September/October 2015

EuroQol Measures Stroke Outcome
By Kimberly Hreha, OTR/L; Karen West, DPT; Caitlin Denzer-Weiler, DPT; Antoinette Gentile, OTR/L; and A.M. Barrett, MD
Today's Geriatric Medicine
Vol. 8 No. 5 P. 26

The EuroQol assessment provides meaningful information about stroke survivors' perceptions of resulting physical deficits and their own quality of life.

Health-related quality of life (HRQoL) refers to the value individuals place on their current living situations in relation to their well-being.1 Many factors contribute to an individual's HRQoL including, but not limited to, functional status, depression, performance in usual activities, pain, and anxiety. Quality of life (QoL) is multifactorial in individuals without medical complications; however, in individuals who have survived a stroke, the idea of QoL becomes increasingly complex.1

Stroke is a leading cause of death in the United States,2 although as medical advances continue, survival rate is increasing and, consequently, increasing numbers of people are living with impairments and for a longer time.3 Thus, stroke is a major contributor to disability. Seventy-five percent of people report that their stroke-related disability impacts their QoL because a stroke can drastically change an individual's physical, social, and/or psychological status. Participation in daily activities, such as walking, may be limited; swallowing may be challenging; or engagement in instrumental activities of daily living, such as cooking, may be compromised due to safety concerns.

Measuring QoL, as estimated by the stroke survivor, can provide therapists with insight into a patient's opinions and concerns regarding the personal impact of his or her stroke.4 The EuroQol or EuroQol-5 dimensions (EQ-5D) questionnaire is a simple instrument used to describe and quantify HRQoL.5 It was developed specifically as a patient-reported outcome measure; however, there are sections for clinician and proxy (ie, family or caregiver) scores.5 The development and validation of this instrument has become an important area of research.1,4,6 Internal consistency, reliability, validity, and responsiveness have been established with this tool for diagnoses such as chronic pain, traumatic brain injury,7 and stroke.8,9 This information has been summarized by the Neurology Section of the American Physical Therapy Association. Assigned research and clinical experts compiled current research in order to make appropriate recommendations based on diagnosis.7 The stroke-related suggestions for use include the following:

• The EQ-5D can be used for the subacute stroke survivor (two to six months postonset) and chronic stroke survivors (greater than six months).

• It is appropriate to use in an inpatient rehabilitation setting, a skilled nursing facility, an outpatient rehabilitation setting, and home health. In addition, it is not suggested that students learn to administer this tool but only that they are exposed to it.

• Finally, the EQ-5D is appropriate to use as an outcome measure for intervention research studies.7

Details of the Measure
Necessary supplies include paper, pencils, copies of the assessment, and the downloaded user-guide book which can be found on the EQ-5D website (www.euroqol.org) and replaces the need for a formal training process. In addition, it is suggested that users request permission to utilize the assessment, and this process can be completed online via a simple registration form on the EQ-5D website. This form can be completed quickly and triggers an e-mail response from the EQ-5D creators, stating that licensure has been granted and noting the cost involved for licensing. The cost varies depending on users' plans for the assessment's use (for example, using the measure to collect information for a randomized controlled trial vs use in clinical practice).

The EQ-5D requires less than five minutes to administer. The EQ-5D provides rehabilitation team members, caregivers, and/or family members the opportunity to determine a stroke survivor's perception on a simple descriptive profile and identify the score on the single index value for health status. For example, overall health status is measured using a visual analog scale ranging from 0% to 100%, with 0% being the worst possible health state and 100% being the best possible health state. There are also five dimensions that are rated on a Likert scale, and each dimension is described as "no problem," "mild to moderate," or "severe." These dimensions include mobility, self-care, usual activities, pain/discomfort, and anxiety/depression.7

The International Classification of Functioning, Disability, and Health (ICF) terminology identifies major factors that contribute to body and structural and functional impairments, activity limitations, and participation restrictions. The field of medical rehabilitation has been indirectly "trained" to work in tandem with this framework. For example, rehabilitation professionals focus on assessing body structure, function, activity, participation, and personal factors in order to develop an optimal treatment plan or better document the need for continued therapy. Thus, if looking to classify the EQ-5D based on the ICF framework, the assessment would encompass body structure, body function, and participation.10

Clinical Implementation
Kessler Institute for Rehabilitation (Kessler) is an inpatient acute rehabilitation hospital in New Jersey that each year treats more than 2,000 stroke survivors. The physical and occupational therapists at Kessler are responsible for administering many different outcome measures, an important way to ensure good clinical practice and enhance clinical care.11 Since 2012, the EQ-5D has been administered at Kessler for stroke survivors. The management team implemented this assessment tool because the Commission on Accreditation of Rehabilitation Facilities required inclusion of a patient-reported outcome measure into assessment measures and the Rehabilitation Measures Database7 recommendation is that EQ-5D is appropriate for use in this practice setting.

Following implementation, it was important for the team to know that the use of this outcome measure was appropriate and feasible for stroke survivors at Kessler. Between 2012 and 2013, we assessed more than 175 moderately impaired stroke survivors and, among them, only 10.2% were unable to complete the EQ-5D due to cognitive/language impairments (ie, delirium, aphasia).12 Since 2013, we have obtained more than 500 patient scores.

Future Implications and the Need for Research
We support stroke research studies being completed in acute rehabilitation settings and we advocate for the EQ-5D to be used as an outcome measure. It would be helpful if a better process were determined for collecting family/caregiver scores because clinically we found it challenging to be compliant when the family members or caregivers were not always present at the time the measure was administered.

