The Analysis Of Quality Of Life For Stroke Patients Under Community-based Rehabilitation In Macau

BackgroundAs the economy develops and living standard rises, the average life expectancy of population is prolonged, about 60% of the middle-aged and elderly are suffering from cardio-cerebrovascular diseases, diabetes, cancer and other chronic diseases. In addition to these patients with dangerous condition (eg:prolonged coma), serious complications or unstable vital signs, most of them can survive a long time. The survivals with varying degrees of disability will bring them physically and mentally pain, thus increase their families and social burdens.Nowadays the rehabilitation expectation of patients is aware, the diseases must be cured and afterward the regional and overall function of patients should be recovered well to take up their social responsibilities. How to improve the quality of life of patients and ultimately integrate them into the community? This has become an important topic in the medical field.Stroke or cerebrovascular accident, is a clinical syndrome causing the regional or entire cerebral dysfunction by the cerebrovascular diseases. It can be sudden onset and fetal if the condition sustains for more than 24 hours. There are many clinical manifestations:sudden loss of consciousness, facial and limb weakness or numbness, inflexible eye movements, bowel and bladder incontinence and balance dysfunction, etc. Common classifications of stroke are ischemic (cerebral infarction) and hemorrhagic (cerebral hemorrhage). The mortality rate has been recently declined and about 85% of patients can be survived. Unfortunately the disability rate is increasing and about 50%-70% of the survivals suffering from cognitive impairment, hemiplegia, aphasia and even loss of daily living.The incidence rate of stroke in Macau is tend to be common, stroke patients are highlighted for attention and obviously their quality of life are lower than peers. Right after the hospitalized treatment for the acute patients, they will be discharged for community-based rehabilitation. The patients with mild condition can go to nursing centre for rehabilitation themselves. Those with restricted mobility can apply for on-site service. In some serious cases they should live in nursing home for long-term rehabilitation.The gaming business of Macau has contributed the rapid growth to the economic and social resources in recent years, the local government, in collaboration with civil societies are active to develop the field of community-based rehabilitation. However, the focus on health problems, improvement strategy for quality of life and analysis of influence factors for stroke patients under community-based rehabilitation are still absence.Many local or foreign scholars had used health survey questionnaire SF-36 (36-item short form) and recorded the general condition to evaluate the quality of life and influence factors for the stroke patients. The reliability, validity and results of those surveys were affirmative. Their studies were mostly focused on the in-patients but not the patients receiving community-based rehabilitation.AimTo have persistent improvement of the service quality by analysis the quality of life and influence factors for stroke patients under community-based rehabilitation in Macau ObjectsFrom July 2009 to January 2010,650 cases of stroke patients were selected from community rehabilitation organizations in Macau. The selected patients must be age 40 years or older, either sex, clear consciousness and able to complete the scale. Those patients with severe trauma, cancers or other critical illness were excluded.Methods1 Sampling methodsIt was a cross-sectional study and investigator did the stratified sampling at 6 different community rehabilitation organizations.660 out of 780 cases were chosen but 10 cases were failed to complete the entire investigation. The final 650 cases were divided into three groups:1) GroupⅠ,230 cases of severe condition receiving long-term accommodation and rehabilitation in nursing home; 2) GroupⅡ,210 cases of mild condition receiving rehabilitation in nursing centre; 3) GroupⅢ,210 cases with restricted mobility receiving service by home visit team. The three groups had been received community-based rehabilitation for six months or more.2 Evaluation methodsThe