Patient-Reported Outcomes Across Stroke Types: More Commonalities Than Contrasts

Health domains are affected to a similar degree among patients with various types of cerebrovascular events — ischemic stroke, intracerebral hemorrhage (ICH) and subarachnoid hemorrhage (SAH) — according to a large observational cohort study from Cleveland Clinic using patient-reported outcome metrics. The findings suggest that a uniform approach to assessing health domains and prioritizing rehabilitation is reasonable for all three stroke subtypes, the investigators conclude.

In contrast, patients with transient ischemic attack (TIA) had worse adjusted scores, relative to the other three stroke subtypes, in multiple domains of health. The findings were recently published in Neurology (2018;91:e2182-e2191).

“Better understanding of the relative effect of cerebrovascular event type on various domains of health could inform rehabilitation programs for patients,” says the study’s lead author, Irene Katzan, MD, MS, a neurologist with Cleveland Clinic’s Cerebrovascular Center. “We undertook this study to evaluate outcomes in several patient-reported health domains and to determine whether factors related to these outcomes differ by event type.”

Patient-reported outcomes from >2,100 patients

To do so, Dr. Katzan and colleagues drew on data from patient- and clinician-reported scales collected as part of routine care through the Knowledge Program, a Cleveland Clinic-developed electronic platform for systematic capture of patient-reported information. Data are collected via electronic tablets before a patient’s ambulatory visit and available to the provider during the visit.

During the study period of February 2015 to June 2017, data were collected from 2,181 patients seen at Cleveland Clinic’s Cerebrovascular Center ambulatory clinic 1 to 18 months after ischemic stroke (64.5 percent), TIA (16.5 percent), ICH (9.9 percent) or SAH (9.1 percent). Patients (or their proxies) completed the following eight measures of health status:

• Executive function
• Physical function
• Satisfaction with social roles
• Fatigue
• Anxiety
• Depression
• Pain interference
• Sleep disturbance

All measures were assessed using Patient-Reported Outcomes Measurement Information System (PROMIS) scales except for executive function, which was measured using the Quality of Life in Neurologic Disorders instrument.

Key findings

The researchers found similar outcomes for all reported health domains among patients with ischemic stroke, ICH and SAH after adjustment for disability and other clinical factors.

Notably, after adjustment for disability, patients with TIA had worse scores than the rest of the sample in five domains: pain interference, fatigue, anxiety, depression and sleep disturbance.

As anticipated, patient-reported outcomes worsened with greater degrees of disability across the entire cohort. After adjustment for disability, the following factors were associated with worse scores in multiple domains:

• Female sex
• Younger age
• Lower income
• Temporal proximity to the cerebrovascular event (< 90 days)

Across all event subtypes, the domains that were most affected were physical function, satisfaction with social roles, and executive function. “A previous study by our group [published in Neurology and recapped in this Consult QD post] exclusively in patients with ischemic stroke demonstrated that these same domains were most affected in that population, so this study extends those findings to all major stroke subtypes and underscores the relevance of assessing these three domains in clinical practice,” observes Dr. Katzan.

Interpretation and implications

“We anticipated differences in outcome between cerebrovascular events but instead found many similarities,” Dr. Katzan continues. “These findings suggest that the brain injury resulting from these various stroke subtypes has a comparable effect on these outcome domains and that it’s reasonable to take a uniform approach to evaluating these outcomes in event survivors. Clinical factors appear to loom larger than stroke subtype in prognostication and allocation of rehabilitation resources.”

She notes that the somewhat counterintuitive finding of worse adjusted outcomes in patients with TIA relative to the rest of the cohort may reflect an expectation of more complete recovery among TIA patients in light of their freedom from persistent physical deficits. “Additionally, different mechanisms may be responsible for the health status of individuals with TIA relative to other event types,” she adds. “Further evaluation is warranted to explore this finding.”

In an editorial accompanying the study (Neurology. 2018;91:1038-1039), two neurologists from Johns Hopkins University School of Medicine recognize the investigation for its large size, broad scope and “important clinical implications.” They conclude that the study “compels implementation of aggressive rehabilitation initiatives tailored to the individual addressing mood, fatigue, sleep, and cognition in addition to physical function.”