Use of health care services after stroke

Transcription

1 222 Qulity in Helth Cre 1993;2: Uniersity of Amsterdm Deprtments of Neurology nd Clinicl Epidemiology R de Hn, clinicl epidemiologist M Limburg, neurologist Institute of Socil Medicine G A M n den Bos, professor of socil medicine Centre for Clinicl Decision Sciences, Ersmus Uniersity, Rotterdm J n der Meulen, clinicl epidemiologist Correspondence to: Dr R de Hn, Deprtment of Neurology, Acdemic Medicl Centre, Meibergdreef 9, 115 AZ Amsterdm, Netherlnds Accepted for publiction 19 October 1993 Use of helth cre serices fter stroke R de Hn, M Limburg, J n der Meulen, G A M n den Bos Abstrct Objecties-To describe the use of cre before nd fter stroke nd to elute equity in ccess to helth cre serices fter stroke Design-Cross sectionl study Setting-The Netherlnds Ptients-382 ptients liing in the community who hd been dmitted to hospitl with stroke six months before Min mesures-sociodemogrphic sttus nd functionl helth sttus ccording to The Brthel index, Rnkin scle, nd sickness impct profile, ssessed during interiew, nd generl prctitioner (GP) chrcteristics obtined by postl questionnire Unirite nd multirite nlyses of the reltion between ptient nd GP relted fctors nd use of cre Results-Compred with the period before stroke the use of cre six months fter stroke incresed significntly, especilly use of physicl therpy, home help, nd ids Multirite nlyses showed tht impired functionl helth incresed the use of cre (rnge in odds rtios 1* to 7) Compred with younger ptients, elderly ptients were more likely to he home help (odds rtio 29) nd ids (2 but less likely to receie therpy (, psychosocil support (5), nd n pprecible mount of cre (5) Being femle (1-7), liing lone (, nd whether the GP ws informed bout ptients' dischrge (2 2) incresed the use of home help Higher finncil income (2 8) nd hing mle GP (3 2) contributed to use of therpy Emotionl distress (1), liing protected (32), nd liing lone (1-7) ccounted for psychosocil support Conclusions-Although older ge, lower income, nd poor dischrge informtion to the GP decresed the use of some types of cre, there is equity in ccess to cre fter stroke, primrily determined by needs in terms of functionl helth sttus nd predisposing fctors such s liing rrngement nd socil circumstnces Implictions-Ptient oriented studies focusing on cre processes nd cre outcomes in terms of subjectie needs, perceied cre deficits, with cre re still required (Qulity in Helth Cre 1993;2: ) nd stisfction Introduction Stroke is the third leding cuse of mortlity in Western countries nd one of the most disbling chronic diseses in the community In the Netherlnds the nnul incidence of stroke is estimted t bout 17/1 popultion, of which 145/1 re first cses' On the bsis of demogrphic chnges incidence rtes re expected to rise2 Thirty per cent of ptients with stroke die in the cute phse,' nd hlf of the suriors he substntilly impired functionl helth outcomes3 About 8% of those dmitted to hospitl re dischrged home,4 nd mny of them depend on long term home cre fcilities5 Most studies of stroke he focused on dignostics, tretment options, nd ssessment of functionl helth outcomes fter stroke; few, howeer, he pid ttention to the use of non-medicl helthcre resources in the (sub)chronic period fter the stroke' Studies of the use of cre fter stroke re meningful for enhncing present supportie cre nd predicting future cre ptterns, nd they cn be used s bsis for deeloping long term helth cre policy In this study we inestigte the use of cre before nd fter stroke nd identify ptient chrcteristics, functionl helth ribles, nd generl prctitioner (GP) chrcteristics tht explin the cre t six months fter stroke The objectie of the study is to elute empiriclly one of the most bsic indictors for qulity of helth cre - nmely, equity in ccess to cre According to Andersen's "Behiour model of helth serices use,"7 ccess to helth cre depends on three fctors: predisposing fctors (for exmple, sociodemogrphic ribles), enbling fctors (for exmple, finncil income), nd need fctors (for exmple, functionl helth sttus nd ptients' perception of helth) The purpose of this model is to find eidence for the (in)equity in ccess to cre Equity is demonstrted when cre is primrily determined by needs nd predisposing fctors such s ge nd socil circumstnces; inequity of cre is when cre is merely explined by predisposing nd enbling fctors, such s sex nd socioeconomic sttus or chrcteristics of the helth cre system itself Ptients nd methods The study group consisted of 382 ptients liing in the community who hd hd stroke six months before Most ptients (23 hd hd first eer stroke, 128 hd hd recurrent stroke, nd in 2 ptients this informtion ws unknown The ptients were suriors of n originl cohort of 7 consecutiely dmitted ptients with stroke who prticipted in multicentre study of the qulity of cre in 23 Qul Helth Cre: first published s 1113/qshc24222 on 1 December 1993 Downloded from on 23 September 218 by guest Protected by copyright

2 Use of helth cre serices fter stroke 223 hospitls in the Netherlnds (258 ptients died fter the stroke; 17 ptients refused to enter the study; 13 ptients were redmitted to hospitls, styed in rehbilittion centres, or lied in nursing homes) The study ws performed from mid-1991 to mid-1992 nd ws pproed by the ethicl committees of the prticipting centres Six months fter their stroke the ptients were interiewed by trined reserch ssistnts using semistructured questionnire Informed consent ws gien by ll ptients In cse ptients suffered from serious communiction impirments ptients' proxies were interiewed Dt were collected on sociodemogrphic chrcteristics (ge, sex, finncil income, liing rrngements, nd regionl leel of urbnistion), functionl helth sttus (dementi, disbility, hndicp, emotionl distress, nd perception of helth), nd use of rious types of forml cre before stroke (t time of onset) nd fter stroke For breity we ggregted forml cre into three brod ctegories: () therpy (physicl therpy, occuptionl therpy, nd speech therpy); (b) psychosocil support (socil cre, mentl cre (for exmple from psychologist nd priest or icr)), socioculturl cre (for exmple, orgnised socil ctiities with other elderly people, group trels), nd support from fellow ptients; (c) ids (= dpttion of home, non-body-dpted ids (for exmple, crutch, cne), body-dpted ids (for exmple, body-dpted shoes, body-dpted wheelchir), nd ids to promote outdoor mobility (for exmple, finncil compenstion for txi rides, electric wheelchir)) Other types of cre (dy cre, nursing cre, nd home help) were not ggregted Tble 1 Sociodemogrphic fctors nd functionl helth fctors t six months fter stroke in 382 ptients liing in community Ptient fctors Differentition Score No (Y) offctor of ptients Need fctors: Hndicp Absent/mild <3 Rnkin scle 195 (51) Seere 33 Rnkin scle 181 (47) Unknown (2) Actiity of dily liing Absent/mild >15 Brthel index 344 (9) disbility Seere <15 Brthel index 35 (9) Unknown 3 (1) Emotionl behiour* Norml < 1 SIP subscle 18 (4 Distressed > 1 SIP subscle 172 (45) Unknown 42 (11) Cognitie functioning Norml >24 MMSE 24 (9) Dementi <24 MMSE 49 (13) Unknown 9 (18) Helth perception (Modertely) helthy 17 ( Unhelthy 14 (37) Unknown (17) Predisposing fctors: Age Younger (49) Older >9 19 (51) Sex Mle 217 (57) Femle 15 (43) Liing rrngements Independent 328 (8) Prtner 23 (72) Alone 92 (28) Protected 54 (1 Regionl leel of Rurl 172 (45) urbniztion Urbn 27 (5 Unknown 3 (1) Enbling fctor: Income Lower income <L;7 nett yerly 124 (33) Higher income >L(J7 nett yerly 158 (41) Unknown 1 (2) *Emotionl behiour nd ge of ptient were dichotomised ccording to the medin tfor exmple, serice flt, home for elderly people SIP = sickness impct profile; MMSE = mini mentl stte exmintion During the interiew the ptient's use of cre before stroke ws registered retrospectiely Dementi ws ssessed with the mini mentl stte exmintion8 nd disbility with the Brthel index9 Hndicp, defined s ny limittions in the ptient's socil role, ws mesured with the modified Rnkin scle,' emotionl distress with the emotionl behiour subscle of the sickness impct profile," nd globl leel of perceied helth with single item ("How would you rte your present helth?") At six months fter the stroke dt on GP chrcteristics were collected by postl questionnire The questionnire contined questions bout sociodemogrphic chrcteristics (ge, sex), type of prctice (solo ersus group), nd whether the GP ws informed in due time bout the ptient's dischrge from the hospitl or rehbilittion centre X2 tests were performed to nlyse the unirite reltions between ptient nd GP chrcteristics nd use of cre t six months fter stroke Since it ws expected tht both ptient nd GP fctors were mutully relted (for exmple, interreltions between ge, functionl helth, emotionl distress, nd informtion bout ptient's dischrge or interdependency between sex, ge, nd finncil income) the effects of ptient nd GP chrcteristics on use of cre were dditionlly nlysed with multirite logistic regression All need fctors, ge, nd the significnt (p- -1) predisposing, enbling, nd GP relted fctors identified from unirite nlysis were forced into the models The effect sizes were expressed s odds rtios (clculted s the ntilogrithm of the regression coefficients of the logistic regression model) with 95% confidence interls The odds rtio pproximtes how much more likely (or unlikely) use of cre is mong ptients with the chrcteristic of interest thn mong ptients without tht chrcteristic Results In ll, 4 ptients (1 2%) were not communictie becuse of cognitie, speech, or lnguge disorders, nd their proxies (mostly their prtners) were interiewed To oid n uncceptbly high ptient burden (especilly tiredness) we did not mesure emotionl distress in 42 (1 1%) of the ptients In 9 ptients (18%) cognitie function could not be ssessed becuse of serious phsi Almost fifth of ptients (, 17%) were unble to score the one item question on perceied helth More thn qurter (1, 2%) refused to gie informtion bout their finncil income (tble 1) Of the 382 GPs, 35 (92%) returned the postl questionnire, 11% of whom reported tht they were not sure whether they hd been informed in due time bout the ptient's dischrge (tble 2) In the period before stroke 191 ptients (5%) hd lredy receied substntil mount of cre, prticulrly physicl therpy (57, 15%), home help (72, 19%), socioculturl cre (49, 13%), nd non-body- Qul Helth Cre: first published s 1113/qshc24222 on 1 December 1993 Downloded from on 23 September 218 by guest Protected by copyright