follow-up and on-site questionnaire survey was done by a rehabilitation physician, the questionnaire was divided into two parts:PartⅠ, quality of life (QOL) score. PartⅡ, influence factors analysis. The QOL score was done by Chinese version of SF-36 health survey questionnaire which included 8 domains of scores:Physical Functioning (PF), Role Physical (RF), Bodily Pain (BP), General Health (GH), Vitality (VT), Social Functioning (SF), Role Emotional (RE) and Mental Health (MH). The final scores were obtained by the conversion of the initial scores for all domains; the final score was ranged from 0 to 100.There were total 29 influence factors and 1-25 factors were done by a self-made scale called general condition of patient:1.gender,2.age,3.marital status,4.education level,5.nationality,6.irregular lifestyles,7.daily income,8.social support,9.type of rehabilitation organization,10.nature of rehabilitation organization,11.time of rehabilitation treatment,12.stroke frequency,13.stroke type,14.lesion number, 15.lesion location,16.associated diseases,17.recovery expectation,18.degree of respect,19.privacy violations,20.environmental comfort and safety,21.fall prevention,22.infectious diseases prevention,23.use of restraint,24.bedsores prevention,25.death arrangement.The last 4 factors were done by the specific scales to calculate and classify the total scores:26.MMSE (Mini Mental State Examination) assessed the dementia status; 27.Barthel Index (BI) assessed the activities of daily living; 28.Neurological Function Defect Scale (NFDS) assessed the level of defect in neurological function; 29.Hamilton Depression Scale (HAMD) assessed the status of depression.3 Statistical analysisThe analysis of 650 valid questionnaires was done by SPSS 13.0 for Windows. The statistical methods for analysis of QOL and influence factors were:Descriptive, Crosstab, One Way Anova, LSD t test, Kruskal Wallis H test and Linear Regression. P<0.05 indicated the statistical significance.Results1 The analysis of QOLThe PF (F=7.36,P=0.001), VT (F=3.498,P=0.031), SF (F=4.533,P=0.011), RE (F=3.341,P=0.036) of three groups were statistically significance. GroupⅢhad the lowest scores in PF (35.01±8.76) and SF (41.61±24.97). GroupⅠhad the highest score in VT (44.07±16.28). GroupⅡhad the highest score in RE (54.60±26.33), the remaining domains and total scores of QOF had no statistical significance (P> 0.05).2 The analysis of influence factors of QOLThere was statistical significance in age (χ2=57.49,P=0.000), GroupⅠhad the most patients in over 80 years (37.8%); while GroupⅡ(31.9%) andⅢ(26.7%) had the most patients in 40-50 years old. In terms of marital status, there was statistical significance (χ2=78.29,P=0.000), most of the patients in GroupⅠ(38.7%) andⅡ(40%) were single; while GroupⅢhad the most widows (35.2%).There was statistical significance in education level (χ2=19.11,P=0.004), Group I had the most patients with university level or higher (31.7%); while most of patients in GroupⅡ(30%) andⅢ(29.5%) were secondary educated. In the point of bad habits, most of the patients were drug addicts (72.8%). There was statistical significance in daily income (χ2=81.83,P=0.000), GroupⅠ(62.6%) andⅢ(60%) had the most patients without income; while GroupⅢhad the most patients with monthly income of$5000-$10000 (28.6%). In the point of social support, most of the patients gained support from their patients (90.5%).There was statistical significance in the type of rehabilitation organization (χ2=1240.9,P=0.000), different type of organization provided individual treatment effect for the patients. In the point of stroke frequency, there was statistical significance (χ2=38.64,P=0.000), GroupⅠ(43%) andⅢ(33.8%) had the most patients with more than 3 times of onsets; while GroupⅡhad the most patients with the second onset (33.8%). There was statistical significance in the type of stroke (χ2=46.8,P=0.000), the most patients suffering from cerebral embolism were 23.5% (GroupⅠ),28.1%(GroupⅡ) and 29.5%(GroupⅢ) respectively.In the point of number of lesion, there was statistical significance (χ2=21.42,P=0.000), GroupⅠ(61.7%) andⅢ(65.7%) had the most patients with multiple lesions; while GroupⅡ(55.2%) had the most patients with single lesion. There was statistical significant in the lesion location (χ2=11.02,P=0.026), GroupⅠ(54.8%) andⅢ(49.5%) had