Date Published: January 28, 2019
Publisher: Public Library of Science
Author(s): Yen Shing Yeoh, Gerald Choon-Huat Koh, Chuen Seng Tan, Tian Ming Tu, Rajinder Singh, Hui Meng Chang, Deidre A. De Silva, Yee Sien Ng, Yan Hoon Ang, Philip Yap, Effie Chew, Reshma A. Merchant, Tseng Tsai Yeo, Ning Chou, N. Venketasubramanian, Kim En Lee, Sherry H. Young, Helen Hoenig, David Bruce Matchar, Nan Luo, Amir H. Pakpour.
This study aimed to quantify health-related quality of life (HRQoL) loss associated with first episode of stroke by comparing patient-reported HRQoL before and after stroke onset. The impact of stroke in local population was also evaluated by comparing the pre- and post-stroke HRQoL with that of the general population.
The HRQoL of stroke survivors was assessed with the EQ-5D-3L index score at recruitment, for recalled pre-stroke HRQoL, and at 3 and 12 month post-stroke. Change in HRQoL from pre-stroke to 3 and 12 month was self-reported by 285 and 238 patients, respectively. Mean EQ index score at each time point (baseline: 464 patients; 3 month post-stroke: 306 patients; 12 month post-stroke: 258 patients) was compared with published population norms for EQ-5D-3L.
There was a significant decrease in HRQoL at 3 (0.25) and 12 month (0.09) post-stroke when compared to the retrospectively recalled patients’ mean pre-stroke HRQoL level (0.87). The reduction at 3 month was associated with the reduction in all EQ-5D-3L health dimensions; reductions remaining at 12 month were limited to dimensions of mobility, self-care, usual activities, and anxiety/depression. Stroke patients had a lower mean EQ index than the general population by 0.07 points pre-stroke (0.87 vs. 0.94), 0.33 points at 3 month (0.61 vs. 0.94) and 0.18 points at 12 month (0.76 vs. 0.94) post-stroke.
Stroke has a substantial impact on HRQoL in Singapore, especially in the first three months post-stroke. Compared to the general population, stroke survivors have lower HRQoL even before stroke onset. This pre-stroke deficit in HRQoL should be taken into account when quantifying health burden of stroke or setting goals for stroke rehabilitation.
Prior to the seventies, the health outcomes of disease were primarily measured with the rather limited “hard” end-points, for example, survival and treatment toxicity. Over the past few decades, concern for psychosocial needs of patients has increased dramatically. There is growing awareness that in certain diseases, particularly chronic diseases, health-related quality of life (HRQoL) may be the most important health outcome to consider in revealing the impact of disease .
A study flow chart is shown in Fig 1. After excluding patients experiencing recurrent stroke, cases answered by caregiver, and cases with missing information in EQ-5D, a total of 464, 306 and 258 patients at baseline (Sample B1), 3 month (Sample B2) and 12 month (Sample B3), respectively, were included for cross-sectional comparison with population norms. At recruitment, the mean age was 61.8 years (standard deviation [SD] = 10.3) and 67.5% of patients were male. Majority of patients were of ethnic Chinese (69.4%), married (71.3%) and of Buddhism/ Taoism faith (48.1%). 52.8% of patients had spouse as their primary caregiver. Ischemic stroke (90.9%) was the main diagnosis. 71.1% of patients reported having hypertension, 68.5% having hyperlipidaemia and 37.1% having diabetes mellitus. Patients were generally having mild stroke (mean NIHSS score = 4.0) with normal cognitive function (mean MMSE > 24). Patients followed-up at 3 month and 12 month had similar characteristics to those surveyed at recruitment except that they were more likely to be married and had a spouse as their primary caregiver. For assessing HRQoL changed before and after stroke, 285 patients were included for assessing change from baseline to 3 month (Sample A1) and 238 patients were included for assessing change from baseline to 12 month (Sample A2). Study samples A1 and A2 were subsets of samples B2 and B3, respectively. The characteristics of the two samples are shown in Table 1.
Comparison of self-reported HRQoL before and after stroke provides the best information on HRQoL loss resulting solely from the onset of stroke. Patients’ perceived pre-stroke HRQoL is an important factor to consider and could certainly influence post-stroke functions over time. Although age-gender standardized population norms was commonly used as reference points to measure the HRQoL loss of disease population, Watson et al.  and Wilson et al.  demonstrated that retrospective baseline measurement of pre-onset HRQoL is more appropriate than the application of population norms for evaluating post event losses. In this study, we quantified HRQoL loss associated with first-time stroke using recalled pre-stroke HRQoL as the baseline measurement. As shown in our study, the HRQoL of stroke survivors at 3 month was 71% of pre-stroke HRQoL and it was recovered up to 90% of the pre-stroke HRQoL at 12 month.
Stroke has substantial impact on HRQoL of Singaporean stroke survivors, especially in the first three month post-stroke. Compared to the general population, stroke survivors have lower HRQoL even before stroke onset. This difference should be taken into account when quantifying health burden of stroke or setting the target of rehabilitation for stroke survivors.