The Stroke Outcomes Study 2 (SOS2): a prospective, analytic cohort study of depressive symptoms after stroke

Testing measurement invariance of the GHQ-28 in stroke patients

BACKGROUND

In order to combine self-reported measures data from multiple studies to conduct an integrated data analysis, the construct measured must have the same meaning across the studies. This study investigated the measurement invariance of the General Health questionnaire (GHQ-28) in two stroke studies before combining the data for an integrative data analysis.

METHODS

The study used data from the Stroke Outcomes Study 1 (SOS1, n = 448) and second Stroke Outcomes Study (SOS2, n = 585). The initial analysis was a confirmatory factor analysis (CFA) for each study separately to confirm the four-factor structure of GHQ-28 questionnaire. Multi-group confirmatory factor analysis (MG-CFA) was used to assess the measurement invariance of the GHQ-28 questionnaire in the two stroke cohorts. Measurement invariance at configural invariance (same items associated with same factor across groups); factor loading invariance (equal factor loadings across groups) and scalar invariance (equal intercepts across groups) was examined.

RESULTS

CFA supported all three invariances measured.

CONCLUSION

Results showed that the GHQ-28 questionnaire has comparable measurement properties in the SOS1 and SOS2 stroke studies. Strong measurement invariance was established, and based on the results from this study, integrative data analysis of GHQ-28 scores from the two stroke studies is merited.

Measuring patient-perceived continuity of care for patients with long-term conditions in primary care

Background

Continuity of care is widely acknowledged as important for patients with multi-morbidity but simple, service-orientated indices cannot capture the full impact of continuity in complex care delivery systems. The patient’s perspective is important to assess outcomes fully and this is challenging because generic measures of patient-perceived continuity are lacking. We investigate the Chao Perception of Continuity (Chao PC) scale to determine its suitability as a measure of continuity of care for patients with a long-term condition (stroke), and co-morbidity, in a primary care setting.

Methods

Design and Setting: A questionnaire study embedded in a prospective observational cohort study of outcomes for patients following acute stroke.

Participants: 168 community dwelling patients (58% male) mean age 68 years a minimum one year post-stroke. Functional status: Barthel Index mean =16.

Intervention: A 23-item questionnaire, the Chao Perception of Continuity (Chao PC) scale, sent by post to their place of residence or administered face to face as part of the final cohort study assessment.

Results

310 patients were invited to participate; 168 (54%) completed a questionnaire.

All 23 questionnaire items were entered into a Principal Component Analysis. Emergent factors from the exploratory analysis were (1) inter-personal trust (relational continuity); (2) interpersonal knowledge and information (informational and relational continuity) and (3) the process of care (managerial continuity). The strongest of these was inter-personal trust.

Conclusion

The context-specific items in the Chao PC scale are difficult for respondents to interpret in a United Kingdom Primary Care setting resulting in missing data and low response rates. The Chao-PC therefore cannot be recommended for wider application as a general measure of continuity of care without significant modification.

Our findings reflect the acknowledged dimensions of continuity and support the concept of continuity of care as a multi-dimensional construct. We demonstrate the overlapping boundaries across the dimensions in the factor structure derived. Trust and interpersonal knowledge are clearly identified as valuable components of any patient-perceived measure of continuity of care.

Electronic supplementary material

The online version of this article (doi:10.1186/s12875-014-0191-8) contains supplementary material, which is available to authorized users.

Lifestyle referral assessment in an acute cardiology setting: study protocol for a randomized controlled feasibility trial

Background

Lifestyle and behaviour change are important factors in the prevention of cardiovascular disease and reduction of premature mortality. Public health initiatives have focused on opportunities for healthcare staff to deliver lifestyle advice routinely in primary and secondary care but there is no consistent approach to onward referrals and the rate of uptake of advice remains low. We do not know if advice is more effective in supporting behaviour change when a systematic approach is taken that includes identification of barriers to change, directing patients toward services, referral to services, and feedback on outcome.

Methods and design

This is a single-centre, randomized, unblinded feasibility trial in an acute hospital setting which aims to assess the feasibility of a definitive trial and provide proof of concept for the systematic delivery of individualized lifestyle advice in patients managed through an acute cardiology in-patient service.

Patients will be recruited before discharge and randomized to two groups. A control group will receive the usual lifestyle assessment and referral, while an intervention group will receive the usual assessment plus the new individualized lifestyle assessment and referral. The new assessment will inform assignment of each patient to one of three categories based on personal barriers to change. Patients may be referred to a formal lifestyle-change programme, through the ‘Leeds Let’s Change’ website, or they may be guided in self-management, using goal setting, or they may be assigned to a ‘deferment’ category, for reassessment at follow-up. These latter patients will be given a contact card for the ‘Leeds Let’s Change’ service.