At Kessler, we have obtained institutional review board approval to perform retrospective research on this topic. Specifically, we plan to explore different areas of function to clarify which factors lead to or indicate improvement on HRQoL measures. In addition, we expect to determine whether the EQ-5D correlates to discharge disposition or acts as predictive of long-term home living, which was recently studied in Germany.13 We are interested in assessing for a correlation between a patient's view of his or her health and the perspectives offered by family members and therapists.

Adaptability and Efficacy
We believe we have successfully achieved our goals of implementing the EQ-5D and obtaining patient scores. However, as previously mentioned, further effort is required to address a more consistent collection of family and caregiver scores. Through continued data collection, we expect to demonstrate other potential variables and correlations. While we believe this assessment is adaptable to other care settings, this suggestion applies only to stroke survivors. There is insufficient empirical evidence to expand this suggestion to the traumatic brain injury population, for example.7 Additionally, because the EQ-5D has been translated into more than 150 languages, it is adaptable to other countries.

Conclusions
The EQ-5D is an assessment that is highly recommended because it is simple, standardized, and applicable to a wide range of health conditions and easily implemented in the clinical setting. It is unique because it identifies a quantitative single value for health status and ordinal ranking of the five dimensions based on a patient's personal perception. As health care professionals are interested in multidimensional factors of health and addressing individualized goals, they should be interested in obtaining and understanding more about each individual's QoL and the perceived impact of his or her stroke.

— Kimberly Hreha, OTR/L, is the stroke clinical research coordinator for Kessler Institute for Rehabilitation's (KIR) three hospitals. An EdD student at Teachers College, Columbia University, her research focuses on spatial neglect and motor impairments following stroke.

— Karen West, DPT, works at KIR with patients with stroke, brain injury, spinal cord injury, and amputation, and acts as the lead for the EuroQol project for the West Orange, New Jersey, campus.

— Caitlin Denzer-Weiler, DPT, specializes in treating neurologic patients, particularly those with stroke or brain injury, at KIR in Chester, New Jersey.

— Antoinette Gentile, OTR/L, the clinical manager of occupational therapy at KIR in Saddle Brook, New Jersey, specializes in neuro-rehabilitation for stroke and brain injury.

— A.M. Barrett, MD, a cognitive and behavioral neurologist and neuroscientist, is the director of the Stroke Lab at Kessler Foundation, chief of the Neurorehabilitation Program Innovation at KIR, coleader of the KIR Stroke Rehabilitation Program, and a professor of physical medicine and rehabilitation at Rutgers New Jersey Medical School.

References
1. Pinto EB, Maso I, Vilela RN, Santos LC, Oliveira-Filho J. Validation of the EuroQol quality of life questionnaire on stroke victims. Arq Neuropsiguiatr. 2001;69(2B):320-323.

2. Go AS, Mozaffanan D, Roger VL, et al. Heart disease and stroke statistics—2014 update: a report from the American Heart Association. Circulation. 2014;129(3):e28-e292.

3. Coffey CE, Cummings JL, eds. The American Psychiatric Press Textbook of Geriatric Neuropsychiatry. 2nd ed. Washington, D.C.: American Psychiatric Publishing; 2000:601-617.

4. Dorman PJ, Waddell F, Slattery J, Dennis M, Sandercock P. Is the EuroQol a valid measure of health-related quality of life? Stroke. 1997;28(10):1876-1882.

5. Dorman PJ, Waddell F, Slattery J, Dennis M, Sandercock P. Are proxy assessments of health status after stroke with the EuroQol questionnaire feasible, accurate, and unbiased? Stroke. 1997;28(10):1883-1887.

6. Dorman PJ, Dennis M, Sandercock P. How do scores on the EuroQol relate to scores on the SF-36 after stroke? Stroke. 1999;30(10):2146-2151.

7. Rehabilitation Measures Database website. http://www.rehabmeasures.org

8. Dorman PJ, Slattery J, Farrell B, Dennis M, Sandercock P. Qualitative comparison of the reliability of health status assessments with the EuroQol and SF-36 questionnaires after stroke. United Kingdom Collaborators in the International Stroke Trial. Stroke. 1998;29(1):63-68.

9. Hunger M, Sabariego C, Stollenwerk B, Cieza A, Leidl R. Validity, reliability and responsiveness of the EQ-5D in German stroke patients undergoing rehabilitation. Qual Life Res. 2012;21(7):1205-1216.

10. World Health Organization. International Classification of Functioning, Disability, and Health. Published 2001. http://psychiatr.ru/download/1313?view=1&name=ICF_18.pdf

11. Sullivan J, Crowner B, Kluding P, et al. Outcome measures for individuals with stroke: process and recommendations from the American Physical Therapy Association neurology section task force. Phys Ther. 2013;93(10):1383-1396.

12. Frisina P, Kutlik A, Hreha K, Barrett A. Measuring Health-Related Quality of Life (HRQOL) During Inpatient Stroke Rehabilitation. Platform presentation at: American Academy for Neurology 66th Annual Meeting; April 29, 2014; Philadelphia, PA.

13. Graessel E, Schmidt R, Schupp W. Stroke patients after neurological inpatient rehabilitation: a prospective study to determine whether functional status or health-related quality of life predict living at home 2.5 years after discharge. Int J Rehabil Res. 2014;37(3):212-219.