Two-year prospective study of psychosocial outcomes and a cost-analysis of 'treatment-as-usual' versus an 'enhanced' (specialist liaison nurse) service for aneurysmal sub arachnoid haemorrhage (ASAH) patients and families

Do patient-reported outcome measures for SAH include patient, family, and caregiver priorities? A scoping review

OBJECTIVE

To systematically describe literature that identified patient/family/caregiver priorities for subarachnoid hemorrhage (SAH)-specific patient-reported outcome measures (PROMs), developed novel SAH PROMs by incorporating patient/family/caregiver perspectives, or involved patient/family/caregiver perspectives in evaluating existing SAH PROMs.

METHODS

We conducted a scoping review using Embase and Ovid MEDLINE from inception to February 6, 2018. Study eligibility and data extraction was performed independently and in duplicate. For each eligible citation, we abstracted information about study population, design, type of patient involvement, and outcome measures. We planned a descriptive summary of all included studies.

RESULTS

Our search yielded 4,961 citations, of which 15 met our eligibility criteria. Four of these included duplicate data, so our final sample consisted of 12 articles. There were 879 patients with SAH and 241 carers from the 11/12 articles that reported these data. One additional study involved 70 individuals but did not specify the number of carers or patients. We did not find any studies where SAH survivors or their families were directly involved in the full continuum of PROM outcome conceptualization from development to evaluation. We found 41 measures identified by patients with SAH. We identified only 2 PROMs developed with patients and only one that was a post hoc evaluation by patients. These 3 PROMs are subarachnoid hemorrhage outcome tool, Wessex Patient Carer Questionnaire, and Functional Status Examination, respectively.

CONCLUSION

We identified 3 PROMs that have involved patients in some way, but the extent to which they reflect patient priorities remains unclear. More work is needed to ensure SAH research is not overlooking outcomes that are important to patients.

Patients Experience High Levels of Anxiety 2 Years Following Aneurysmal Subarachnoid Hemorrhage

OBJECTIVE

To explore anxiety levels during the first 2 years after rupture of aneurysmal subarachnoid hemorrhage.

METHODS

A consecutive sample of patients with aneurysmal subarachnoid hemorrhage (aSAH) (n = 88, 84.6% of eligible) from a Swedish neurosurgical clinic were followed-up with a prospective cohort design at 3 time points; 6 months, 1 year, and 2 years after the onset. Data were collected by postal questionnaires and telephone interviews: State trait anxiety inventory, Hospital anxiety and depression scales, Barthel index, Telephone interview for cognitive status, and a set of study-specific questions.

RESULTS

Most of the respondents scored above the State trait anxiety inventory Swedish norm value on anxiety levels at all 3 follow-up time points. About 59% (n = 52) of respondents scored above the cutoff value for clinical significant level of anxiety in at least 1 time point during the first 2 years after rupture of aSAH. There were no significant differences in levels of anxiety versus the observational period and the 3 follow-up time points. The most significant explanatory variable to high levels of anxiety at all 3 follow-up time points was low perceived recovery.

CONCLUSIONS

Levels of anxiety remained high and stable throughout the first 2 years after rupture of aSAH. High levels of anxiety may reduce health-related quality of life substantially. Identification of individuals with high levels of anxiety and supportive care could therefore potentially improve long-term outcome.

Subarachnoid hemorrhage patients' fears of recurrence are related to the presence of posttraumatic stress disorder

BACKGROUND

Subarachnoid hemorrhage (SAH) patients illustrate a chronic fear of recurrence. A third of patients develop posttraumatic stress disorder (PTSD) after SAH, and PTSD after other conditions is associated with a more negative outlook on life.

OBJECTIVE

We examined whether recurrence fears are related to PTSD and whether this is associated with the patients making more negative health appraisals. We also examined the helpfulness of current treatments.

