Advertisement
Research Article| Volume 30, ISSUE 3, P475-482, June 2023

Download started.

Ok

Physical function, depressive symptoms, and quality of life with post-acute stroke care

  • Shu-Chin Yao
    Affiliations
    Division of Nursing, Chang Gung Memorial Hospital, Chiayi Branch, Taiwan
    Search for articles by this author
  • Suh-Ing Hsieh
    Affiliations
    Department of Nursing & Graduate Institute of Nursing, Chang Gung University of Science and Technology, Taiwan

    Division of Nursing, Chang Gung Memorial Hospital, Taoyuan Branch, Taiwan
    Search for articles by this author
  • Jiann-Der Lee
    Affiliations
    Department of Neurology, Chang Gung Memorial Hospital, Chiayi Branch, Taiwan
    Search for articles by this author
  • Tsui-Ping Chu
    Affiliations
    Division of Nursing, Chang Gung Memorial Hospital, Chiayi Branch, Taiwan
    Search for articles by this author
  • Jun-Yu Fan
    Correspondence
    Correspondence to: Department of Nursing & Graduate Institute of Nursing, Chang Gung University of Science and Technology, 261, Wen-Hua 1st Road, Kwei-Shan, Tao-Yuan 333-03, Taiwan. Tel.: +886-3-2118999; fax: +886-3-2118866.
    Affiliations
    Department of Nursing & Graduate Institute of Nursing, Chang Gung University of Science and Technology, Taiwan

    Division of Nursing, Chang Gung Memorial Hospital, Linkou Branch, Taiwan
    Search for articles by this author
Open AccessPublished:February 28, 2023DOI:https://doi.org/10.1016/j.colegn.2023.01.001

      ABSTRACT

      Background

      Few studies have investigated changes in physical function, psychological status, and quality of life (QOL) among stroke survivors receiving post-acute care (PAC). Nursing care has an important effect on patient outcomes, but there is very little evidence of nurses’ role in rehabilitation after stroke in Taiwan.

      Aim

      To investigate the trajectories of physical function, depressive symptoms, QOL, and factors associated with QOL in patients who received a hospital-based PAC program over 12 weeks after stroke.

      Methods

      A quasi-experimental design was employed and the study conducted in a teaching hospital in central Taiwan. Measurement tools included the Barthel Index, modified Rankin Scale, Instrumental Activities of Daily Living Scale, Geriatric Depression Scale, and Stroke Impact Scale. Data were collected at weeks one, four, eight and twelve after stroke. Descriptive, inferential, generalized estimating equations, and multiple linear regression analyses were performed.

      Findings

      Overall, 61 stroke survivors (mean age, 67.59 ± 15.64 years) were enrolled: 93.44% of strokes were ischaemic, and 59.02% of participants were male. Forty-one patients had received hospital-based PAC, while 20 had not. The PAC group exhibited significant improvements (all p < 0.05) in physical function recovery, depressive symptoms, and QOL from the 8th week post stroke compared with the regular care group. Functional recovery and depressive symptoms were significantly associated with QOL at weeks four, eight and twelve weeks after stroke.

      Discussion

      The hospital-based PAC program led to improved physical function, depressive symptoms, and QOL in patients over the 12 weeks following stroke. Physical function and depression after stroke were factors significantly associated with the patients’ QOL.

      Conclusion

      Both functional and psychological recovery impact the QOL of stroke survivors. Nurses are responsible for enhancing stroke survivors’ functional activities, recognising and supporting their psychological issues, and improving their QOL via interventions implemented during the PAC rehabilitation program.

      Keywords

      Summary of relevance
      Problem or Issue
      Limited evidence is available regarding the changing trends of physical function, psychological status, and quality of life (QOL) in patients with stroke receiving post-acute care (PAC).
      What is already known
      PAC is associated with improved functional recovery of patients with stroke.
      What this paper adds
      In the long term, patients with stroke who received PAC showed significantly better trajectories of physical function, psychological status, and QOL than those who did not.

      1. Introduction

      In Taiwan, stroke is the fourth leading cause of death (

      Ministry of Health and Welfare(2021). Executive Yuan. 2020 Cause of Death Statistics. 〈https://www.mohw.gov.tw/cp-5256-63399-2.html〉.

      ). Patients who survive a stroke often develop different levels of impairment associated with physical disabilities in adult patients and impose a heavy burden on the economy and society (
      • Avan A.
      • Digaleh H.
      • Di Napoli M.
      • Stranges S.
      • Behrouz R.
      • Shojaeianbabaei G.
      • et al.
      Socioeconomic status and stroke incidence, prevalence, mortality, and worldwide burden: an ecological analysis from the Global Burden of Disease Study 2017.
      ,
      • Donkor E.S.
      Stroke in the 21st century: a snapshot of the burden, epidemiology, and quality of life.
      ,
      • Wafa H.A.
      • Wolfe C.D.A.
      • Emmett E.
      • Roth G.A.
      • Johnson C.O.
      • Wang Y.
      Burden of stroke in Europe: thirty-year projections of incidence, prevalence, deaths, and disability-adjusted life years.
      ).
      • Rudberg A.S.
      • Berge E.
      • Gustavsson A.
      • Näsman P.
      • Lundström E.
      Long-term health-related quality of life, survival and costs by different levels of functional outcome six months after stroke.
      , using the Oxford Handicap Scale and the three-level version of the EuroQol-5 dimension (EQ-5D) questionnaire, demonstrated that patients with a better functional outcome level 6 months poststroke had a significantly better health-related quality of life (HRQOL) 18 months poststroke, better long-term survival, and lower medical expenditure (shorter length of stay in the hospital) up to 36 months. Based on these findings,
      • Rudberg A.S.
      • Berge E.
      • Gustavsson A.
      • Näsman P.
      • Lundström E.
      Long-term health-related quality of life, survival and costs by different levels of functional outcome six months after stroke.
      suggested that limited functional outcomes caused by long-term disability might be a critical factor affecting quality of life (QOL) after stroke.
      After a stroke, survivors often experience feelings of irritability, forgetfulness, anger, anxiety, or depression (). The prevalence of depression after mild-to-moderate stroke was 35.3%, 24.9%, and 25.7% at 3 months, 6 months, and 12 months, respectively (
      • Dong L.
      • Williams L.S.
      • Brown D.L.
      • Case E.
      • Morgenstern L.B.
      • Lisabeth L.D.
      Prevalence and course of depression during the first year after mild to moderate stroke.
      ), and these depressive symptoms could last for 6 years (
      • Ytterberg C.
      • Cegrell L.
      • von Koch L.
      • Wiklander M.
      Depression symptoms 6 years after stroke are associated with higher perceived impact of stroke, limitations in ADL and restricted participation.
      ). These results were consistent with those of two meta-analyses showing that the prevalence of poststroke depression (PSD) ranged from 18% to 33% in stroke survivors (
      • Jørgensen T.S.
      • Wium-Andersen I.K.
      • Wium-Andersen M.K.
      • Jørgensen M.B.
      • Prescott E.
      • Maartensson S.
      • et al.
      Incidence of depression after stroke, and associated risk factors and mortality outcomes, in a large cohort of Danish patients.
      ,
      • Mitchell A.J.
      • Sheth B.
      • Gill J.
      • Yadegarfar M.
      • Stubbs B.
      • Yadegarfar M.
      • et al.
      Prevalence and predictors of post-stroke mood disorders: a meta-analysis and meta-regression of depression, anxiety and adjustment disorder.
      ). Patients with PSD had higher mortality rates (
      • Jørgensen T.S.
      • Wium-Andersen I.K.
      • Wium-Andersen M.K.
      • Jørgensen M.B.
      • Prescott E.
      • Maartensson S.
      • et al.
      Incidence of depression after stroke, and associated risk factors and mortality outcomes, in a large cohort of Danish patients.
      ), more obvious cognitive deficits, more long-term disability, poor QOL, and higher suicidal tendencies compared with those without PSD (
      • Blöchl M.
      • Meissner S.
      • Nestler S.
      Does depression after stroke negatively influence physical disability? A systematic review and meta-analysis of longitudinal studies.
      ,
      • Hu J.
      • Ma L.
      • Yang Z.Y.
      Does citalopram effectively treat post-stroke depression?: a protocol for systematic review and meta analysis.
      ,
      • Medeiros G.C.
      • Roy D.
      • Kontos N.
      • Beach S.R.
      Post-stroke depression: a 2020 updated review.
      ). Stroke survivors displayed the lowest QOL in the first month after stroke, which gradually increased after rehabilitation treatment reached the optimal level six months after stroke. However, most patients had neither maintained nor regained their initial QOL one year after rehabilitation discharge (
      • Schindel D.
      • Schneider A.
      • Grittner U.
      • Jöbges M.
      • Schenk L.
      Quality of life after stroke rehabilitation discharge: a 12-month longitudinal study.
      ). Besides physical function and emotional status, other covariates, such as age, sex, education level, marital status, and severity and type of stroke, were significantly correlated with HRQOL (
      • Avan A.
      • Digaleh H.
      • Di Napoli M.
      • Stranges S.
      • Behrouz R.
      • Shojaeianbabaei G.
      • et al.
      Socioeconomic status and stroke incidence, prevalence, mortality, and worldwide burden: an ecological analysis from the Global Burden of Disease Study 2017.
      ).
      In the United States of America, approximately 70% of stroke survivors with Medicare received post-acute care (PAC) rehabilitation; however, PAC provision is highly heterogeneous, varying in the type of care setting, duration, intensity, and the degree of involvement of the medical specialists and registered nurses (
      • Winstein C.J.
      • Stein J.
      • Arena R.
      • Bates B.
      • Cherney L.R.
      • Cramer S.C.
      • et al.
      Guidelines for adult stroke rehabilitation and recovery: a guideline for healthcare professionals from the American Heart Association/American Stroke Association.
      ).
      • Wu K.Y.
      • Wu S.C.
      • Hung Y.N.
      • Wu C.C.
      • Lin L.C.
      • Hu H.H.
      The need for post-acute care for stroke patients in Taiwan.
      conducted a retrospective cohort study aimed to estimate whether PAC was needed for patients with stroke in Taiwan. The results showed that approximately 10.11–23.13% of patients with stroke might benefit from PAC, and its payment/reimbursement policy had to be considered to reduce acute medical expenditures. Therefore, since January 2014, the National Health Insurance Administration (NHIA) of Taiwan implemented the Post-Acute Care–Cerebrovascular Diseases (PAC–CVD) program to facilitate recovery of patients post stroke (
      • Lee W.J.
      • Chou M.Y.
      • Peng L.N.
      • Liang C.K.
      • Liu L.K.
      • Liu C.L.
      • et al.
      Predicting clinical instability of older patients in post-acute care units: a nationwide cohort study.
      ;