3 224 de Hn, Liniburg, n der Meulen, n den Bos Tble 2 Chrcteristics of 35 GPs responding to postl questionnire Chrcterrstic Differewtitioni Ndo (M) of GPs Age* Younger <45 yers 15 (47) Older -'45 yers 19 (48) Unknown 1 (5) Sex Mle 315 (9) Femle 34 (1) Unknown 1 () Orgnistion of Group 8 (25) prctice Solo 259 (7 Unknown 5 (1) Informed bout Informed 85 (2 ptient's dischrge Not informed 22 (5) Unknown 39 (11) *Age of generl prctitioner wles dichotomised ccording to the medin dpted ids (52, 14%) (figure) Except for non-body-dpted ids, these types of cre were unrelted to whether the ptient hd or hd not hd preious stroke (use of nonbody-dpted ids in ptients with recurrent or first eer stroke ws 21% (2/125) nd 1% (24/23) respectiely; 95% confidence interl of difference 2% to 19%) In the period between dischrge from hospitl nd six months fter stroke 219 ptients (57%) temporrily mde use of rious types of cre, specificlly physicl therpy (1 18, 31 %), occuptionl therpy (9, 18%)), speech therpy (5, 15%), nursing cre ( %), nd socil cre (5, 13%) (figure) Of the totl 1348 cre modlities gien in the first hlf yer fter the stroke, 445 (33%) were stopped within this period Compred with use of cre before stroke, cre used six months fter stroke incresed significntly, especilly for physicl therpy (by 17% (4 ptients); 95% confidence interl 11% to 23%), home help (15% (5); 9% to 21%), non-body-dpted ids (23% (89); 17% 5 r ii, 34 C 35 ), ) s C to 29%), nd ids to promote outdoor mobility (18% (8); 13% to 23%) (figure) Agin no reltion could be shown between types of cre fter stroke nd whether the ptient hd hd first or recurrent stroke except for non-bodydpted ids: use in ptients with recurrent or first eer stroke ws 4% (59/128) nd 32% (74/23 respectiely; 95% confidence interl of difference 4% to 25% Of ll 382 ptients, 94 (25%) did not use ny cre t ll Among the remining 288 (75%) who did receie cre, 181 (47%) were "low" users, consuming between one nd three types of cre nd 17 (28%) were "high" users, receiing four or more types of cre Of the totl 93 cre modlities gien t six months fter stroke, 57 (3%) were consumed by these high users To show the differences between ptients who were or were not users of cre, s well s the differences between high nd low users of cre t six months fter stroke, we focused on the min types of cre used nd ggregted some specific cre types into three brod ctegories (see ptients nd methods section) Need fctors, especilly in terms of hndicp, disbility, nd emotionl distress, were positiely relted both to types of cre nd mount of cre used (tbles 3 nd With regrd to the predisposing fctors types of cre were relted to ge, sex, liing rrngements, nd regionl leel of urbnistion Ptients with higher finncil income receied more therpy but mde less use of ids Furthermore, cre used ws positiely relted to the GP being mle nd to whether the GP ws informed bout the ptient's dischrge (tble 3) When ll need fctors, ge, nd the uniritely identified significnt fctors were Lii Before stroke Between dischrge nd months fter stroke U At months fter stroke Therpy Psychosocil support Aids Percentge of ptients with stroke (n = 382) using core before nd fter stroke, ccording to type of cre (figure boe ech br re percentge lues) 3/ Qul Helth Cre: first published s 1113/qshc24222 on 1 December 1993 Downloded from on 23 September 218 by guest Protected by copyright

4 Use of helth cre serices fter stroke 225 Tble 3 Reltie frequencies ofptient nd GP relted fctors: differences between users of cre nd non-users mong 382 ptients with strokef Figures re number (percentge) of ptients Home help Therpy Psychosocil support Aids Users Non-users Users Non-users Users Non-users Users Non-users (n = 128) (n = 25 (n = 145) (n = 237) (n = 122) (n = 2) (n = 197) (n = 185) Ptient fctors Needs fctors: Seere hndicp 8/12 (3) 97/243 (*** 1/143 (7) 81/233 (35)*** /121 (55) 115/255 (45)* 139/194 (72) 42/182 (23)*** Seere disbility 15/128 (12) 2/245 (8) 24/143 (17) 11/23 (5)*** 