Healthcare policy in the area of stroke: experiences of Tuscany

Francesco Benventi

Dipartimento Territorio-Fragilità

AUSL11 Empoli, Italy

Łódź 26-27 February 2013

Tu

scan

y

Str

oke i

n T

uscan

y

Chronic Stroke Epidemiology

Incidence: 190-220/100000

Survival:

1 year: 70-80%

5 years: 50%

10 years: >35%

Prevalence: 600-800/100000

Residual disability:

Severe: 30-40%

Moderate: 35-40%

Mild or none: 20-35%

Str

oke i

n T

uscan

y

Source

AUSL11, 2012

Str

oke i

n T

uscan

y Hospital admissions for stroke (DRG14)

0

100

200

300

400

500

600

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

years

nu

mb

er

Deaths after stroke

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2002 2003 2004 2005 2006 2007 2008 2009 2010

year

Stroke: Hospital

Critical clinical instability Yes

History severe dementia+disability

no

yes

No

Envirommental and social conditions

adequate

Not adequate

Home Integrated home care

Nursing home

Post stroke disability Mild/moderate Envirommental

and social conditions

adequate

Not adequate

Rehabilitation DH or outpatient clinic

Nursing Home or Residential extrahospital

rehabilitation

Severe

Intensive Hospital Rehabilitation

No

End If clinically unstable

End/FU

End

Residual disability No or mild

End

Moderate

Severe

Critical adverse clinical event

End/FU

End/FU

Stroke: Hospital

Critical clinical instability Yes

History severe dementia+disability

no

yes

No

Envirommental and social conditions

adequate

Not adequate

Home Integrated home care

Nursing home

Post stroke disability Mild/moderate Envirommental

and social conditions

adequate

Not adequate

Rehabilitation DH or outpatient clinic

Nursing Home or Residential extrahospital

rehabilitation

Severe

Intensive Hospital Rehabilitation

No

End If clinically unstable

End/FU

End

Residual disability No or mild

End

Moderate

Severe

Critical adverse clinical event

End/FU

End/FU

25%

32%

28% 15%

Sharing information

Galileo Hospital Lab Radiology Hospital specialists outpatient clinics

Patidok Community rehabilitation

Millewin GP records

Aster Home care Nursing homes

Clin

ical P

ath

ways

Acute Hospital are

Rehab Nursing Home

Hospital rehabilitation

Community rehabilitation

Home care

Day Hospital

Nursing Home

Clin

ical P

ath

ways

Chronic Stroke Epidemiology

Incidence: 220/100000

Survival:

1 year: 70-80%

5 years: 50%

10 years: >35%

Prevalence: 600-800/100000

Residual disability:

Severe: 30-40%

Moderate: 35-40%

Mild or none: 20-35%

Str

oke i

n T

uscan

y

Stroke: Hospital

Critical clinical instability Yes

History severe dementia+disability

no

yes

No

Envirommental and social conditions

adequate

Not adequate

Home Integrated home care

Nursing home

Post stroke disability Mild/moderate Envirommental

and social conditions

adequate

Not adequate

Rehabilitation DH or outpatient clinic

Nursing Home or Residential extrahospital

rehabilitation

Severe

Intensive Hospital Rehabilitation

No

End If clinically unstable

End/FU

End

Residual disability No or mild

End

Moderate

Severe

Critical adverse clinical event

End/FU

End/FU

Acute Hospital Care

Rehab Nursing Home

Hospital rehabilitation

Community rehabilitation

Home care

APA

Upper limb care

CLEAR

Day Hospital

Nursing Home

Clin

ical P

ath

ways

UO

C C

UR

A E

RIA

BIL

ITA

ZIO

NE

DE

LL

E F

RA

GIL

ITA

’

UO

S R

IAB

ILIT

AZ

ION

E T

ER

RIT

OR

IAL

E

Dir

ecto

r D

r. A

nto

nio

Tavia

ni

PA

TH

WA

Y F

OR

CH

RO

NIC

SP

AS

TIC

SY

ND

RO

ME

S

REHABILITATION

PLATEAU

IMPAIRMENTS

CORRECTABLE?