      National Health Insurance Administration of Taiwan Ministry of Health and Welfare, Executive Yuan (2022). Post-acute Care-Cerebrovascular Diseases (2020.04.10 update). (In Chinese). 〈https://www.nhi.gov.tw/Content_List.aspx?n=5A0BB383D955741C&topn=D39E2B72B0BDFA15〉 [Accessed 5 July 2022].

      ). The PAC–CVD program, a high-intensity hospital-based rehabilitation treatment plan, including physical and occupational therapies and language training, is implemented within six months after stroke, and the physical function of patients is measured every three weeks after receiving PAC (
      • Han D.S.
      • Lin C.W.
      • Lu L.
      • Hsiao M.Y.
      • Wu C.H.
      • Liang H.W.
      • et al.
      Taiwan guidelines for stroke rehabilitation.
      ,
      • Lee W.J.
      • Chou M.Y.
      • Peng L.N.
      • Liang C.K.
      • Liu L.K.
      • Liu C.L.
      • et al.
      Predicting clinical instability of older patients in post-acute care units: a nationwide cohort study.
      ). Data indicate that patients exhibited significant improvements in their modified Rankin Scale (mRS), Instrumental Activities of Daily Living (IADL), and Barthel Index (BI) scores after receiving PAC, indicating decreased dependency on others for their activities (
      • Hsien H.H.
      • Liou W.C.
      • Yang Y.H.
      Post-acute care improves daily activity functions of stroke patients: an effectiveness analysis.
      ,
      • Lai C.L.
      • Tsai M.M.
      • Luo J.Y.
      • Liao W.C.
      • Hsu P.S.
      • Chen H.Y.
      Post-acute care for stroke—a retrospective cohort study in Taiwan.
      ,
      • Weng S.-C.
      • Hsu C.-Y.
      • Shen C.-C.
      • Huang J.-A.
      • Chen P.-L.
      • Lin S.-Y.
      Combined functional assessment for predicting clinical outcomes in stroke patients after post-acute care: a retrospective multi-center cohort in central Taiwan.
      ,
      • Wu W.J.
      • Chang I.C.
      • Lin C.T.
      • Wang S.C.
      • Ku Y.R.
      The effects of enhanced physical therapy on post-acute stroke patients.
      ). However, studies have rarely investigated the recovery trends of physical function, psychological conditions, and QOL before, during, and after the PAC rehabilitation program.
      In Taiwan, nurses work with survivors of stroke, but there is very little evidence of their involvement in rehabilitation after stroke. Most stroke survivors with stable neurological conditions were discharged to another facility or home. The hospital-based PAC program is an updated clinical practice that differs from previous rehabilitation for stroke survivors in Taiwan. Thus, the study aimed to investigate the trajectories of physical function, depressive symptoms, QOL, and factors associated with QOL in patients who received a hospital-based PAC program over 12 weeks following stroke. Using this information, we can address the nurses’ role in nursing practice and empower them to fulfil their roles in stroke rehabilitation while improving the outcomes for stroke survivors (
      • Clarke D.J.
      Nursing practice in stroke rehabilitation: systematic review and meta-ethnography.
      ,
      • Meng X.
      • Chen X.
      • Liu Z.
      • Zhou L.
      Nursing practice in stroke rehabilitation: perspectives from multi-disciplinary healthcare professionals.
      ).

      2. Participants, ethics, and methods

      2.1 Study design, setting, and participants

      In this quasi-experimental study, patients in the neurology ward of a regional teaching hospital in central Taiwan were screened for eligibility to participate in the PAC–CVD program between July 2017 and January 2019. The inclusion criteria for patients were: (1) onset of acute ischaemic or haemorrhagic stroke confirmed by imaging or diagnosed by a physician within the past 8–30 days, (2) at least 20 years of age, (3) clear consciousness and ability to communicate, and (4) an mRS score of 2–4 points. The exclusion criteria for patients were: (1) diagnosis of cognitive decline or mental health conditions by a physician before the stroke, (2) aphasia (including motor aphasia) or illiteracy combined with severe hearing loss and inability to use verbal or nonverbal communication, (3) diagnosis of depression by a physician before the stroke, or (4) a post-acute stroke stage with prior rehabilitation treatments unrelated to stroke. The patients who opted for PAC and agreed to participate in the follow-up study constituted the PAC group, whereas those who did not wish to participate in the PAC program but agreed to participate in the follow-up study constituted the regular care group.
      The sample size was computed with a prior power analysis using the G-power version 3.1.9.2 software (Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Germany). With a power of 80%, alpha of 0.05, an effect size of 0.25, and four repeats, the required sample size was calculated as 48. Of the 62 eligible patients, one participated in the first investigation alone and withdrew. Overall, 61 patients were enroled, with 41 in the PAC group and 20 in the regular care group. The ages ranged from 20 to 91 years, with an average age of 67.59 ± 15.64 years, and the majority were males (36, 59.02%), married (51, 83.61%), had an elementary school education (21, 34.43%), and were unemployed before stroke onset (36, 59.02%) (Table 1).
      Table 1Comparison of the homogeneity of patients in the PAC and regular care groups (n = 61).
      VariablesAll patientsPAC group (n = 41)Regular care group (n = 20)t/x2p-value
      n (%)Mean (SD)n (%)Mean (SD)n (%)Mean (SD)
      Age (years)67.59 (15.64)65.00 (15.07)72.90 (15.80)−1.890.06
      NIHSS score at admission8.00 (4.74)8.51 (4.94)6.95 (4.25)1.210.23
      Sex1.480.22
       Male36 (59.02)22 (53.66)14 (70.00)
       Female25 (40.98)19 (46.34)6 (30.00)
      Marital status0.67
      Fisher’s accurate test.
       Married51 (83.61)33 (80.49)18 (90.00)
       Single/divorced/widow10 (16.39)8 (19.51)2 (10.10)
      Education level0.73
      Fisher’s accurate test.
       Illiterate21 (34.43)14 (34.15)7 (35.00)
       Elementary school21 (34.43)11 (26.83)10 (50.00)
       Junior high school6 (9.84)5 (12.20)1 (5.00)
       High school or higher13 (21.58)9 (21.95)2 (10.00)
      Work status before stroke3.140.08
       Yes25 (40.98)20 (48.78)5 (25.00)
       No36 (59.02)21 (51.22)15 (75.00)
      Type of stroke0.29
      Fisher’s accurate test.
       Ischaemic57 (93.44)37 (90.24)20 (100.00)
       Haemorrhagic4 (6.66)4 (9.76)0 (0.00)
      Location of stroke0.03
      Fisher’s accurate test.
      p < 0.05.
       Left brain23 (37.70)19 (46.34)4 (20.00)
       Right brain33 (54.10)17 (41.46)16 (80.00)
       Diencephalon/pontine5 (8.20)5 (8.20)0 (0.00)
      Number of strokes0.240.62
       First time48 (78.69)33 (80.49)15 (75.00)
       Second time (inclusive)13 (21.31)8 (19.51)5 (15.00)
      CCI (0–5)1.34 (1.34)1.15 (1.20)1.75 (1.55)−1.680.10
      BI score at admission (0–85)35.16 (22.02)35.12 (22.09)35.25 (22.45)−0.020.98
      mRS score at admission (2–4)3.84 (0.42)3.88 (0.33)3.75 (0.55)0.960.35
      Length of stay in PAC (days)39.27 (16.02)
      Note. tt test; x2 = chi-square; PAC = post-acute care; CCI = Charlson comorbidity index; BI = Barthel Index; mRS = modified Rankin Scale; NIHSS = stroke severity (National Institutes of Health Stroke Scale; SD = standard deviation.
      * p < 0.05.
      a Fisher’s accurate test.