METHODS

Two SAH samples were generated. Sample 1 (n = 82) was assessed 13 months after ictus for PTSD, cognition, fear of recurrence, and beliefs concerning future health. Sample 2 (n = 60) was assessed 18 months after ictus for PTSD and to determine how much current treatments increased their confidence about not having another SAH.

RESULTS

Thirty-four percent of sample 1 had PTSD. Although clinically and cognitively comparable, PTSD patients feared recurrence more and were comparatively more pessimistic about their chances of further SAH. Thirty-six percent of sample 2 had PTSD. These most fearful patients reported finding current treatments the least helpful.

CONCLUSION

Fear of recurrence after SAH is related to PTSD. Participants with PTSD were more pessimistic about their future health. Treatment for PTSD could alleviate fears of SAH recurrence and promote better outcome.

Depression and post-traumatic stress disorder after aneurysmal subarachnoid haemorrhage in relation to lifetime psychiatric morbidity

Introduction

Little is known about the roles that lifetime psychiatric disorders play in psychiatric and vocational outcomes of aneurysmal subarachnoid haemorrhage (SAH).

Materials and methods

Eighty-three SAH patients without apparent cognitive dysfunction were assessed using the Structured Clinical Interview for DSM-IV axis I disorders (SCID-I) after their SAH. Diagnoses were assessed for three time periods, ‘lifetime before SAH', ‘12 months before SAH’ and ‘7 months after SAH'.

Results

Forty-five percentage of patients with SAH reported at least one lifetime psychiatric disorder. After SAH, symptoms of depression and/or post-traumatic stress disorder (PTSD) were seen in 41%, more often in those with a psychiatric history prior to SAH (p = 0.001). In logistic regressions, depression after SAH was associated with a lifetime history of major depression, or of anxiety or substance use disorder, as well as with lifetime psychiatric comorbidity. Subsyndromal or full PTSD was predicted by a lifetime history of major depression. After the SAH, 18 patients (22%) had received psychotropic medication and/or psychological treatment, 13 of whom had a disorder. Those with a lifetime history of major depression or treatment with antidepressants before SAH had lower return to work rates than others (p = 0.019 and p = 0.031, respectively). This was also true for those with symptoms of depression and/or PTSD, or with antidepressant treatment after SAH 0 = 0.001 and p = 0.031, respectively).

Conclusions

Depression and PTSD are present in a substantial proportion of patients 7 months after SAH. Those with a history of psychiatric morbidity, any time before the SAH, are more at risk and also constitute a risk group for difficulties in returning to work.

Re-evaluating the National Subarachnoid Haemorrhage study (2006) from a Patient-Related-Outcome-Measure perspective: comparing fiscal outcomes of Treatment-as-Usual with an enhanced service

BACKGROUND

Subarachnoid haemorrhage (SAH) is neurological catastrophe, creating major disruption for patient and family, hence the importance of considering Patient-Related-Outcome-Measures (PROM). This study uses the National Study of SAH (2006) to explore any fiscal benefits to patients and NHS if they had an enhanced Neuro-Vascular-Specialist-Nurse (NVSN) service compared to Treatment-as-Usual (TAU).

METHOD

Ensuring total confidentiality, clinical data from the National Study (n=2397) were matched with regional clinical data of a TAU (n=137) and prospective NVSN service (n=184) patients. The TAU and NVSN fiscal outcomes were projected onto the National Study patients to provide estimates of the potential benefits that could accrue nationally from a NVSN service based upon length of stay and earlier return to work of patients and carers.

RESULTS

There were substantial benefits for NVSN cohort related to shorter time in hospital, reduced family disruption, earlier return to work and fiscal benefits to family and the NHS. NVSN patients and carers potential savings were estimated at £ 8.097 million and £ 2.492 million to the service, £ 10.497 million overall.

PRACTICE IMPLICATIONS

This PROM approach allows the 'patient's voice' to be heard, which facilitates speedier patient and family recovery, showing that an integrated treatment approach in 'high tech' neuro-surgery is cost-effective.

