The Care and Rehabilitation of Stroke Patients One Year Following the Event

Stroke is a major health problem in the western world, and places significant financial burden on the health system. Since most of those who suffer from stroke are age 65 or over, and since stroke is the primary reason for disability among the elderly, it may be used to measure their care and rehabilitation by the health system.

This study examined treatment in hospitals and in the community of stroke victims during the year following the stroke, with attention to differences in the availability and accessibility of services among health plans and geographic regions, and to unmet needs. During one year, a prospective follow-up was conducted of 616 people with stroke who were admitted to seven large hospitals around Israel. The average age of the patients was 72, and about one-quarter of them were age 80 or over.

During the year following the stroke, 30% of the patients died (17% of them during the acute stage). Two-thirds of them returned directly to the community, while the remainder went to geriatric rehabilitation hospitals or long-term care institutions before returning to the community. Most of them returned to the community within three months of the stroke. About half of those who survived one year after the stroke had some impairment of their motor functioning, ability to communicate, or cognition, or a disability that affected their quality of life.

The patients were admitted to internal medicine or neurological wards and remained hospitalized for an average of 11 days. About half of them received physiotherapy during their hospital stay, but only a few received other rehabilitative therapies. Most of the patients who were transferred to continued hospitalization received rehabilitative therapies during the first three months following the stroke, compared to only a few of those who returned directly to the community. No differences were found among the health plans in the proportion of patients who returned directly to the community or were transferred for further hospitalization. However, members of Clalit Health Services were more likely to be transferred to a geriatric rehabilitation hospital than members of the other health plans. Patterns of discharge were especially important given that patients who went to a geriatric rehabilitation hospital had a greater chance of improving their functioning three months and even one year after the event, than were those who went directly to the community or to a long-term care institution.

The study found significant differences among wards and hospitals, and highlight the need to develop criteria, standards, and clinical guidelines for the diagnosis and treatment of stroke patients. The brevity of the hospital stay and the small quantity of community rehabilitation services, along with the complexity of stroke, emphasize the need to determine the best discharge destination. The findings of this study were discussed by the National Geriatric Council and served as a basis for discussions in the Ministry of Health. The Ministry has instructed the health plans and hospital directors not to send individuals who need rehabilitation to long-term care institutions, so that patients can maximize their functional potential after stroke. The finding that rehabilitation services in the community are limited, emphasizes a need to examine the reasons for barriers to these services, as well as how to expand them and develop alternative patterns of rehabilitation in the community. The study also identified a need to examine National Health Insurance Law regulations on the rehabilitative services that the health plans are obligated to provide. Thought should be given to the health plans’ activity in this area, so as to ensure that services are appropriate.

This study was carried out with help of a grant from the Israel National Institute for Health Policy and Health services Research.