      2.2 Hospital-based post-acute care program vs. regular care

      2.2.1 Hospital-based post-acute care program

      In this study, patients in the PAC group with a stable medical condition and physical functional status between mild and moderately severe dysfunction (mRS score, 2–4) and within 8–30 days after the onset of acute stroke were provided 3–6 weeks of integrated rehabilitation, including physical and occupational therapies and language training. The NHIA covers costs of this hospital-based PAC program for up to 12 weeks, and a well-trained care team comprising a rehabilitation physician, physical therapist, occupational therapist, speech-language pathologist, and case manager is assigned to continuously evaluate the patient’s progress, extending the period, if necessary, for no more than 12 weeks. The PAC program was scheduled for twice a day on weekdays, depending on the patient’s ability; each treatment lasted 90–120 min. Each patient received physiotherapy (PT) or occupational therapy (OT) according to their disability status; speech-language therapy was arranged once a week according to the needs of the patients.

      2.2.2 Regular care

      Patients in the regular care group were those who did not wish to participate in the PAC program but agreed to participate in the follow-up. These patients received PT or OT once a day during hospitalisation or were discharged to home or another facility to receive rehabilitation program or further medical management.

      2.3 Measurements

      2.3.1 Demographics and disease information

      Demographics data and medical information, such as sex, age, marital status, education level and work status, the number of strokes, stroke type, stroke location, stroke severity (National Institutes of Health Stroke Scale [NIHSS]), and comorbidities (Charlson comorbidity index [CCI]) were collected from reviewing their medical records.
      Self-administered questionnaires were used to collect data on physical function, depressive symptoms, and QOL. For illiterate participants, a family member or caregiver provided the responses on the patient’s behalf while the nurse filled out the questionnaire. For Geriatric Depression Scale (GDS-15) and Stroke Impact Scale Version 3.0 (SIS V3.0), the nurse read the questions and filled out the answers on behalf of the patient.

      2.3.2 Physical function

      The BI, developed by
      • Mahoney F.I.
      • Barthel D.W.
      Functional evaluation: the Barthel Index.
      , measures the progress of inpatient rehabilitation, using different activities of daily living (ADL) related to self-care and mobility. The scale comprises 0–100 points, ranging from total dependency (0–20 points) to independency (100 points) in performing ADL. In this study, the overall Cronbach’s α value of the BI was 0.90.
      The IADL, developed by
      • Lawton M.P.
      • Brody E.M.
      Assessment of older people: self-maintaining and instrumental activities of daily living.
      , comprises a questionnaire to assess independent living skills and everyday functions in older adults. The total score ranges from 0 to 24 points for adult females and 0–15 points for adult males, the higher the score, the better the independence.
      • Kadar M.
      • Ibrahim S.
      • Razaob N.A.
      • Chai S.C.
      • Harun D.
      Validity and reliability of a Malay version of the Lawton Instrumental Activities of Daily Living Scale among the Malay speaking elderly in Malaysia.
      showed that Cronbach’s α of the internal consistency of IADL was 0.838 and that the test–retest and inter-rater reliabilities were 0.950 and 0.957, respectively.
      The mRS, originally developed in 1957 and modified in the 1980s, is used to assess the degree of disability in stroke survivors (
      • Uyttenboogaart M.
      • Stewart R.E.
      • Vroomen P.C.
      • De Keyser J.
      • Luijckx G.J.
      Optimizing cutoff scores for the Barthel Index and the modified Rankin Scale for defining outcome in acute stroke trials.
      ). The scale comprises 0–6 points, running from no symptoms (0 points) to dead (6 points). The test–retest reliability κw is 0.81–0.95, the internal consistency κ is 0.56–0.78, and the construct validity is related to the type and size of stroke and neural defect (
      • Banks J.L.
      • Marotta C.A.
      Outcomes validity and reliability of the modified Rankin Scale: implications for stroke clinical trials: a literature review and synthesis.
      ); if structured interviews are used, it can reach 81% consistency, and the unweighted κ is 0.74 (
      • Wilson J.T.
      • Hareendran A.
      • Hendry A.
      • Potter J.
      • Bone I.
      • Muir K.W.
      Reliability of the modified Rankin Scale across multiple raters: benefits of a structured interview.
      ).

      2.3.3 Depression symptoms

      The original GDS-30, developed by
      • Yesavage J.A.
      • Brink T.L.
      • Rose T.L.
      • Lum O.
      • Huang V.
      • Adey M.
      • et al.
      Development and validation of a geriatric depression screening scale: a preliminary report.
      , was condensed to GDS-15 in 1986 (
      • Sheikh J.I.
      • Yesavage J.A.
      Geriatric Depression Scale (GDS): recent evidence and development of a shorter version.
      ). The latter comprises 15 yes/no-type questions to measure the depressive symptoms among older patients related to three levels of content: emotion, cognition, and behaviour. A total score of 0–4 points indicates a normal state of mind, 5 points or more indicates clinical depression and a more comprehensive assessment with the doctor should be done, and greater than or equal to 10 indicates major depression. A study found that GDS-15 had a sensitivity of 84% and specificity of 89%, according to the Diagnostic and Statistical Manual (4th edition) diagnostic criteria (
      • Baillon S.
      • Dennis M.
      • Lo N.
      • Lindesay J.
      Screening for depression in Parkinson’s disease: the performance of two screening questions.
      ).

      2.3.4 Quality of life

      The SIS V3.0, developed by
      • Duncan P.W.
      • Lai S.M.
      • van Culin V.
      • Huang L.
      • Clausen D.
      • Wallace D.
      Development of a comprehensive assessment toolbox for stroke.
      , measures disability and the QOL of patients with stroke, and the SIS V3.0 comprises a self-reporting questionnaire with 8 domains (domains 1–8) and 1 self-assessment question (domain 9). The total score of each domain ranges from 0 to 100 points; a higher score indicates better QOL.
      • Liang P.J.
      • Lin P.S.
      Reliability and validity of the Stroke Impact Scale 3.0. In Taiwanese stroke patients.
      demonstrated a good internal consistency (Cronbach’s α = 0.89–0.96), except for the emotional aspect (Cronbach’s α = 0.70) of the psychometric properties of the SIS V3.0 in assessing patients with stroke in Taiwan. In this study, the overall Cronbach’s α value of the SIS V3.0 was 0.93.

      2.4 Procedure

      This study was approved by the institutional review board (IRB No: 201700582B0) before data collection. The principal investigator or coinvestigator verified the medical records of potential subjects who met the inclusion criteria and explained to them the purpose and follow-up procedures of this study. Then, data on demographics and disease were collected. The subjects were followed up in the 1st, 4th, 8th, and 12th weeks post stroke. They completed five questionnaires, namely the BI, IADL, mRS, GDS-15, and SIS V3.0, at each visit.