Which variables help explain the poor health-related quality of life after subarachnoid hemorrhage? A meta-analysis

OBJECTIVE

Patients with subarachnoid hemorrhage (SAH) are younger than typical stroke patients. Poor psychosocial outcome after SAH therefore leads to a disproportionately high impact on patients, relatives, and society. Addressing this problem requires an understanding of what causes poor psychosocial outcome. Numerous studies have examined potential predictors but produced conflicting results. We aim to resolve this uncertainty about the potential value of individual predictors by conducting a meta-analysis. This approach allows us to quantitatively combine the findings from all relevant studies to identify promising predictors of psychosocial outcome and determine the strength with which those predictors are associated with measures of psychosocial health.

METHODS

Psychosocial health was measured by health-related quality of life (HRQOL). We included in our analysis those predictors that were most frequently examined in this context, namely patient age, sex, neurologic state at the time of hospital admission, bleed severity, physical disability, cognitive impairment, and time between ictus and psychosocial assessment.

RESULTS

Only 1 of the traditional variables, physical disability, had any notable affect on HRQOL. Therefore, the cause of most HRQOL impairment after SAH remains unknown. The situation is even worse for mental HRQOL, an area that is often significantly affected in SAH patients. Here, 90% of the variance remains unexplained by traditional predictors.

CONCLUSION

Studies need to turn to new factors to account for poor patient outcome.

Stroke liaison workers for stroke patients and carers: an individual patient data meta-analysis

BACKGROUND

Many patients experience depression, social isolation and anxiety post stroke. These are associated with a poorer outcome. Ameliorating these problems may improve patient wellbeing.

OBJECTIVES

To evaluate the impact of a healthcare worker or volunteer whose multi-dimensional roles have been grouped under the title 'stroke liaison worker'.

SEARCH STRATEGY

We searched the Cochrane Stroke Group Trials Register (searched February 2009), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 1, 2009), MEDLINE (1966 to 2009), EMBASE (1980 to 2009) and four other databases. We performed a cited reference search, searched conference proceedings and trials registers, checked reference lists and contacted authors and trial investigators.

SELECTION CRITERIA

Randomised controlled trials investigating the impact of a stroke liaison worker versus usual care.

DATA COLLECTION AND ANALYSIS

We invited trialists to participate in a review of individual patient data. Primary outcomes for patients were subjective health status and extended activities of daily living. Primary outcomes for carers were subjective health status including measures of carer strain.

MAIN RESULTS

We included 16 trials involving 4759 participants. Analysis did not show a significant overall difference for subjective health status (standardised mean difference (SMD) -0.03, 95% confidence interval (CI) -0.11 to 0.04, P = 0.34) or extended activities of daily living (SMD 0.04, 95% CI -0.03 to 0.11, P = 0.22). There was no overall significant effect for the outcome of carer subjective health status (SMD 0.04, 95% CI -0.05 to 0.14, P = 0.37). Patients with mild to moderate disability (Barthel 15 to 19) had a significant reduction in dependence (odds ratio (OR) 0.62, 95% CI 0.44 to 0.87, P = 0.006). This would equate to 10 fewer dependent patients (95% CI 17 fewer to 4 fewer) for every 100 patients seen by the stroke liaison worker. Similar results were seen for the outcome of death or dependence for the subgroup with Barthel 15 to 19 (OR 0.55, 95% CI 0.38 to 0.81, P = 0.002). This risk difference equates to 11 fewer dead or dependent patients (95% CI 17 fewer to 4 fewer) for every 100 patients seen by the stroke liaison worker.

AUTHORS' CONCLUSIONS

There is no evidence for the effectiveness of this multifaceted intervention in improving outcomes for all groups of patients or carers. Patients with mild to moderate disability benefit from a reduction in death and disability. Patients and carers do report improved satisfaction with some aspects of service provision.

