Journal of the Formosan Medical Association (2020) 119, 254e259

Available online at www.sciencedirect.com

ScienceDirect

journal homepage: www.jfma-online.com

Original Article

A functional recovery profile for patients

with stroke following post-acute
rehabilitation care in Taiwan
Sou-Hsin Chien a,b,c, Pi-Yu Sung a,c,d, Wen-Ling Liao d,
Sen-Wei Tsai a,c,d,*

a
Department of Post-Acute Care Center, Taichung Tzu Chi Hospital, Buddhist Tzu Chi Medical
Foundation, Taichung City 427, Taiwan
b
Department of Plastic Surgery, Taichung Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation,
Taichung City 427, Taiwan
c
School of Medicine, Tzu Chi University, Hualien 970, Taiwan
d
Department of Physical Medicine and Rehabilitation, Taichung Tzu Chi Hospital, Buddhist Tzu Chi
Medical Foundation, Taichung City 427, Taiwan

Received 10 March 2019; received in revised form 10 April 2019; accepted 14 May 2019

KEYWORDS Background: Functional impairment is frequently seen in patients with stroke. Although the
Post-acute care; progression of functional recovery after stroke has been proposed, the recovery profile after
Rehabilitation; acute stroke is not well described. The objective of this study is to investigate functional re-
Stroke; covery in stroke patients entering post-acute rehabilitation care.
Modified ranking scale Methods: A retrospective cohort study collected the data of patients who entered the stroke
Post-acute Care (PAC) programs. Ninety-five patients after stroke with a modified Ranking
Scale (mRS) score of 3e4 who were referred to a post-acute care unit for intensive rehabilita-
tion were recruited. The patients underwent functional, quality of life, and neuropsychologi-
cal evaluation tests at admission and before discharge. The test scores before discharge were
used as outcome variables and were compared with the test scores at admission to show func-
tional recovery.
Results: The average length of stay was 58.15 days. After an intensive rehabilitation interven-
tion, significant improvements were observed in all test scores. Additionally, a significant
removal rate for nasogastric tubes (p Z 0.000) and Foley catheters (p Z 0.003) was found
at discharge.
Conclusion: This study showed that the PAC rehabilitation unit was beneficial for patients with
acute stroke who had functional impairments. The study results may call for further investiga-
tion to identify and develop better models for the delivery of rehabilitation in the stroke PAC
unit.

* Corresponding author. Physical Medicine and Rehabilitation, Taichung Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Sec. 1,
Fengxing Rd., Tanzi Dist., Taichung City 427, Taiwan.
E-mail address: tsaisenwei@gmail.com (S.-W. Tsai).