      2.5 Data analysis

      The basic information of stroke survivors was analysed using descriptive statistics. In inferential statistical analysis, independent sample t-tests, chi-square tests, and Pearson’s correlation coefficient were used to test for differences in the basic attributes between the PAC and regular care groups and the interrelationship among outcome variables. Generalized estimating equations (GEEs) were used to analyse the changing trends and differences in physical function, depression symptoms, and QOL of these patients at week one, four, eight and twelve after stroke. Each GEE model included a main effect of the PAC and regular care groups, a main effect of time, and a two-way interaction effect of group by times, which indicates group differences concerning the changes from time 1 (week 1) to time 4 (week 12). Finally, multiple linear regression analysis was used to explore the predictors that affected the QOL of patients in the post-acute stage of stroke. Data analysis was performed using SPSS 22 (IBM SPSS, Armonk, NY: IBM Corp)(
      • IBM Corp
      IBM SPSS statistics for windows, version 22.0.
      ).

      3. Results

      3.1 Demographics and disease information of stroke survivors

      Table 1 summarises the details of the basic information of 61 patients. In terms of stroke type, 57 patients (93.44%) had an ischaemic stroke; the majority were first-time infarctions (48, 78.69%) located in the right brain (33, 54.10%), with an average NIHSS score of 8.00 ± 4.74 at admission and an average CCI of 1.34 ± 1.34.

      3.2 Changing trends in physical function, depression symptoms, and quality of life of patients

      Parameters of the regular care group at admission or in the 1st week after stroke were used as baseline values to evaluate the changing trend of patients’ physical function (BI, mRS, and IADL scores), depression symptoms (GDS-15 score), and QOL (SIS V3.0 score) in the 1st, 4th, 8th, and 12th week after stroke (Table 2).
      Table 2Changing trends in physical function, depressive symptoms, and QOL of patients with stroke (n = 61).
      SubjectPAC group (n = 41)Regular care group (n = 20)
      T0T1T2T3T4T0T1T2T3T4
      Physical function
       BI35.1242.07
      p < 0.01.
      49.63
      p < 0.001.
      65.73
      p < 0.001.
      73.78
      p < 0.001.
      35.2537.5046.7048.5050.25
       mRS3.883.76
      p < 0.01.
      3.59
      p < 0.001.
      2.93
      p < 0.001.
      2.51
      p < 0.001.
      3.753.653.553.503.55
       IADL3.46
      p < 0.01.
      4.20
      p < 0.001.
      5.80
      p < 0.001.
      7.54
      p < 0.001.
      3.253.553.953.90
      GDS-157.76
      p < 0.01.
      6.46
      p < 0.001.
      4.66
      p < 0.001.
      3.41
      p < 0.001.
      9.308.158.808.55
      SIS V3.0 domain 1–8367.73
      p < 0.01.
      447.38
      p < 0.001.
      539.69
      p < 0.001.
      577.68
      p < 0.001.
      374.32406.57411.15412.16
      SIS V3.0 domain 918.78
      p < 0.01.
      32.20
      p < 0.001.
      55.3763.41
      p < 0.001.
      19.0026.0028.5030.50
      Note. T0 = admission; T1 = 1st week after stroke; T2 = 4th week after stroke; T3 = 8th week after stroke; T4 = 12th week after stroke. PAC = post-acute care; BI = Barthel Index; GDS = Geriatric Depression Scale; IADL = Instrumental Activities of Daily Living; mRS = modified Rankin Scale; SIS V3.0 = Stroke Impact Scale Version 3.0.
      ** p < 0.01.
      *** p < 0.001.

      3.2.1 Physical function

      The BI scores of the PAC group in the 1st, 4th, 8th, and 12th weeks after stroke were 6.95 (p = 0.008), 14.51 (p < 0.001), 30.61 (p < 0.001), and 38.66 (p < 0.001) points higher, respectively, than those at the time of admission (35.12). In contrast, the BI scores of the regular care group in the 1st, 4th, 8th, and 12th weeks after stroke displayed a gradual upward trend over time; the difference was not significant (p > 0.05). The mRS scores of the PAC group in the 1st, 4th, 8th, and 12th weeks after stroke reduced by 0.12 (p = 0.048), 0.29 (p = 0.005), 0.95 (p < 0.001), and 1.37 (p < 0.001) points, respectively. The mRS scores of the regular care group in the 1st, 4th, 8th, and 12th weeks after stroke gradually decreased over time, there was no significant difference (p > 0.05). The IADL scores of the PAC group in the 4th, 8th, and 12th weeks after stroke were 0.73 (p = 0.006), 2.34 (p < 0.001), and 4.07 (p < 0.001) points higher, respectively, than that in the 1st week. In contrast, the IADL scores of the regular care group in the 4th, 8th, and 12th weeks after stroke displayed a gradual upward trend over time, there was no significant difference (p > 0.05).

      3.2.2 Depression symptoms

      For those who scored 5 or more points in the PAC group, case numbers gradually dropped as follows: 31 (75.6%), 29 (70.7%), 17 (41.5%), and 15 (36.6%) patients after the 1st, 4th, 8th, and 12th week after stroke, respectively. The mean GDS-15 scores of the PAC group were 7.76, 6.46, 4.66, and 3.41 after the 1st, 4th, 8th, and 12th week after stroke and were reduced by 1.29 points (p < 0.001), 3.10 points (p < 0.001), and 4.34 points (p < 0.001), respectively, compared with those in the 1st week. In contrast, a total of 5 points or more in the regular care group was scored by 16 (80.0%), 16 (80.0%), 17 (85.0%), and 16 (80.0%) patients after the 1st, 4th, 8th, and 12th week after stroke, respectively. The mean GDS scores of the regular care group were 9.30, 8.15, 8.80, and 8.55 in the 1st, 4th, 8th, and 12th week after stroke, respectively, and they plateaued over time, there was no significant difference (p > 0.05).

      3.2.3 Quality of life

      The SIS V3.0 scores of domains 1–8 of the PAC group in the 4th, 8th, and 12th week after stroke were 79.65 (p < 0.001), 171.96 (p < 0.001), and 209.94 (p < 0.001) points higher, respectively, than those in the 1st week. Similarly, their scores for domain 9 in the 4th, 8th, and 12th week after stroke were 13.42 (p < 0.001), 36.59 (p < 0.001), and 44.63 (p < 0.001) points higher, respectively, than those in the 1st week. The SIS V3.0 scores of domains 1–8 and domain 9 of the regular care group in the 4th, 8th, and 12th week after stroke displayed a gradual upward trend over time, there was no significant difference (p > 0.05).

      3.2.4 Differences in physical function, depression symptoms, and quality of life of patients

      Table 3 summarises the BI, mRS, IADL, GDS-15, and self-evaluated recovery (domain 9 of SIS V3.0) scores of the two patient groups. These data show that these parameters changed significantly, starting from the 8th week after stroke (p < 0.05). The QOL of the two patient groups differed significantly, starting from the 4th week after stroke (p < 0.01). Therefore, compared with stroke survivors receiving RC, those receiving PAC showed a significant improvement in physical function, depressive symptoms, and QOL from the 8th week after stroke.
      Table 3Analysis of the effectiveness of PAC for improving the physical function, depressive symptoms, and QOL of stroke survivors.
      Predictive variablesBSEWald χ²p-value
      Group × timepoint (BI)
      PACG × T14.703.431.880.170
      PACG × T23.065.450.320.574
      PACG × T317.366.846.450.011
      PACG × T423.667.2810.550.001
      Group × timepoint (mRS)
      PACG × T1−0.020.090.060.810
      PACG × T2−0.090.240.150.703
      PACG × T3−0.700.257.650.006
      PACG × T4−1.170.2619.40<0.001
      Group × timepoint (IADL)
      PACG × T20.430.321.830.176
      PACG × T31.640.784.470.035
      PACG × T43.420.8715.59<0.001
      Group × timepoint (GDS)
      PACG × T2−0.140.640.050.825
      PACG × T3−2.600.869.220.002
      PACG × T4−3.590.9713.57<0.001
      Group × timepoint (SIS 1–8)
      PACG × T247.4114.4410.780.001
      PACG × T3135.1325.6027.87<0.001
      PACG × T4172.1129.3234.47<0.001
      Group × timepoint (SIS 9)
      PACG × T26.424.691.870.171
      PACG × T327.096.1319.50<0.001
      PACG × T433.136.0729.79<0.001
      Notes. The timepoint of the reference group for BI and mRS was the time of admission. The timepoint of the other groups was the 1st week after stroke. BI = Barthel Index; RG = regular care group; PAC = post-acute care; PACG = PAC group; GDS = Geriatric Depression Scale; IADL = Instrumental Activities of Daily Living; mRS = modified Rankin Scale; SE = standard error; SIS V3.0 = Stroke Impact Scale Version 3.0.