9/122 (7) 2/257 (1) 33/19 (17) 2/183 (1)*** Emotionl distress 7/117 (57) 13/217 (47) 71/125 (57) 11/215 (47)* 7/111 () 15/229 (** 98/174 (5) 74/1 (45)** Dementi 2/1 (25) 22/21 (11)*** 2/114 (18) 29/199 (15) 2/13 (19) 29/21 (1 31/15 (2) 18/157 (11)* Feeling unhelthy 51/1 (48) 87/25 (42) 49/112 (4 91/24 (45) 48/1 (45) 92/21 (4 73/157 ( 7/159 (42) Predisposing fctors: Older ge 89/128 (7) 12/24 (41)*** 5/145 (45) 131/237 (55)* 5/122 ( 14/2 (5 12/197 ( 7/185 (38)*** Mle 51/128 ( 1/24 (5)*** 79/145 (5 138/237 (58) 3/122 (52) 154/2 (59) 99/197 (5) 118/185 (** Liing independently 17/128 (8 215/24 (87) 121/145 (83) 27/237 (87) 97/122 (8) 231/2 (89)** 155/197 (79) 173/185 (9*** Liing lone 53/17 (5) 39/215 (18)*** 3/121 (25) 2/27 (3) 34/97 (35) 58/231 (25)* 5/155 (32) 42/173 (2 Urbn enironment 4/127 (5) 138/244 (57) 72/144 (5) 135/235 (57) 2/121 (51) 145/258 (5) 98/19 (5) 19/183 ()* Enbling fctor: Higher income 4/91 (51) 19/187 (58) 7/111 (3) 88/171 (51)* 4/9 (51) 112/192 (58) 72/144 (5) 8/138 (2)** GPfctors Older ge 57/113 (5) 19/213 (51) 8/13 (52) 11/24 (5) 52/19 (48) 117/225 (52) 91/173 (53) 78/11 (48) Mle 15/118 (89) 23/223 (91) 129/135 (9) 18/214 (87)** 17/11 (92) 28/233 (89) 14/181 (91) 151/18 (9) Solo prctice 83/117 (71) 171/22 (78) 11/131 (77) 158/214 (7 88/113 (78) 171/232 (7 137/17 (78) 122/19 (72) Informed bout dischrge 41/1 (39) 44/21 (22)*** 4/117 (3 45/194 (23)** 27/13 (2) 58/28 (28) 54/15 (33) 31/14 (21)** tcontinuous ribles were dichotomised ccording to the medin Differences between frequencies were nlysed with X2 tests: *p - 1, **p < -5, ***p < -1 Missing lues were omitted from this nlysis forced into multirite logistic regression models the results showed tht seerity of hndicp incresed the types nd mount of cre used Compred with younger ptients, elderly ptients were more likely to he home help nd ids but less likely to receie therpy, psychosocil support, nd n pprecible mount of cre Using home help ws dditionlly explined by being femle, liing lone, nd whether the GP ws informed bout the ptient's dischrge Ptients' higher finncil income nd mle sex of the GP contributed significntly to use of therpy wheres emotionl distress nd liing rrngements (liing protected nd liing lone) ccounted for use of psychosocil support serices (tble 5) Tble 4 Reltie frequencies ofptient nd generl prctitioner relted fctors: differences between low users of cre (between one nd three types of cre) nd high users of cre (four or more types of cre)ft Figures re number (percentge) of ptients Low users High users (n = 181) (n = 17) Ptient fctors Need fctors: Seere hndicp 87/177 (49) 83/1 (78)*** Seere disbility 11/179 () 24/17 (22)*** Emotionl distress 81/13 (5) /94 (** Dementi 22/147 (15) 2/85 (2 Feeling unhelthy 71/149 (48) 39/85 ( Predisposing fctors: Older ge 18/181 () 54/17 (5) Mle 95/181 (52) 55/17 (51) Liing independently 151/181 (83) 85/17 (79) Liing lone 5/151 (33) 2/85 (31) Urbn enironment 98/178 (55) 52/17 (49) Enbling fctor: Higher income 7/138 (51) 43/79 (5 GPfctors Older ge 85/13 (52) 47/93 (51) Mle 153/17 (92) 91/99 (92) Solo prctice 122/14 (7 74/97 (7) Informed bout 41/143 (29) 33/91 (3) dischrge fcontinuous ribles were dichotomised Differences between frequencies were nlysed with x2 tests: *p s 1, **p < 5, ***p < o1 Missing lues were omitted from this nlysis Discussion In this study we described the types nd mount of cre serices used fter dischrge from hospitl by ptients with stroke, nd we identified the fctors tht explin these cre ptterns Although in this smple the mount of cre before stroke ws lredy substntil, the use of home helth cre serices by ptients in the (sub)chronic