https://doi.org/10.1016/j.jfma.2019.05.013
0929-6646/Copyright ª 2019, Formosan Medical Association. Published by Elsevier Taiwan LLC. This is an open access article under the CC
BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
A functional recovery profile for patients with stroke
Copyright ª 2019, Formosan Medical Association. Published by Elsevier Taiwan LLC. This is an
open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-
nc-nd/4.0/).
Introduction
Although advances in acute stroke treatment, such as
thrombolytic and endovascular interventions, have
increased post-stroke survival, stroke remains one of the
most common causes of disability.1 Post-stroke disability is
a major health burden worldwide.2,3 Moreover, variation
exists in how stroke care services are provided in different
regions and countries. The variations in post-stroke care
are mostly dependent on the availability of financial and
medical resources.4,5
In the United States, stroke post-acute care (PAC) can
take place in the inpatient rehabilitation center, a skilled
nursing facility, or in the patient’s home, and the spending
is mostly provided by Medicare.6 According to previous re-
ports, Medicare spending in the United States on PAC ac-
counts for more than 15% of Medicare spending.4,7 In
Europe, studies have surveyed the results of stroke through
different registries, including the European Registers of
Stroke (EROS) and Collaborative Evaluation of Rehabilita-
tion in Stroke across Europe (CERISE). Although most post-
stroke patients receive institutional rehabilitation care,
large variations exist in rehabilitation services and out-
comes among different countries.8,9
In Taiwan, post-stroke rehabilitation in the past was
primarily conducted in inpatient rehabilitation facilities for
six months after discharge from acute settings. Thereafter,
patients with functional limitation received outpatient
rehabilitation. However, this inpatient rehabilitation pro-
gram was not well structured, and the rehabilitation regi-
mens were not well defined. Because spending for post-
stroke care has increased and a necessity has been identi-
fied to provide PAC with an aim of improving functional
recovery and smooth transitions between inpatient settings
and home,10 research and outcome data for post-stroke
rehabilitation are necessary in Taiwan.11,12
In 2014, Taiwan National Health Insurance (TNHI) stan-
dardized and specified a highly intensive post-stroke inpa-
tient rehabilitation program named Post-Acute Care
Cerebrovascular Diseases (PAC-CVD).13 To be enrolled in
this PAC-CVD program, patients with a modified Rankin
Scale (mRS) score of 3e4 should be transferred to a highly
intensive PAC rehabilitation facility certified by the TNHI
within 30 post-stroke days. Some suggested functional
scores should be recorded during this PAC care. This highly
intensive PAC plan is defined as high frequency (3e5 times/
day) of an intensive rehabilitation program, including
physical therapy, occupational therapy and speech therapy,
provided in a multidiscipline rehabilitation team approach
depending on the patient’s ability. The maximal duration of
the PAC-CVD hospital length of stay is limited to 12 weeks.
Functional recovery after stroke is essential for per-
forming self-care and activities of daily living (ADLs).
Despite evidence that stroke patients entering
255
multidisciplinary rehabilitation units have lower mortality,
less disability, and improved outcomes,14 we have limited
knowledge of the recovery patterns in these patients. Un-
derstanding the recovery profile across mobility, ADLs and
quality of life (QoL) may improve our understanding of
neurorehabilitation for post-stroke patients.
In this observational study based on TNHI PAC adminis-
trative data from stroke patients in one single hospital, we
analyzed the recorded data and observed the functional
recovery profiles in patients following the PAC rehabilita-
tion program. This study may contribute to the develop-
ment of better models for the delivery of rehabilitation in
the stroke PAC unit.
Methods
Subjects and settings
This study was conducted in the PAC rehabilitation unit of
Taichung Tzu Chi Hospital with the provision of inpatient
multidisciplinary care, including physical therapy, occupa-
tional therapy, and speech therapy. Patients who were
enrolled in this PAC plan were transferred to the Taichung
Tzu Chi PAC rehabilitation unit from acute settings in either
medical centers or regional hospitals within 30 days after
the onset of cerebrovascular disease. According to the TNHI
regulation, before entering the stroke PAC program, all
patients should sign an informed consent form concerning
the PAC plan and provide permission to use their anony-
mized medical data for research.
From March 2014 to December 2017, all consecutive
patients transferred to the Taichung Tzu Chi PAC unit who
met the following inclusion criteria were recruited: (1)
first-ever stroke as defined by the ICD-10 classification (I63,
I61 or I60); (2) transferred to the PAC unit within 30 days
after stroke onset; and (3) their functional score met the
criterion of a mRS score of 3e4. The exclusion criteria were
as follows: (1) the length of hospital stay in the PAC unit
was less than 30 days because of very good recovery; (2) a
recurrent stroke occurred in the PAC unit; and (3) incom-
plete medical clearance or records were not available
during the PAC period. This study was approved by the
ethics committee of Taichung Tzu Chi Hospital (No. REC
107-16).
Outcome variables for functional recovery were assessed
upon admission to the PAC unit and at 3, 6, 9, and 12 weeks
or at discharge after admission to the PAC unit. The
outcome variables measured in this study included the
mRS, Barthel Activity Daily Living Index (BI), LawtoneBrody
Instrumental Activity Daily Living scale (LB-IADL), Func-
