Centre for Biostatistics, School of Health Sciences, The University of Manchester, Faculty of Biology Medicine and Health, Manchester, UK
Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine Faculty of Public Health and Policy, London, UK.
BMJ Open. 2022 Apr 1;12(4):e059684. doi: 10.1136/bmjopen-2021-059684.
'More is better' is a recognised mantra within stroke therapy, however, this has been developed in patients receiving long term rehabilitation. We investigated the relationship between amount of therapy received (from therapists and psychologists) and key patient outcomes during inpatient care.
A secondary analysis of data from a prospective cohort study was performed. Multilevel mixed models adjusting for measured confounders (eg, severity), explored the relationship between therapy dose (average minutes per day of stay) and outcomes (disability, length of stay, home at discharge and mortality). Therapy was explored using simple linear terms and flexible natural cubic splines to allow for more complex relationships.
Data from the Sentinel Stroke National Audit Programme, covering England, Wales and Northern Ireland between July 2013 and July 2015 contained 94 905 adults with a stroke and still an inpatient after 72 hours. These patients received 92% (physiotherapy), 88% (occupational therapy), 57% (speech and language therapy) and 5% (clinical psychology), respectively.
The average amount of therapy, for individual and 'any' therapy combined per day of stay was low. Overall, 41% were discharged with an 'independent' modified Rankin Scale (≤2), 14% died, 44% were discharged home, and the median length of stay was 16 days. We observed complex relationships between amount of therapy received and outcomes. An additional minute of 'any' therapy, occupational therapy, speech and language therapy and clinical psychology was associated with improved outcomes. Conversely, more physiotherapy was also associated with lower mortality and shorter length of stay, but also lower independence and discharge home.
Our findings suggest for stroke inpatients requiring therapy, 'More is better' may be overly simplistic. Strong limitations associated with analysis of routine data restrict further robust investigation of the therapy-response relationship. Robust prospective work is urgently needed to further investigate the relationships observed here.
“多即是好”是卒中治疗中公认的原则，但这是在接受长期康复治疗的患者中发展起来的。我们研究了住院期间接受的治疗量（来自治疗师和心理学家）与关键患者结局之间的关系。
对一项前瞻性队列研究数据的二次分析。使用多水平混合模型调整了测量混杂因素（例如严重程度），探讨了治疗剂量（住院期间每天的平均分钟数）与结局（残疾、住院时间、出院时回家和死亡率）之间的关系。使用简单线性项和灵活的自然三次样条来探索治疗，以允许更复杂的关系。
2013 年 7 月至 2015 年 7 月，来自 Sentinel Stroke National Audit Programme 的数据覆盖了英格兰、威尔士和北爱尔兰的 94905 名成年人，他们在 72 小时后仍为住院患者。这些患者分别接受了 92%（物理治疗）、88%（职业治疗）、57%（言语和语言治疗）和 5%（临床心理学）。
每天接受的治疗量，个体和“任何”治疗的平均量都很低。总体而言，41%的患者出院时改良 Rankin 量表评分为≤2，14%死亡，44%出院回家，住院时间中位数为 16 天。我们观察到接受的治疗量与结局之间存在复杂的关系。“任何”治疗、职业治疗、言语和语言治疗以及临床心理学增加一分钟与结局改善相关。相反，更多的物理治疗也与死亡率降低和住院时间缩短相关，但也与独立性降低和出院回家相关。
我们的发现表明，对于需要治疗的卒中住院患者，“多即是好”可能过于简单化。与分析常规数据相关的强烈限制限制了对治疗反应关系的进一步深入研究。迫切需要进行稳健的前瞻性工作，以进一步研究这里观察到的关系。