      3.3 Associated factors affecting the quality of life of patients with stroke

      After the variables of demographic characteristics were converted to categorical variables, physical function (measured by BI and IADL) and depressive symptoms (measured by GDS-15) were regressed against the QOL at the four timepoints. The regression analyses revealed that the potential factors associated with QOL in the 4th, 8th, and 12th week after stroke (p < 0.05) included age, NIHSS score, CCI, marital status, education level, work status, physical function, and depressive symptoms.
      The QOL in the 4th week reached statistical significance with F7, 53 = 39.48, p < 0.001, and the explanatory power of the regression model reached 0.839 (adjusted R2 = 0.818). After adjusting for other covariates, higher BI score (B = 1.71, p < 0.001), higher IADL score (B = 14.06, p < 0.001), and lower GDS-15 score (B = −11.94, p < 0.001) were associated with better QOL in the 4th week in stroke survivors. The QOL in the 8th week reached statistical significance with F9, 51 = 45.05 (p < 0.001), and the explanatory power of the regression model reached 0.888 (adjusted R2 = 0.869). After adjusting for other covariates, higher CCI score (B = 12.71, p = 0.042), higher BI score (B = 1.37, p = 0.026), higher IADL score (B = 7.36, p = 0.008), and lower GDS-15 score (B = −15.49, p < 0.001) were associated with better QOL in the 8th week post stroke. The QOL in the 12th week reached statistical significance with F9, 51 = 107.37, p < 0.001, and the explanatory power of the regression model reached 0.950 (adjusted R2 = 0.941). After adjusting for other covariates, higher BI score (B = 2.06, p < 0.001), lower mRS score (B = −26.53, p = 0.018), higher IADL score (B = 6.80, p < 0.001), and lower GDS-15 score (B = −12.22, p < 0.001) were associated with better QOL in the 12th week post stroke (Table 4).
      Table 4Predictors of QOL in the 4th, 8th, and 12th weeks in stroke survivors.
      Independent variablesT2T3T4
      BSEt valuep-valueBSEt valuep-valueBSEt valuep-value
      Intercept283.4676.183.72<0.001467.62101.184.62<0.001426.5467.446.33<0.001
      Education level: junior high school or above
      Education level: Below elementary school (reference).
      −0.1621.87−0.010.99410.4724.860.420.6755.9718.370.330.746
      Age0.830.651.280.2050.940.891.050.2970.640.621.020.312
      NIHSS score−2.171.59−1.360.179
      Marital status: No
      Marital status: yes (reference).
      28.8922.291.300.2019.7316.050.610.547
      Work status: Yes
      Work status: no (reference).
      −3.8318.82−0.200.8393.6813.580.270.787
      CCI12.716.102.080.0425.754.131.390.169
      BI1.710.453.77<0.0011.370.602.300.0262.060.405.17<0.001
      MRS15.759.391.680.099−27.0515.76−1.720.092−26.5310.89−2.440.018
      IADL14.063.024.65<0.0017.362.652.780.0086.801.704.01<0.001
      GDS-15−11.941.92−6.21<0.001−15.492.38−6.50<0.001−12.221.55−7.87<0.001
      R20.8390.8880.950
      Adjusted R20.8180.8690.941
      F39.4845.05107.37
      p-value<0.001<0.001<0.001
      T2 = 4th week after stroke; T3 = 8th week after stroke; T4 = 12th week after stroke.
      BI = Barthel Index; GDS = Geriatric Depression Scale; IADL = Instrumental Activities of Daily Living; mRS = modified Rankin Scale; SE = standard error; SIS V3.0 = Stroke Impact Scale Version 3.0.
      a Education level: Below elementary school (reference).
      b Marital status: yes (reference).
      c Work status: no (reference).

      4. Discussion

      4.1 Demographics and disease information of stroke survivors

      In this study, the mean age of the 61 patients was 67.59 (±15.64) years, similar to that in studies by
      • Chien S.H.
      • Sung P.Y.
      • Liao W.L.
      • Tsai S.W.
      A functional recovery profile for patients with stroke following post-acute rehabilitation care in Taiwan.
      (66.01±15.36 years),
      • Huang H.C.
      • Tsai J.Y.
      • Liu T.C.
      • Sheng W.Y.
      • Lin T.C.
      • Lin C.W.
      • et al.
      Functional recovery of stroke patients with postacute care: a retrospective study in a northern medical center.
      (two groups—68.22±14.52 years vs. 68.51±11.22 years), and
      • Weng S.-C.
      • Hsu C.-Y.
      • Shen C.-C.
      • Huang J.-A.
      • Chen P.-L.
      • Lin S.-Y.
      Combined functional assessment for predicting clinical outcomes in stroke patients after post-acute care: a retrospective multi-center cohort in central Taiwan.
      (67.20 ± 14.70 years). In contrast, the average age of participants in the study by
      • Lai C.L.
      • Tsai M.M.
      • Luo J.Y.
      • Liao W.C.
      • Hsu P.S.
      • Chen H.Y.
      Post-acute care for stroke—a retrospective cohort study in Taiwan.
      was younger at 63.01 (±13.24) years. The average length of the PAC program in the current study was 39.27 (±16.02) days, shorter than those in other studies: 43.57 (±26.28) days and 58.15 (±16.93) days (
      • Chien S.H.
      • Sung P.Y.
      • Liao W.L.
      • Tsai S.W.
      A functional recovery profile for patients with stroke following post-acute rehabilitation care in Taiwan.
      ,
      • Lai C.L.
      • Tsai M.M.
      • Luo J.Y.
      • Liao W.C.
      • Hsu P.S.
      • Chen H.Y.
      Post-acute care for stroke—a retrospective cohort study in Taiwan.
      ).

