (deaths attributable to any cause among cases of acute stroke), "case fatality" (deaths caused by cerebrovascular diseases among cases of acute stroke), and "population mortality" (deaths caused by stroke in the elderly general population). Mortality was higher in men than in women according to all measures except population mortality caused by subarachnoid hemorrhage. There was no sex difference in 1-year case fatality. One-year all-cause mortality among cases of nonhemorrhagic stroke or all types of stroke was higher in men than in women. Similar sex differences were found in 4-year population mortality caused by nonhemorrhagic stroke or all types of stroke combined. The 3 measures differed with respect to sex difference in stroke mortality. How stroke is defined and how mortality is measured does affect sex difference. Key Words: measurement Ⅲ sex difference Ⅲ stroke mortality D isparity in the outcome of chronic diseases may be a useful indicator of an opportunity for improving preventive or therapeutic care. The natural history of stroke has been studied by many researchers who have found age, sex, and race differences in mortality.Some studies of stroke mortality did not find a significant sex difference 1-3 ; others found a relatively higher risk among men 4,5 or among women. 6 -8 Some of these investigations studied mortality associated with only 1 type of stroke. 5,7 Many investigations studied mortality from all types of stroke combined. Two of the 3 studies of sex difference in mortality caused by nonhemorrhagic stroke in the general population found increased risk among women, 6,8 whereas 2 of the 3 corresponding studies that measured case fatality rates among patients with acute stroke found increased risk among men. 4,5 There are many reasons for discrepancy between these studies with respect to the magnitude and the direction of sex difference in stroke mortality. This study addressed 2 factors-how stroke was defined and how mortality was measured-by estimating 3 different measures of sex-specific stroke mortality in the same geographically defined population during the same time period. The objective was to determine the effect of using different measures on sex difference in stroke mortality. Materials and MethodsThe measures of stroke mortality used in this study were (a) 1-year case mortality defined as deaths attributable to any cause among cases of acute stroke, (b) 1-year case fatality defined as deaths caused by cerebrovascular diseases among cases of acute stroke, and (c) 4-year population mortality defined as deaths caused by stroke in the general population in a 4-year period. The study cohort was 40 450 fee-for-service Medicare beneficiaries aged 65 to 99 years who were hospitalized in Indiana and Kentucky for acute stroke from January 1, 1994 to December 31, 1996. Medicare administrative data were used to identify the demograph...