the most patients with lesions in bilateral hemispheres; while most of patients in GroupⅡ(40.5%) had lesion in left hemisphere. In the point of associated diseases, most patients had diabetes (68.4%).There was statistical significance in the total score of MMSE (F=10.23,P =0.000), GroupⅡscored the highest (16.70±1.63) but no statistical significance (H=4.126,.P=0.127) was found in the dementia level.There was statistical significance in the total score of Barthel Index(F=63.57, P=0.000), GroupⅡscored the highest (44.42±22.66).The level of dependency (H=110.724,P=0.000) was statistically significant and GroupⅠhad the highest dependency (Mean Rank:386.5).There was statistical significance in the total score of neurological defect (F =51.54,P=0.000), GroupⅡhad scored the highest (24.58±5.04). The level of neurological defect was statistical significance (H=41.999,P=0.000) and GroupⅢhad the highest level of neurological defect (Mean Rank:373.3). No statistical significance was found in the remaining factors (P> 0.05).3 The relation between quality of life and influence factorsIn order to examine the impact of 29 factors on quality of life, Linear Regression was used to obtain P and B values in the three groups respectively. P<0.05 indicated the correlation, B value is positive indicated the better condition than the control or vice versa. The results showed:PF was related with type of rehabilitation organization (P=0.031), GroupⅠ(B=3.079,P=0.011) and GroupⅡ(B=2.564,P=0.043) had the higher PF than GroupⅢ.BP was related to Barthel Index level (P=0.003), the patients with mild dependency (B=13.325,P=0.048) had higher BP than the total dependency, while the severe dependent had lower BP than the total dependency.GH was related with stroke frequency (P=0.019), stroke type (P=0.026), recovery expectation (P=0.026) and dementia level (P=0.015). The patients with first (B=2.937,P=0.036) and second (B=2.908,P=0.033) onset had higher GH than the patients with more than 3 times of onsets. The patients with expectation of partial recovery (B=-2.494,P=0.043) had lower GH than the full recovery. The patients with moderate depression (B=3.542,P=0.005) had higher GH than the severe depressed.VT was related with type of rehabilitation organization (P=0.005) and recovery expectation (P=0.046), the patients with no expectation of recovery (B=-3.916, P=0.018) had lower VT than the full recovery.SF was related with type of rehabilitation organization (P=0.003) and associated diseases (P=0.031), GroupⅠ(B=9.762,P=0.002) andⅡ(B=10.660,P=0.001) had higher SF than GroupⅢ. The patients with no associated diseases (B=5.139,P=0.031) had higher SF than the associated diseases.MH was related with nationality (P=0.012). The total score of SF-36 was related with the lesion location, the patients with right hemisphere damage (B=21.124, P=0.001) had higher total score than the bilateral damage.RP and RE were not related with the 29 factors (P>0.05). In this research we noticed that the QOL of stroke patients were mainly influenced by the factors such as type of rehabilitation organization and recovery expectation.Conclusion1 The incidence rate of stroke was tended to the younger population and cerebal embolism was common in Macau. The patients were more than 3 times of onsets and bilateral hemispheres damaged. They were also associated with diabetes;2 The patients were secondary educated, unmarried, drug addicts, no daily income but they gained support from their friends;3 The patients had varying level of life dependency, dementia, depression and neurological defect;4 There were statistical signifance in PF, SF, VT and RE domains but no signifance in the total score so that these rehabilitation organizations were able to improve the QOL for the stroke patients;5 The QOL can be influenced by many factors:type of rehabilitation organization, recovery expectation, nationality, associated diseases, stroke frequency, stroke type, lesion location, life dependency and depression level, in which the type of rehabilitation organization and recovery expectation were the significant factors.6 Macau government should strengthen the screening and health education for the high-risks people, improve the community rehabilitation facilities and give adequate social support to enhance rehabilitation consciousness of stroke patients.