      4.2 Changing trends in physical function, depression symptoms, and quality of life

      4.2.1 Physical function

      This study revealed that the BI, mRS, and IADL scores of patients receiving PAC improved gradually over time, displaying significant differences at the 8th and 12th week after stroke, consistent with the results of
      • Wu W.J.
      • Chang I.C.
      • Lin C.T.
      • Wang S.C.
      • Ku Y.R.
      The effects of enhanced physical therapy on post-acute stroke patients.
      ,
      • Huang H.C.
      • Tsai J.Y.
      • Liu T.C.
      • Sheng W.Y.
      • Lin T.C.
      • Lin C.W.
      • et al.
      Functional recovery of stroke patients with postacute care: a retrospective study in a northern medical center.
      ,
      • Lai C.L.
      • Tsai M.M.
      • Luo J.Y.
      • Liao W.C.
      • Hsu P.S.
      • Chen H.Y.
      Post-acute care for stroke—a retrospective cohort study in Taiwan.
      ,
      • Chien S.H.
      • Sung P.Y.
      • Liao W.L.
      • Tsai S.W.
      A functional recovery profile for patients with stroke following post-acute rehabilitation care in Taiwan.
      , and
      • Weng S.-C.
      • Hsu C.-Y.
      • Shen C.-C.
      • Huang J.-A.
      • Chen P.-L.
      • Lin S.-Y.
      Combined functional assessment for predicting clinical outcomes in stroke patients after post-acute care: a retrospective multi-center cohort in central Taiwan.
      . This study also provided evidence that the PAC program enhances a stroke survivor’s functional recovery and may increase independence in their ADL (
      • Hsieh C.Y.
      • Tsao W.C.
      • Lin R.T.
      • Chao A.C.
      Three years of the nationwide post-acute stroke care program in Taiwan.
      ,
      • Huang H.C.
      • Tsai J.Y.
      • Liu T.C.
      • Sheng W.Y.
      • Lin T.C.
      • Lin C.W.
      • et al.
      Functional recovery of stroke patients with postacute care: a retrospective study in a northern medical center.
      ,
      • Peng L.N.
      • Lu W.H.
      • Liang C.K.
      • Chou M.Y.
      • Chung C.P.
      • Tsai S.L.
      • et al.
      Functional outcomes, subsequent healthcare utilization, and mortality of stroke postacute care patients in Taiwan: a nationwide propensity score-matched study.
      ,
      • Weng S.-C.
      • Hsu C.-Y.
      • Shen C.-C.
      • Huang J.-A.
      • Chen P.-L.
      • Lin S.-Y.
      Combined functional assessment for predicting clinical outcomes in stroke patients after post-acute care: a retrospective multi-center cohort in central Taiwan.
      ). Most previous studies measured two timepoints—before initiation and after completion of PAC—to assess the changes in the BI, mRS, and IADL scores and, thus, could not identify the critical changing timepoint (
      • Chien S.H.
      • Sung P.Y.
      • Liao W.L.
      • Tsai S.W.
      A functional recovery profile for patients with stroke following post-acute rehabilitation care in Taiwan.
      ,
      • Hsien H.H.
      • Liou W.C.
      • Yang Y.H.
      Post-acute care improves daily activity functions of stroke patients: an effectiveness analysis.
      ;
      • Hsieh C.Y.
      • Tsao W.C.
      • Lin R.T.
      • Chao A.C.
      Three years of the nationwide post-acute stroke care program in Taiwan.
      ;
      • Huang H.C.
      • Tsai J.Y.
      • Liu T.C.
      • Sheng W.Y.
      • Lin T.C.
      • Lin C.W.
      • et al.
      Functional recovery of stroke patients with postacute care: a retrospective study in a northern medical center.
      ,
      • Lai C.L.
      • Tsai M.M.
      • Luo J.Y.
      • Liao W.C.
      • Hsu P.S.
      • Chen H.Y.
      Post-acute care for stroke—a retrospective cohort study in Taiwan.
      ;
      • Peng L.N.
      • Lu W.H.
      • Liang C.K.
      • Chou M.Y.
      • Chung C.P.
      • Tsai S.L.
      • et al.
      Functional outcomes, subsequent healthcare utilization, and mortality of stroke postacute care patients in Taiwan: a nationwide propensity score-matched study.
      ;
      • Weng S.-C.
      • Hsu C.-Y.
      • Shen C.-C.
      • Huang J.-A.
      • Chen P.-L.
      • Lin S.-Y.
      Combined functional assessment for predicting clinical outcomes in stroke patients after post-acute care: a retrospective multi-center cohort in central Taiwan.
      ;
      • Wu W.J.
      • Chang I.C.
      • Lin C.T.
      • Wang S.C.
      • Ku Y.R.
      The effects of enhanced physical therapy on post-acute stroke patients.
      ). The study tracked these changes at four timepoints—1st, 4th, 8th, and 12th week after stroke after adjusting covariates to identify the changing trends in physical function recovery among stroke survivors.

      4.2.2 Depressive symptoms

      Although 36.6% of stroke survivors receiving PAC in this study reported depressive symptoms, the proportion decreased gradually but significantly over time. The result was similar to that of
      • Wang S.
      • Wang C.X.
      • Zhang N.
      • Xiang Y.T.
      • Yang Y.
      • Shi Y.Z.
      • et al.
      The association between post-stroke depression, aphasia, and physical independence in stroke patients at 3-month follow-up.
      and
      • Dong L.
      • Williams L.S.
      • Brown D.L.
      • Case E.
      • Morgenstern L.B.
      • Lisabeth L.D.
      Prevalence and course of depression during the first year after mild to moderate stroke.
      , who found that 34.7% and 35.3% of patients exhibited depressive symptoms three months after stroke. Moreover, the result was consistent with the American Heart Association/American Stroke Association’s statement that PSD is associated with poorer functional outcomes after stroke (
      • Towfighi A.
      • Ovbiagele B.
      • El Husseini N.
      • Hackett M.L.
      • Jorge R.E.
      • Kissela B.M.
      • et al.
      Poststroke depression: a scientific statement for healthcare professionals from the American Heart Association/American Stroke Association.
      ). The physical function in the PAC group improves and becomes more independent after receiving PAC, which in turn may potentially positively affect their psychological condition and may potentially reduce depressive symptoms. In addition, the study enabled us to simultaneously identify changing trends in depressive symptoms as well as the functional recovery after stroke.

      4.2.3 Quality of life

      The QOL of stroke survivors receiving PAC and their stroke recovery increased significantly, but gradually at the 4th, 8th, and 12th week after stroke. These results were similar to those of
      • Lai C.L.
      • Tsai M.M.
      • Luo J.Y.
      • Liao W.C.
      • Hsu P.S.
      • Chen H.Y.
      Post-acute care for stroke—a retrospective cohort study in Taiwan.
      , who showed significant improvement in EQ-5D (mobility, self-care, usual activities, and anxiety/depression) among 168 patients after stroke with an average of 43.57 days in the PAC program. However, the results differed from those of
      • Schindel D.
      • Schneider A.
      • Grittner U.
      • Jöbges M.
      • Schenk L.
      Quality of life after stroke rehabilitation discharge: a 12-month longitudinal study.
      , who followed patients after discharge from the rehabilitation program and found that the majority had neither maintained nor regained their initial QOL at three, six and twelve months after rehabilitation discharge.

      4.3 Associated factors affecting the quality of life of stroke survivors

      This study showed that physical function and depressive symptoms are significant factors associated with QOL in the 4th, 8th, and 12th weeks after stroke. The results suggest that patients with stroke who can perform ADL independently and have fewer depressive symptoms have a better QOL at three months after stroke compared with those who are dependent on others for ADL and exhibit depressive symptoms. The results were similar to those of
      • Hsien H.H.
      • Liou W.C.
      • Yang Y.H.
      Post-acute care improves daily activity functions of stroke patients: an effectiveness analysis.
      ,
      • Lai C.L.
      • Tsai M.M.
      • Luo J.Y.
      • Liao W.C.
      • Hsu P.S.
      • Chen H.Y.
      Post-acute care for stroke—a retrospective cohort study in Taiwan.
      ,
      • Weng S.-C.
      • Hsu C.-Y.
      • Shen C.-C.
      • Huang J.-A.
      • Chen P.-L.
      • Lin S.-Y.
      Combined functional assessment for predicting clinical outcomes in stroke patients after post-acute care: a retrospective multi-center cohort in central Taiwan.
      , and
      • Wu W.J.
      • Chang I.C.
      • Lin C.T.
      • Wang S.C.
      • Ku Y.R.
      The effects of enhanced physical therapy on post-acute stroke patients.
      , demonstrating that the tendency toward depression and dependency on others for daily activities affected the QOL of stroke survivors.
      • Heikinheimo T.
      • Chimbayo D.
      Quality of life after first-ever stroke: an interview-based study from Blantyre, Malawi.
      and
      • Weng S.-C.
      • Hsu C.-Y.
      • Shen C.-C.
      • Huang J.-A.
      • Chen P.-L.
      • Lin S.-Y.
      Combined functional assessment for predicting clinical outcomes in stroke patients after post-acute care: a retrospective multi-center cohort in central Taiwan.
      also found that patients with lower mRS scores had better QOL than those with higher scores. Similarly,
      • Rudberg A.S.
      • Berge E.
      • Gustavsson A.
      • Näsman P.
      • Lundström E.
      Long-term health-related quality of life, survival and costs by different levels of functional outcome six months after stroke.
      reported that limited functional outcomes caused by long-term disability might be an essential factor affecting the QOL. The study also revealed the impact of PSD on physical function and QOL of stroke survivors; the PAC program may have a direct beneficial effect on physical recovery and an indirect effect on QOL of stroke survivors (
      • Towfighi A.
      • Ovbiagele B.
      • El Husseini N.
      • Hackett M.L.
      • Jorge R.E.
      • Kissela B.M.
      • et al.
      Poststroke depression: a scientific statement for healthcare professionals from the American Heart Association/American Stroke Association.
      ,
      • Wong H.J.
      • Lua P.L.
      • Harith S.
      • Ibrahim K.A.
      Health-related quality of life profiles and their dimension-specific associated factors among Malaysian stroke survivors: a cross sectional study.
      ).