tional Oral Intake Scale (FOIS), EuroQol Five Dimensions
Questionnaire 3-level (EQ-5D-3L), Berg Balance Scale (BBS),
Mini Mental State Examination (MMSE); and Concise Chinese
256
Aphasia Test (CCAT). The endpoints were as follows: (1) no
functional improvement based on two consecutive evalua-
tions and (2) the length of stay was 12 weeks after admis-
sion to the Taichung Tzu Chi PAC unit.
Data analysis
Baseline and demographic characteristics are presented as
the mean (standard deviation). Student’s t-test was used to
compare the basic characteristics and outcome scores be-
tween admission and discharge. Pearson’s Chi-square test
was used to compare changes in the levels of the patients’
numbers on the EQ-5D-3L at admission and discharge. The
differences were considered statistically significant when
p < 0.05. The analyses were performed using SPSS (version
13.0; SPSS Inc., Chicago, IL, USA).
Results
Descriptive statistics of the patients
The patients’ characteristics, including age, gender, stroke
type, the use of a nasogastric tube, the use of a urinary
catheter, and the length of stay in the PAC wards, are
summarized in Table 1. A total of 95 patients (54 male
patients and 41 female patients) who met the inclusion
criteria were recruited (Inclusion and Exclusion Flow Dia-
gram) (Fig. 1). Among these 95 subjects, the mean age
was 66.01  15.36 years, the average period after stroke
before admission to the PAC unit was 14.35  7.42 days,
and the average length of stay in the PAC unit was
58.15  16.93 days. A total of 76 patients (80.0%) suffered
from ischemic stroke, and 19 patients (20.0%) suffered
from hemorrhagic stroke; additionally, 21 patients (22.11%)
had a nasogastric tube and 10 patients (10.53%) needed a
urinary catheter.
Functional recovery after the PAC program
The clinical characteristics and the functional changes of
the patients before and following the PAC plan are pre-
sented in Table 2. The mean mRS score was 3.8  0.45 at
admission and improved to 2.96  0.91 at discharge
Table 1 Baseline data for the stroke patients.
Variables Total (n Z 95)
Gender
Male, n (%) 54 (56.84)
Female, n (%) 41 (43.16)
Age, years, mean (SD) 66.01 (15.36)
Days after stroke, days, mean (SD) 14.35 (7.42)
Stroke type
Ischemic, n (%) 76 (80)
Hemorrhagic, n (%) 19 (20)
Nasogastric tube used at admission, n (%) 21 (22.11)
Foley catheter used at admission, n (%) 10 (10.53)
Length of stay in the PAC, days, mean (SD) 58.15 (16.93)
Abbreviation: SD: standard deviation; PAC, post-acute care.
S.-H. Chien et al.
(p Z 0.000). In the activities of the daily living domain, the
BI improved from 34.95  19.98 at admission to
69.16  23.11 (p Z 0.000) at discharge; the LB-IADL also
improved from 1.36  1.35 to 2.71  1.83 (p Z 0.000). In
the nutritional status domain, the FOIS improved from
5.34  2.25 to 6.66  0.93 (p Z 0.000). In the balance
domain, the BBS improved from 20.5  18.44 before PAC
training to 37.81  18.5 at discharge (p Z 0.000).
In the mental status domain, the MMSE score improved
from 20.35  8.9 initially to 23.92  7.73 at discharge
(p Z 0.000). In the language domain, the CCAT score also
improved from 9.6  2.82 to 10.43  2.25 (p Z 0.000). The
rate of successful nasogastric tube removal was 66.7%, and
the rate of urinary catheter removal was 90% at discharge.
Table 3 shows the changes in the number and ratio of the
EQ-5D-3L scores at admission and discharge. In the generic
health status measurement dimension of the EQ-5D-3L,
significant improvements were observed for all sub-
categories at discharge, including mobility (from 2.14  0.4
to 1.74  0.4, p Z 0.000), self-care (from 2.21  0.41 to
1.85  0.39, p Z 0.000), usual activity (from 2.19  0.38 to
1.87  0.36, p Z 0.000), pain/discomfort (from 1.47  0.5
to 1.22  0.42, p Z 0.000), and anxiety/depression (from
1.67  0.52 to 1.36  0.48, p Z 0.000). For the mobility,
self-care, and usual activity subcategories, the numbers in
level 3 were reduced significantly, whereas those in level 1
increased. In the pain/discomfort and anxiety/depression
subcategories, the changes occurred predominantly with a
shift in the numbers from level 2 to level 1.
Discussion
This observational study provides striking evidence of sig-
nificant improvement in functional recovery after stroke
following PAC rehabilitation services. Differences in health
care systems, countries and regions can impact stroke
rehabilitation programs and outcomes. One of the major
outcome measurements is functional disability, which usu-
ally is calculated by evaluating ADL functions.15 Another
widely adapted measurement in clinical trials to evaluate
post-stroke outcomes is the mRS.16 Lai et al. found that 62%
of patients had at least a shift of one grade in the mRS from
baseline after stroke.17 The results in this study were
coincident with those of Lai’s report and showed an
improvement of approximately one grade in the mRS from
3.8  0.45 at admission to 2.96  0.91 at discharge.
The BI is a common ADL outcome measurement scale in
stroke trials. The BI was originally established to assess the
ADLs of the elderly population and has been widely used in
stroke patients for outcome assessment.18
A previous study suggested that a 20-point threshold in
the BI would certainly indicate an important change.19
Scores below 40 on the BI are well accepted to represent
complete dependence on others, whereas scores on the BI
of greater than 60 represent a status transition from com-
plete dependence to assisted independence. Finally, a BI
score greater than 85 represents independence or minor
assistance with activities of daily living.20 The BI was also
suggested to be a strong predictor of post-stroke healthcare
costs. Previous studies have shown that health care costs
are much higher in post-stroke patients with functional
A functional recovery profile for patients with stroke 257