HOSPITAL

REHABILITATION

COMMUNITY

REHABILITATION

REHABILITATION

NURSING HOME

EXTRAHOSPITAL

SEMI-RESIDENTIAL

REHABILITATION

YES

NO

END

NO

YES

END

AFA+CLEAR

FOLLOW

UP

APAs

Physical activity programs, carried out in group, adapted to chronic alterations of functional status

for tertiary prevention of disability

Disease or Syndrome

Primary Prevention

Tertiary Prevention

Cancer (breast, colon, prostate) Yes No

Coronary artery disease Yes Yes

Chronic obstructive pulmonary disease No Yes

Dementia (different from multiinfarct dementia) No No

Depression Yes Yes

Diabetes type 2 Yes Yes

Mobility impairment, falls Yes Yes

Chronic renal failure Yes Yes

Peripheral vascular disease Yes Yes

Hypertension Yes Yes

Back pain No Yes

Congestive hearth failure No Yes

Obesity Yes Yes

Arthritis No Yes

Osteoporosis Yes Yes

Parkinson’s dis., CNS degenerative disorders No Yes

Stroke Yes Yes

Venous stasis disease Yes Yes

Fiatarone Singh MA, J Gerontol Med Sci 57A, M262-82, 2002

Ad

ap

ted

Ph

ysic

al A

cti

vit

y

Impairments

Functional limitations

Disability

Sedentary life style

Depression,

lack of vocational pursuits,

higher family and social

support, etc.

Sarcopenia, altered joint

flexibility, cardiovascular

deconditioning,

osteoporosis, etc.

Worse gait, endurance,

balance, manual dexterity,

etc.

Decrements of AADLs,

IADLs, BADLs…

Ad

ap

ted

Ph

ysic

al A

cti

vit

y

Sedentary life style

Impairments

Functional limitations

Disability

\

Moderate Disability

Severe Disability

Mild Disability

Ad

ap

ted

Ph

ysic

al A

cti

vit

y

Impairments

Functional limitations

Disability

Active life-style

Better integration in the

community, lower family and

social support,

Preservation of vocational

pursuits, QoL, etc.

Better muscle and joint

function, endurance,

increased BMD, etc. Easier focused

interventions for

improving gait, balance,

manual dexterity, etc.

Less disability for

AADLs, IADLs, BADLs…

Ad

ap

ted

Ph

ysic

al A

cti

vit

y

Life Style

Fre

quency

Health Low High

Low

High

Ph

ysic

al

acti

vit

i fo

r re

cre

ati

oal

or

healt

h p

urp

oses

LR 35/03

No

t to

p p

erf

orm

an

ce

ag

on

isti

c

sp

ort

acti

vit

y

To

p p

erf

orm

an

ce

sp

ort

acti

vit

y

Exercise opportunity A

dap

ted

Ph

ysic

al A

cti

vit

y

Life Style

Fre

quency

Health Low High

Low

High

Hig

h d

isa

bilit

y A

PA

Ph

ysic

al

acti

vit

i fo

r re

cre

ati

oal

or

healt

h p

urp

oses

LR 35/03

DGR 595/05

DGR 459/09

No

t to

p p

erf

orm

an

ce

ag

on

isti

c

sp

ort

acti

vit

y

Lo

w d

isa

bil

ity A

PA

To

p p

erf

orm

an

ce

sp

ort

acti

vit

y

Exercise opportunity A

dap

ted

Ph

ysic

al A

cti

vit

y

2.20 €

per session

Ad

ap

ted

Ph

ysic

al A

cti

vit

y

( ) + = 2.20 €

Fucecchio

S. Croce S.A.

Castelfranco

Montopoli

S. Miniato

Gambassi

Montaione

Montelupo

Empoli

Montespertoli

Certaldo

Capraia e Limite

Cerreto Guidi Vinci

Castelfiorentino

Low disability High disability

AUSL: APA classes

0

50

100

150

200

250

300

2003 12004 2005 2006 2007 2008 2009 2010 2011 2012 2013

Nu

mb

er

Residents 230000

Aged >65 22%

Participants >6000

Ad

ap

ted

Ph

ysic

al A

cti

vit

y

Ad

ap

ted

Ph

ysic

al A

cti

vit

y

FOR HYPOMOBILITY SYNDROMES AND OSTEOPOROSIS

AND CHRONIC SYNDROMES STABILIZED IN THE

OUTCOMES APA PROGRAMS ARE APPROPRIATE…..