period fter their stroke incresed significntly Physicl therpy, occuptionl therpy, nd speech therpy were the primry rehbilittie interentions in the period between dischrge nd six months fter stroke Of ll cre used in the first hlf yer fter stroke, 33%/o ws stopped within six months With the exception of physicl therpy, the focus of helth cre serices t six months fter stroke seemed to switch from temporry rehbilittie "cure" to more permnent "cre," prticulrly in terms of home help, socioculturl cre, home dpttion, nd ids There were strong reltions between medicl need fctors in terms of functionl helth nd use of cre six months fter stroke Home help ws one of the min (nonggregted) types of cre used nd, not surprisingly, ws consumed primrily by elderly ptients, ptients who lied lone, nd femle ptients As expected, emotionlly unstble ptients, those who lied protected, nd ptients who lied lone tended to receie more psychosocil support thn ptients with opposite chrcteristics Older ptients, howeer, receied psychosocil support less commonly This finding my reflect "cohort effect" rther thn n effect of chronologicl ge Members of older birth cohorts my be more erse to demnding forml psychologicl help thn younger dults The results indicte tht higher finncil income incresed the use of rehbilittie therpy This finding supports n erlier study on use of physicl therpy mong ptients with Qul Helth Cre: first published s 1113/qshc24222 on 1 December 1993 Downloded from on 23 September 218 by guest Protected by copyright

5 22 de Hn, Limburg, n der Meulen, n den Bos h t 4 t3 t g II -N -N DI eq II t ' V, o 2 V5 4 2I coo o 2 s o w o o d b oo 1 oo1 -- T m e-- eqe : (~ em~ /s o o ' -R % '- q1 '- - NeM N d r -'4 - s-s (D -/ o - U ur tn O 1 : C -: -: - : o o - V w 4N i So co o- -oc - ~ : ( NOo + o - oo (1 Ctn 4 l o Cc Cq oo) CS r m t- o o coo N4 'IO Or c C --: o -o: 4 te) T It' o e 4 4 oo i CS oo ~o 1 t o V V /% - coo M ' 'O q I-, Ce (;' 1- - c:4 If' 'N 4 4 le 'OL w It -"N - ( o,-q eq1 -% - '4 CO 't eq4" " t oo C;r :4 : tn 11 IV o -o u -~~ b 4-)2I * l~ U be crs ' CO 3: E 5r C o 3j(A oc S-) 2o~ 1 Qul Helth Cre: first published s 1113/qshc24222 on 1 December 1993 Downloded from on 23 September 218 by guest Protected by copyright

6 Use of helth cre serices fter stroke 227 chronic diseses in reltion to their socil nd economic sttus'2 The fct tht both older ptients nd those with femle GP were less likely to receie therpy cnnot be clerly explined To dte rious studies he identified consistently high nd low users of helth cre serices3"14 Our study disclosed tht t six months fter stroke 28% of the younger nd functionlly impired ptients mde use of 3% of the totl mount of gien cre The finding tht high users were younger thn the low users contrdicts the frequently stted generl ssumption tht elderly ptients re ery high users of ll types of helth cre serices 1 The ilbility of informtion bout the ptient's dischrge from the hospitl (or rehbilittion centre) ws relent fctor in explining the use of home help fterwrds: if the GP ws informed of dischrge the ptient ws more likely to use home help This my indicte tht well informed GP is more likely to initite help Alterntiely if hospitl tem considers home help to be necessry, the GP my be more likely to be contcted The results suggest tht the present system of orgnistion of cre my be improed by creting more effectie communiction between cre giers In ny new cre progrmme ("stroke serice") tht ims t dpting tretment nd circumstnces to the ptient's needs, enhncing supportie cre, nd eluting efficcy of both cre nd rehbilittie interentions the lines of communiction should