Predicting Patient-Reported Stroke Outcomes: A Validation of the Six Simple Variable Prognostic Model

Abstract

Background: Case-mix represents the range of disease severity and baseline characteristics that may be the cause of variation in outcomes between individuals and populations. Adjustment for case-mix is therefore important to allow meaningful comparison of healthcare outcomes. The best available case-mix adjustment model for stroke (the Six Simple Variable [SSV] model) was developed to adjust the hard endpoints of independent survival, survival and alive and living at home. There is increasing interest in the measurement of patient-reported outcomes through self-completed questionnaires, though there are currently no robust adjustment models for any such outcome. We aimed to determine whether the SSV prognostic model derived to predict 6-month post-stroke independent survival has wider utility in case-mix adjustment of a patient-reported functional outcome measure, the Subjective Index of Physical and Social Outcome (SIPSO), collected by post 6 months after stroke onset. Methods: We examined data from 176 patients admitted following an acute stroke and recruited into a prospective cohort study in three participating acute hospitals in Yorkshire, UK. Patients in receipt of palliative care or with transient ischaemic attack were excluded. Using the beta coefficients from the published SSV model to predict independent survival, individual probabilities of ‘good' outcome as measured with the dichotomised SIPSO collected by post 6 months after stroke onset were calculated. The ability of the SSV case-mix adjustment model to discriminate patients with ‘good' over ‘poor' outcome was assessed through calculation of C statistics. Correct predictions were visualised with calibration plots. Results: The C statistics for the SSV model to predict the physical and social subscales of the SIPSO outcome measure were 0.73 (95% CI 0.65-0.79) and 0.66 (0.58-0.82), respectively. Inclusion of patients who died prior to follow-up and ascribing them a score of 0 improved the discrimination (0.76 [0.70-0.82] and 0.70 [0.64-0.76], respectively). Calibration plots demonstrated a tendency to over-optimistic predictions, although confidence limits were wide. Conclusions: The SSV model predicts adequately the physical component of the SIPSO patient-reported outcome measure and may be useful to adjust this outcome for case-mix following stroke in survivors to follow-up. This could be of benefit in observational studies, stratified randomisation for trials, and in comparison of between-institution clinical trials. Further exploration of the generalizability of the model to adjust other patient-reported stroke outcomes may be warranted.

Change in cognitive performance is associated with functional recovery during post-acute stroke rehabilitation: a multi-centric study from intermediate care geriatric rehabilitation units of Catalonia

“…Regarding the meaning of a longer hospital stay and an increased time of rehabilitation, doubts about the effective impact of these variables remain (we found 1 % increased chance of better outcome for every day of rehabilitation). Previous literature reported discordant results about the impact of longer hospital stay and rehabilitation on functional outcomes after stroke, with some authors finding positive results [11,30,31], whereas others a negative impact [32].…”

Home-Time Is a Feasible and Valid Stroke Outcome Measure in National Datasets

“…SSV is a prognostic scale that includes pre-stroke living arrangements and independence, and post stroke orientation, arm movement, mobility and verbal response. 7 We assessed SSV as an ordinal scale, in aggregate and individual components, and as a quasi-continuous measure including age. 8 SSV is used as a case-mix adjuster in trials and has been shown to have excellent prognostic utility.…”

“…8 SSV is used as a case-mix adjuster in trials and has been shown to have excellent prognostic utility. 7 Age and NIHSS were combined to calculate SPAN score, another validated prognostic scale. 9 We described association for the complete group and subgroups of 90-day survivors and those admitted from home.…”

Integrating Palliative Care Into the Care of Neurocritically Ill Patients

“…Adjustment for case-mix and the use of patient or family-reported outcomes in future studies may help improve prognostication, but, importantly, such models will always suffer from this inherent limitation. [33, 34] Models that predict functional recovery are also limited by the challenges in predicting an individual patient's ability to adapt (“response shift”) to a neurologic deficit that the patient has not yet experienced, as well as reframing or changing perceptions of quality of life that can occur over time. [35, 36]…”