Discussion

Lifestyle change is an important mechanism for improving health and wellbeing across the population but there are widely acknowledged difficulties in addressing lifestyle factors with patients and supporting behaviour change. A systematic approach to assessment would facilitate audit and provide an indicator of the quality of care. The new assessment template has been designed to be quick and easy to use in practice and could, for example, be added to a primary care consultation or form part of a nursing discharge assessment in an acute setting.

Trial registration

Current Controlled Trials ISRCTN41781196.

Comparison of two depression measures for predicting stroke outcomes

OBJECTIVES

Little is known about the effect of lifetime history of depression on ischemic stroke outcomes. This study compared a measure of current symptoms of depression at the time of the stroke and a measure of lifetime history of depression for their ability to predict quality of life and functioning at 3 and 12 months after stroke.

METHODS

A cohort of 460 ischemic stroke patients from the 2005 Greater Cincinnati/North Kentucky Stroke Study was assessed within 2 weeks of the stroke, including the 10-item Center for Epidemiological Studies Depression Scale (CESD) for current symptoms of depression. Lifetime history of depression was also assessed by a 2-question measure at 3 and 12 months after stroke. Two outcome measures, Stroke Specific Quality of Life (SSQOL) and the modified Rankin Scale (mRS) to assess functional status, were also collected at 3 and 12 months.

RESULTS

Of the 322 survivors included in the analysis, 52.2% reported depression on at least one measure. Both current symptoms and lifetime history of depression predicted poor functional outcomes and poor quality of life at 3 and 12 months, after adjustment for age, race, sex, prior stroke, baseline functional status, and stroke severity. The combination of depression measures was a better predictor of poor outcomes than either measure alone.

CONCLUSION

Depression by either measure was a frequent, substantial, and independent predictor of poor outcomes at 3 and 12 months after stroke. Stroke outcomes studies should further examine the predictive value of assessing both depressive symptoms at the time of the stroke and lifetime history of depression.

A pilot study to assess use of passive extension bias to facilitate finger movement for repetitive task practice after stroke

BACKGROUND AND PURPOSE

The purpose of this study was to investigate whether active range of finger motion could be increased through the introduction of passive, external extension joint torques in stroke survivors.

PARTICIPANTS

Five chronic stroke survivors with severe hand impairment resulting from hemiparesis took part in the study.

METHOD

Participants completed 2 experimental sessions in which hand movement and function were assessed. In one session, they wore a custom orthotic glove (X-Glove) that passively supplied extension torques to the joints of the fingers. In the second session, they performed the same tasks as in the other session, but without the glove. Outcome measures consisted of active range of motion, distance of the fingertip from the hand, selected tasks from the Graded Wolf Motor Function Test (GWMFT), and the Box and Blocks (BB) test. Primary results with and without the glove were compared using paired t tests with a Bonferroni correction.

RESULTS

Active range of motion improved significantly by over 50%, from 4.4 cm to 6.7 cm, when the X-Glove was worn (P = .011). The distance of the fingertip from the metacarpophalangeal joint increased by an average of 2.2 cm for 4 of the subjects, although this change was not significant across all 5 subjects (P = .123). No significant differences were observed in the BB or GWMFT whether the X-Glove was worn or not.

DISCUSSION AND CONCLUSION

Introduction of passive extension torque can improve active range of motion for the fingers, even in chronic stroke survivors with substantial hand impairment. The increased range of motion would facilitate therapeutic training of the hand, potentially even in the home environment, although the bulk of the orthosis should be minimized to facilitate interactions with real objects.

Psychological disorders after stroke are an important influence on functional outcomes: a prospective cohort study

BACKGROUND AND PURPOSE

Psychological disorders are recognized as an important and common problem after stroke but little is known about their longer-term effects on functional outcomes. We investigated the trajectory of psychological symptoms after stroke and studied their impact on physical functional recovery.

METHODS

The Stroke Outcomes Study was a prospective cohort study conducted in West Yorkshire, UK, from 2002 to 2006. Baseline assessments were conducted within 2 to 6 weeks of an index stroke event and follow-up at 9, 13, 26, and 52 weeks thereafter. Measures of psychological symptoms (assessed using the 28-item General Health Questionnaire) and function (modified Barthel Index) were completed at each visit. Longitudinal latent class analysis identified psychological symptom trajectories. Logistic regression modeled poor functional outcome. Multiple imputation was used as a sensitivity analysis.

RESULTS

Five hundred ninety-two (55% of eligible patients) consented to participate. Four hundred forty-four (76%) complete sets of data (5 time points) were obtained for analysis. Four distinct classes of patients emerged from the analyses based on trajectory of psychological symptoms in the first 26 weeks after stroke. There was a strong association between functional outcome and class as defined by psychological symptom trajectory, which was not explained by age, sex, or initial disability after stroke.

CONCLUSIONS

Currently, the assessment of psychological distress is concentrated in the first weeks after stroke. Our results suggest that the timing of assessment and intervention needs to be reconsidered to take into account the trajectory of psychological symptoms rather than assessment at a single time point.