Ad

ap

ted

Ph

ysic

al A

cti

vit

y Participants

0

5000

10000

15000

20000

25000

2008 2009 2010 2011 2012

Num

ber

High disability Low disability

Classes

0

300

600

900

1200

1500

2008 2009 2010 2011 2012

Nu

mb

er

Gyms/pools

0

200

400

600

800

2008 2009 2010 2011 2012

Nu

mb

er

Municipalities

0%20%40%60%80%

100%

2008 2009 2010 2011 2012

Conferenze Stato Regioni ed Unificata

Adapted Physical Activity

for chronic stroke survivors

Recovery plateau

Reh

ab

ilit

ati

on

Reh

ab

ilit

ati

on

Re

ha

bil

ita

tio

n

Re

ha

bil

ita

tio

n

Time from stroke

Acute &

Subacute

Chronic

AP

A S

tro

ke

Recovery plateau

Conventional rehabilitation

"Task-oriented" exercise

Community-based exercise program

Time from stroke

Acute &

Subacute

Chronic

AP

A S

tro

ke

23:726-734;2009

Inclusion criteria

Time from stroke >8 months

Age >40 years

Able to walk independently for 6 minutes (also with walking aids) at a velocity 0,2-0,6 stature/sec

No critical comorbidity or severe dementia

AP

A S

tro

ke

METHODS

Duration 6 months

APA group recruited in Empoli Health Authority area

Usual care group (control group) recruited in Pisa and Florence Health Authorities

Project approved by Local Ethical Committee

AP

A S

tro

ke

Coordination Center

Stroke APA courses

ISS project:

“Obtaining Optimal Functional Recovery and Efficient Managed

Care for the Chronic Stroke Population”

Fucecchio

S. Croce S.A.

Castelfranco

Montopoli

S. Miniato

Gambassi

Montaione

Montelupo

Castelfiorentino

Empoli

Montespertoli

Certaldo

Capraia e Limite

Cerreto Guidi Vinci

Community gyms or social clubs

Trainers not Health Professionals

AP

A S

tro

ke

1,90 €

per session

No transportation provided by LHA

AP

A S

tro

ke

( ) + = 1.90 €

Safety

No adverse clinical

event in gymnasiums

AP

A S

tro

ke

0

10

20

30

40

50

60

70

80

APA Functional ∆ > Control Functional

∆

APA Baseline

APA Post 6 months

Control Baseline

Control Post 6 months

Group x time

P < .005 for

all

AP

A S

tro

ke

Glucose

0,0

40,0

80,0

120,0

160,0

0 +30 +60 +90 +120

mg

/dL

Before

After 6 months

Insulin

0,0

40,0

80,0

120,0

160,0

0 +30 +60 +90 +120

mU

/L

Before

After 6 months

minutes

minutes

1mU/L =7,217 pMol/L

Baseline and Post APA Intervention Mean Glucose and Insulin

Curves in Individuals without IGT or DM A

PA

Str

oke

Better or cured

Health

0%

20%

40%

60%

80%

100%

APA group Usual care group

1 year after the end of the study… telephone interview

How do you rate your…

as compared to one year ago?

same

worse N=38 N=38

Gait

0%

20%

40%

60%

80%

100%

APA group observed APA group reported Usual care group reported

1-25%

N=38 N=38

>26%

<0%

Variation

gait velocity

AP

A S

tro

ke

Acute

phase

Chronic

phase

Rehabilitation APA

Continuity with rehabilitation?

Acute

phase

Chronic

phase

Rehabilitation APA

(DIS)CONTINUITY

OVERLAPPING

AP

A S

tro

ke

N=81

GAIT VELOCITY

0

0,1

0,2

0,3

0,4

0,5

0 1 2 3 4 5 6 7 8 9 10 11 12

Months in APA

sta

ture

/se

c

Can further interventions on

impairments in the chronic phase

of the disease improve outcome?

AP

A S

tro

ke

Baseline assessment

130

Excluded:

20 refused FU interview

(8 continuing APA)

3 not found

6 dead

1 year FU interview

101

Continuing APA

70

Interrupted APA

30

3 Other

0 Cost

4 Transportation

2 Family/work

6 Health

15 Lack of motivation

Self reported causes of

interruption: N.

Can we improve adherence? A

PA

Str

oke

Thanks

f.benvenuti@usl11.toscana.it

www.usl11.toscana.it