be well deeloped nd formlised Our study hs four limittions Firstly, we focused only on forml use of helth cre Since informl cre giers re probbly common proiders of cre in the community, dditionl cre ws probbly gien by the ptient's proxy For exmple, nlysing the use of forml nd informl home cre by disbled elderly people, Kemper found tht the ilbility of proxy reduced the probbility of receiing forml cre, by bout 7-1% from tht when no proxy ws ilble 1 Secondly, we ssessed only the frequency of use of cre fter stroke nd therefore knew little of the ptterns of intensity of cre Thirdly, we studied solely the period up to six months fter stroke nd cn speculte only on how cre ptterns fter stroke ultimtely will deelop oer time Finlly, lthough on n ggregte leel "equity" is significnt bsic indictor for qulity of cre, on n indiidul leel this concept tells us nothing bout the cre processes For exmple, despite the substntil mount of cre gien to ptients with stroke they my still perceie needs for dditionl cre Nturlly, it is doubtful whether ll unmet cre demnds of ptients re synonymous with objectie clinicl needs; from ptient's iewpoint, howeer, unmet demnds re needs, nd consequently they my reflect inefficcy of cre We conclude tht use of helth cre serices fter stroke ws mostly explined by needs nd predisposing fctors such s ge, liing rrngement, nd socil circumstnces This finding supports the principle of equity on which the helth cre system in the Netherlnds is bsed Howeer, some inequitble cre cnnot be ruled out; while djusting for the impct of need fctors, older ge nd lower finncil income decresed the use of rehbilittie therpy The GP being informed bout ptient's dischrge lso explined the lloction of cre Besides elutions of the lloction of helth cre resources, studies re needed of lterntie indictors of qulity of cre These studies, on n indiidul ptient leel, should be focused on cre processes nd cre outcomes in terms of subjectie needs, perceied cre deficits, nd stisfction with cre We thnk Prof Dr H n Creel, Deprtment of Neurology, Acdemic Medicl Centre, Amsterdm, for supporting this study nd for his helpful dice in prepring this mnuscript This study ws funded by De Nederlndse Hrtstichting (NHS 4 nd Ontwikkelingsgeneeskunde (OG ) 1 Hermn B, Leyten ACM, n Luijk JM, Frenken CWGM, Op de Coul AAW, Schulte BPM Epidemiology of stroke in Tilburg, the Netherlnds: the popultion-bsed stroke incidence register 2 Incidence, initil clinicl picture nd medicl cre, nd three week cse ftlity Stroke 1982;13: Mlmgren R, Bmford J, Wrlow C, Sndercock P, Slttery J Projecting the number of ptients with first eer strokes nd ptients newly hndicpped by stroke in Englnd nd Wles BMJ 1989;298:5-3 Doe HG, Schneider KC, Wllce JD Eluting nd predicting outcome of cute cerebrl sculr ccident Stroke 1984;15: Sillimn RA, Wgner EH, Fletcher RH The socil nd functionl consequences of stroke for elderly ptients Stroke 1987;18:2-3 5 Ebrhim S, Brer D, Nouri F An udit of follow up serices for stroke ptients fter dischrge from hospitl Interntionl Disbility Studies 9:13-5 Thorngren M, Westling B Utilistion of helth cre resources fter stroke A popultion bsed study of 258 hospitlised cses followed during the first yer Act Neurol Scnd 199 1;84: Andersen R, Krits J, Anderson OW Equity in helth serices, empiricl nlysis in socil policy Cmbridge: Bllinger, Folstein MF, Folstein SE, McHugh PR "Mini-mentl stte" A prcticl method for grding the cognitie stte of ptients for the clinicin JT Psychitr Res 1975; 12: Wde DT, Collin C The Brthel ADL index: stndrd mesure of physicl disbility? 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