      5. Limitations and suggestions

      The study population was limited to a single hospital in central Taiwan. Therefore, the participants may not represent all stroke survivors. Moreover, the regular care group was underrepresented in the study and only comprised 20 participants. The results of this study need to be verified with a larger cohort and with a randomised clinical design to reduce sampling error. Moreover, the rehabilitation programs may differ between participants because the disabilities caused by each stroke are different. In addition to the timepoints at which patients arrived at the rehabilitation centre, their rehabilitation motivation and support systems likely contributed to whether they opted for hospital-based rehabilitation or regular care, and thus, the outcomes attained.
      Future nursing research is needed to assess nurses’ role in PAC patient recruitment and motivation for participation in PAC programs, especially concerning patient age, ADL ability, and level of depression.

      6. Practice implications

      In Taiwan, there is very little evidence of the nurses’ role in after stroke rehabilitation. The hospital-based PAC program is an updated clinical practice and differs from previous after stroke rehabilitation for stroke survivors. To fulfil the nurses’ role, a comprehensive understanding of the PAC program is needed in order to improve stroke survivors’ physical function, recover independence in performing ADLs, and decrease the incidence of depression, all of which, when viewed holistically, have been shown to improve QOL (
      • Clarke D.J.
      Nursing practice in stroke rehabilitation: systematic review and meta-ethnography.
      ,
      • Meng X.
      • Chen X.
      • Liu Z.
      • Zhou L.
      Nursing practice in stroke rehabilitation: perspectives from multi-disciplinary healthcare professionals.
      ). However, more needs to be known about the nursing role and the effect nurses have on patient outcomes during and following PAC program participation.

      7. Conclusions

      This study investigated the trajectories in physical function, depressive symptoms, and QOL of stroke survivors who received PAC after stroke. The physical function, depressive symptoms, and QOL of participants who received hospital-based PAC significantly improved over time (p < 0.05), especially from week eight after stroke. However, no significant changes in these characteristics were observed in patients who received regular care after stroke. Physical function recovery (measured by BI and IADL) and degree of depressive symptoms (measured by GDS-15) were factors associated with QOL in the 4th, 8th, and 12th week after stroke.

      Authorship contribution statement

      Shu-Chin Yao designed and performed the experiments. Shu-Chin Yao and Suh-Ing Hsieh performed the analysis. Jiann-Der Lee and Tsui-Ping Chu were involved in administrative cooperation and supervised the work. Jun-Yu Fan designed and processed the experimental data, performed the analysis, and wrote the paper. All authors discussed the results and contributed to the final paper.

      Funding

      The authors wish to acknowledge all 61 participants for the time and effort they contributed to this study. This work was supported by a Grant from the Administration Center of the Medical Research Department, Chang Gung Memorial Hospital, Taiwan (BMRPB80), which was awarded to the corresponding author.

      Ethical statement

      All study participants provided informed consent, and the study design was approved by the appropriate ethics review board (IRB NO: 201700582B0).

      Conflict of interest

      There are no conflicts of interest to declare.

      References

      1. American Heart Association (2022). Emotional and Behavioral Effects of Stroke. 〈https://www.stroke.org/en/about-stroke/effects-of-stroke/emotional-effects-of-stroke〉.

        • Avan A.
        • Digaleh H.
        • Di Napoli M.
        • Stranges S.
        • Behrouz R.
        • Shojaeianbabaei G.
        • et al.
        Socioeconomic status and stroke incidence, prevalence, mortality, and worldwide burden: an ecological analysis from the Global Burden of Disease Study 2017.
        BMC Medicine. 2019; 17191https://doi.org/10.1186/s12916-019-1397-3
        • Baillon S.
        • Dennis M.
        • Lo N.
        • Lindesay J.
        Screening for depression in Parkinson’s disease: the performance of two screening questions.
        Age and Ageing. 2014; 43: 200-205https://doi.org/10.1093/ageing/aft152
        • Banks J.L.
        • Marotta C.A.
        Outcomes validity and reliability of the modified Rankin Scale: implications for stroke clinical trials: a literature review and synthesis.
        Stroke. 2007; 38: 1091-1096https://doi.org/10.1161/01.STR.0000258355.23810.c6
        • Blöchl M.
        • Meissner S.
        • Nestler S.
        Does depression after stroke negatively influence physical disability? A systematic review and meta-analysis of longitudinal studies.
        Journal of Affective Disorders. 2019; 247: 45-56https://doi.org/10.1016/j.jad.2018.12.082
        • Chien S.H.
        • Sung P.Y.
        • Liao W.L.
        • Tsai S.W.
        A functional recovery profile for patients with stroke following post-acute rehabilitation care in Taiwan.
        Journal of the Formosan Medical Association. 2020; 119: 254-259https://doi.org/10.1016/j.jfma.2019.05.013
        • Clarke D.J.
        Nursing practice in stroke rehabilitation: systematic review and meta-ethnography.
        Journal of Clinical Nursing. 2014; 23: 1201-1226https://doi.org/10.1111/jocn.12334
        • Donkor E.S.
        Stroke in the 21st century: a snapshot of the burden, epidemiology, and quality of life.
        Stroke Research and Treatment. 2018; 20183238165https://doi.org/10.1155/2018/3238165
        • Dong L.
        • Williams L.S.
        • Brown D.L.
        • Case E.
        • Morgenstern L.B.
        • Lisabeth L.D.
        Prevalence and course of depression during the first year after mild to moderate stroke.
        Journal of the American Heart Association. 2021; 10e020494https://doi.org/10.1161/JAHA.120.020494
        • Duncan P.W.
        • Lai S.M.
        • van Culin V.
        • Huang L.
        • Clausen D.
        • Wallace D.
        Development of a comprehensive assessment toolbox for stroke.
        Clinics in Geriatric Medicine. 1999; 15: 885-915
        • Han D.S.
        • Lin C.W.
        • Lu L.
        • Hsiao M.Y.
        • Wu C.H.
        • Liang H.W.
        • et al.
        Taiwan guidelines for stroke rehabilitation.
        Taiwan Rehabilitation Medicine Journal. 2016; 44: 1-9https://doi.org/10.6315/2016.44(1)01
        • Heikinheimo T.
        • Chimbayo D.
        Quality of life after first-ever stroke: an interview-based study from Blantyre, Malawi.
        Malawi Medical Journal. 2015; 27: 50-54https://doi.org/10.4314/mmj.v27i2.4
        • Hsien H.H.
        • Liou W.C.
        • Yang Y.H.
        Post-acute care improves daily activity functions of stroke patients: an effectiveness analysis.
        Journal of Gerontology and Gerontology of Taiwan. 2015; 10: 159-171https://doi.org/10.29461/TGG.201508_10(3).0003
        • Hsieh C.Y.
        • Tsao W.C.
        • Lin R.T.
        • Chao A.C.
        Three years of the nationwide post-acute stroke care program in Taiwan.
        Journal of the Chinese Medical Association. 2018; 81: 87-88https://doi.org/10.1016/j.jcma.2017.09.003
        • Hu J.
        • Ma L.
        • Yang Z.Y.
        Does citalopram effectively treat post-stroke depression?: a protocol for systematic review and meta analysis.
        Medicine. 2020; 99e20608https://doi.org/10.1097/MD.0000000000020608
        • Huang H.C.
        • Tsai J.Y.
        • Liu T.C.
        • Sheng W.Y.
        • Lin T.C.
        • Lin C.W.
        • et al.
        Functional recovery of stroke patients with postacute care: a retrospective study in a northern medical center.
        Journal of the Chinese Medical Association. 2019; 82: 424-427https://doi.org/10.1097/JCMA.0000000000000076
        • IBM Corp
        IBM SPSS statistics for windows, version 22.0.
        IBM Corp, Armonk, NY2013
        • Jørgensen T.S.
        • Wium-Andersen I.K.
        • Wium-Andersen M.K.
        • Jørgensen M.B.
        • Prescott E.
        • Maartensson S.
        • et al.
        Incidence of depression after stroke, and associated risk factors and mortality outcomes, in a large cohort of Danish patients.
        JAMA Psychiatry. 2016; 73: 1032-1040https://doi.org/10.1001/jamapsychiatry.2016.1932
        • Kadar M.
        • Ibrahim S.
        • Razaob N.A.
        • Chai S.C.
        • Harun D.
        Validity and reliability of a Malay version of the Lawton Instrumental Activities of Daily Living Scale among the Malay speaking elderly in Malaysia.
        Australian Occupational Therapy Journal. 2018; 65: 63-68https://doi.org/10.1111/1440-1630.12441
        • Lai C.L.
        • Tsai M.M.
        • Luo J.Y.
        • Liao W.C.
        • Hsu P.S.
        • Chen H.Y.
        Post-acute care for stroke—a retrospective cohort study in Taiwan.
        Patient Preference and Adherence. 2017; 11: 1309-1315https://doi.org/10.2147/PPA.S136041
        • Lawton M.P.
        • Brody E.M.
        Assessment of older people: self-maintaining and instrumental activities of daily living.
        The Gerontologist. 1969; 9: 179-186
        • Lee W.J.
        • Chou M.Y.
        • Peng L.N.
        • Liang C.K.
        • Liu L.K.
        • Liu C.L.
        • et al.
        Predicting clinical instability of older patients in post-acute care units: a nationwide cohort study.
        Geriatrics and Gerontology International. 2014; 14: 267-272https://doi.org/10.1111/ggi.12083
        • Liang P.J.
        • Lin P.S.
        Reliability and validity of the Stroke Impact Scale 3.0. In Taiwanese stroke patients.
        Formosan Journal of Physical Therapy. 2016; 41: 28-36https://doi.org/10.6215/FJPT.PTS1433262535
        • Mahoney F.I.
        • Barthel D.W.
        Functional evaluation: the Barthel Index.
        Maryland State Medical Journal. 1965; 14: 61-65
        • Medeiros G.C.
        • Roy D.
        • Kontos N.
        • Beach S.R.
        Post-stroke depression: a 2020 updated review.
        General Hospital Psychiatry. 2020; 66: 70-80https://doi.org/10.1016/j.genhosppsych.2020.06.011
        • Meng X.
        • Chen X.
        • Liu Z.
        • Zhou L.
        Nursing practice in stroke rehabilitation: perspectives from multi-disciplinary healthcare professionals.
        Nursing and Health Sciences. 2020; 22: 28-37https://doi.org/10.1111/nhs.12641
      2. Ministry of Health and Welfare(2021). Executive Yuan. 2020 Cause of Death Statistics. 〈https://www.mohw.gov.tw/cp-5256-63399-2.html〉.