Costs of stroke using patient-level data: a critical review of the literature

BACKGROUND AND PURPOSE

With decision-analytic models becoming more popular to assess the cost-effectiveness of health care interventions, the need for robust estimates on the costs of cerebrovascular disease is paramount. This study reports the results from a literature review of the costs of cerebrovascular diseases, and assesses the quality of the published evidence against a set of defined criteria.

METHODS

A broad literature search was conducted. Those studies reporting mean/median costs of cerebrovascular diseases derived from patient-level data in a developed country setting were included. Data were abstracted using standardized reporting forms and assessed against 4 predefined criteria: use of adequate methodologies, use of a population-based study, inclusion of premorbid resource use, and reporting of costs by different patient subgroups.

RESULTS

A total of 120 cost studies were identified. The cost estimates of stroke were compared by taking into account the effects of inflation and price differentials between countries. Average costs of stroke ranged from $468 to $146 149. Differences in costs were also found within country, with estimates in the USA varying 20-fold. Although the costing methodologies used were generally appropriate, only 5 studies were based on population-based studies, which are the gold standard study design when comparing incidence, outcome, and costs.

CONCLUSIONS

This review showed large variations in the costs of stroke, mainly attributable to differences in the populations studied, methods, and cost categories included. The wide range of cost estimates could lead to selection bias in secondary health economic analyses, with authors including those costs that are more likely to produce the desired results.

Posttraumatic stress disorder in the family and friends of patients who have suffered spontaneous subarachnoid hemorrhage

Object

Significant others (SOs), such as spouses and life partners, of patients who have survived subarachnoid hemorrhage (SAH) can experience psychiatric symptoms and psychosocial disability. The cause of such symptoms has not been established. Authors of the present study analyzed whether posttraumatic stress disorder (PTSD) subsequent to a loved one's SAH is a plausible explanation for these symptoms.

Methods

The authors examined a large representative sample of 86 patient/SO pairs 3.5 months postictus. All SOs were evaluated using a diagnostic PTSD measure, and coping skills were assessed. The cognitive, physical, and emotional status of patients was comprehensively examined.

Results

Twenty-six percent of SOs met the diagnostic criteria for PTSD, which represents a 3-fold increase in the rate expected within the general population. To establish the cause of PTSD, a logistic regression was performed, and results of this test showed that the use of maladaptive coping strategies was the best predictor of the disorder. A patient's level of disability held no significant association with the development of PTSD in his or her SO.

Conclusions

The elevated incidence of PTSD in SOs helps to explain why these persons report concerning levels of psychiatric symptomatology and psychosocial disability. Greater attention must be given to an SO's adjustment to the experience of having a loved one suffer an SAH. This need is all the more pertinent given that SOs often act as informal caregivers and that PTSD could interfere with their ability to effectively minister. Because bad coping skills seem to be the main cause of PTSD, teaching SOs better strategies might prevent the disorder and any resulting psychosocial disability.

Anxiety and depression and their influence on the quality of life after total hip replacement: preliminary report

Objective. The study investigated health-related quality of life in relation to mental status (anxiety and depression) and demographic factors in patients before and after total hip replacement due to osteoarthrosis. Methods. The SF-36, HADS, socio-demographic data questionnaire was delivered to a group of 184 subjects (108 females, 76 males) at the mean age at the time of surgery of 59 years. Questionnaires were delivered to the subjects 2 weeks before the surgery and 6 months after the operation (by mail). Results. Patients after hip replacement showed significant improvement in health-related quality of life in most domains of SF-36 score and summary scale of PCS (Physical Component Summary Scale) and MCS (Mental Component Summary Scale). They also showed improvement in mental status. Elderly patients were more likely to show worse score in MCS and PCS before and after surgery. BMI (body mass index) was correlated only with preoperative PCS. Mental status was associated with postoperative PCS and MCS. Patients who were satisfied with the results of the surgery showed higher PCS and MCS score. Conclusion. Hip replacement surgery brings significant improvement to the quality of life. Age and mental status of those patients influence markedly their postoperative performance.