        • Mitchell A.J.
        • Sheth B.
        • Gill J.
        • Yadegarfar M.
        • Stubbs B.
        • Yadegarfar M.
        • et al.
        Prevalence and predictors of post-stroke mood disorders: a meta-analysis and meta-regression of depression, anxiety and adjustment disorder.
        General Hospital Psychiatry. 2017; 47: 48-60https://doi.org/10.1016/j.genhosppsych.2017.04.001
      3. National Health Insurance Administration of Taiwan Ministry of Health and Welfare, Executive Yuan (2022). Post-acute Care-Cerebrovascular Diseases (2020.04.10 update). (In Chinese). 〈https://www.nhi.gov.tw/Content_List.aspx?n=5A0BB383D955741C&topn=D39E2B72B0BDFA15〉 [Accessed 5 July 2022].

        • Peng L.N.
        • Lu W.H.
        • Liang C.K.
        • Chou M.Y.
        • Chung C.P.
        • Tsai S.L.
        • et al.
        Functional outcomes, subsequent healthcare utilization, and mortality of stroke postacute care patients in Taiwan: a nationwide propensity score-matched study.
        Journal of the American Medical Directors Association. 2017; 18: 990.e7-990.e12https://doi.org/10.1016/j.jamda.2017.06.020
        • Rudberg A.S.
        • Berge E.
        • Gustavsson A.
        • Näsman P.
        • Lundström E.
        Long-term health-related quality of life, survival and costs by different levels of functional outcome six months after stroke.
        European Stroke Journal. 2018; 3: 157-164https://doi.org/10.1177/2396987317753444
        • Schindel D.
        • Schneider A.
        • Grittner U.
        • Jöbges M.
        • Schenk L.
        Quality of life after stroke rehabilitation discharge: a 12-month longitudinal study.
        Disability and Rehabilitation. 2021; 43: 2332-2341https://doi.org/10.1080/09638288.2019.1699173
        • Sheikh J.I.
        • Yesavage J.A.
        Geriatric Depression Scale (GDS): recent evidence and development of a shorter version.
        Clinical Gerontologist: The Journal of Aging and Mental Health. 1986; 5: 165-173https://doi.org/10.1300/J018v05n01_09
        • Towfighi A.
        • Ovbiagele B.
        • El Husseini N.
        • Hackett M.L.
        • Jorge R.E.
        • Kissela B.M.
        • et al.
        Poststroke depression: a scientific statement for healthcare professionals from the American Heart Association/American Stroke Association.
        Stroke. 2017; 48: e30-e43https://doi.org/10.1161/STR.0000000000000113
        • Uyttenboogaart M.
        • Stewart R.E.
        • Vroomen P.C.
        • De Keyser J.
        • Luijckx G.J.
        Optimizing cutoff scores for the Barthel Index and the modified Rankin Scale for defining outcome in acute stroke trials.
        Stroke. 2005; 36: 1984-1987
        • Wafa H.A.
        • Wolfe C.D.A.
        • Emmett E.
        • Roth G.A.
        • Johnson C.O.
        • Wang Y.
        Burden of stroke in Europe: thirty-year projections of incidence, prevalence, deaths, and disability-adjusted life years.
        Stroke. 2020; 51: 2418-2427https://doi.org/10.1161/STROKEAHA.120.029606
        • Wang S.
        • Wang C.X.
        • Zhang N.
        • Xiang Y.T.
        • Yang Y.
        • Shi Y.Z.
        • et al.
        The association between post-stroke depression, aphasia, and physical independence in stroke patients at 3-month follow-up.
        Frontiers in Psychiatry. 2018; 9374https://doi.org/10.3389/fpsyt.2018.00374
        • Weng S.-C.
        • Hsu C.-Y.
        • Shen C.-C.
        • Huang J.-A.
        • Chen P.-L.
        • Lin S.-Y.
        Combined functional assessment for predicting clinical outcomes in stroke patients after post-acute care: a retrospective multi-center cohort in central Taiwan.
        Frontiers in Aging Neuroscience. 2022; 14834273https://doi.org/10.3389/fnagi.2022.834273
        • Wilson J.T.
        • Hareendran A.
        • Hendry A.
        • Potter J.
        • Bone I.
        • Muir K.W.
        Reliability of the modified Rankin Scale across multiple raters: benefits of a structured interview.
        Stroke. 2005; 36: 777-781https://doi.org/10.1161/01.STR.0000157596.13234.95
        • Winstein C.J.
        • Stein J.
        • Arena R.
        • Bates B.
        • Cherney L.R.
        • Cramer S.C.
        • et al.
        Guidelines for adult stroke rehabilitation and recovery: a guideline for healthcare professionals from the American Heart Association/American Stroke Association.
        Stroke. 2016; 47: e98-e169https://doi.org/10.1161/STR.0000000000000098
        • Wong H.J.
        • Lua P.L.
        • Harith S.
        • Ibrahim K.A.
        Health-related quality of life profiles and their dimension-specific associated factors among Malaysian stroke survivors: a cross sectional study.
        Health and Quality of Life Outcomes. 2021; 19210https://doi.org/10.1186/s12955-021-01847-0
        • Wu K.Y.
        • Wu S.C.
        • Hung Y.N.
        • Wu C.C.
        • Lin L.C.
        • Hu H.H.
        The need for post-acute care for stroke patients in Taiwan.
        Taiwan Gong Gong Wei Sheng Za Zhi. 2012; 31 (in Chinese)251
        • Wu W.J.
        • Chang I.C.
        • Lin C.T.
        • Wang S.C.
        • Ku Y.R.
        The effects of enhanced physical therapy on post-acute stroke patients.
        Formosan Journal of Physical Therapy. 2016; 41: 165-166
        • Yesavage J.A.
        • Brink T.L.
        • Rose T.L.
        • Lum O.
        • Huang V.
        • Adey M.
        • et al.
        Development and validation of a geriatric depression screening scale: a preliminary report.
        Journal of Psychiatric Research. 1982; 17: 37-49https://doi.org/10.1016/0022-3956(82)90033-4
        • Ytterberg C.
        • Cegrell L.
        • von Koch L.
        • Wiklander M.
        Depression symptoms 6 years after stroke are associated with higher perceived impact of stroke, limitations in ADL and restricted participation.
        Scientific Reports. 2022; 127816https://doi.org/10.1038/s41598-022-11097-9