Figure 1 Inclusion and exclusion flow diagram.

Table 2 Effect of PAC on functional performance and quality of life in patients with stroke.
Variables N Admission Discharge p-value
mRS 95 3.8  0.45 2.96  0.91 0.000*
BI 95 34.95  19.98 69.16  23.11 0.000*
LB-IADL 95 1.36  1.35 2.71  1.83 0.000*
FOIS 95 5.34  2.25 6.66  0.93 0.000*
BBS 95 20.5  18.44 37.81  18.5 0.000*
MMSE 95 20.35  8.9 23.92  7.73 0.000*
CCAT 95 9.6  2.82 10.43  2.25 0.000*
Nasogastric tube used, n (%) 21 (22.11) 7 (7.773) 0.000*
Foley catheter used, n (%) 10 (10.53) 1 (1.05) 0.003*
Notes: *p < 0.05. Data presented as the mean  SD unless otherwise indicated.
Abbreviations: mRS, modified Ranking Scale; BI, Barthel Activity Daily Living index; LB-IADL, LawtoneBrody Instrumental Activity Daily
Living scale; FOIS, Functional Oral Intake Scale; EQ-5D, EuroQol Five Dimensions questionnaire; BBS, Berg Balance Scale; MMSE, Mini
Mental State Examination; CCAT, Concise Chinese Aphasia Test.

dependency and more disability.21 In this study, the results
regarding changes in the BI showed an improvement from a
BI mean score of 34.95 at admission to 69.16 at discharge.
Our study result is coincident with a previous report by Lai
et al. that an improvement in the BI mean score of about
36 at discharge in PAC plan.12 This more than 20-point
change was not only clinically significant but also showed
that this PAC plan transitioned the ADL function from
complete dependence to assisted independence. This
result also implied that the future health care costs for
these post-stroke patients would be reduced after PAC
care.
Stroke patients have a high risk of falling. Falls are
common consequences of post-stroke limb weakness.22
Researchers have identified some specific risk factors for
falls in people after stroke; the cases of a fall after stroke
are usually a combination of these factors, such as
increased age, foot dragging, uneven standing sway,
greater posture sway, and reduced force generation when
standing.23 Among these factors, balance function is one of
the most important.24 Hyndman et al. reported that a poor
balance function was an important factor that predicted
falls in stroke patients living in the community. Therefore,
rehabilitation training has focused on balance improvement
for fall prevention in stroke. One commonly used assess-
ment tool in rehabilitation settings is the BBS.
The BBS was initially developed for use in assessing
balance and risk for falls in elderly individuals. Studies also
showed that it could be used in patients with stroke.25,26
Subjects with BBS scores of less than 20 are usually sug-
gested to have balance impairment, scores from 21 to 40
represent subjects with acceptable balance, and BBS scores
258 S.-H. Chien et al.

Table 3 Effect of PAC on the improvement of EQ-5D-3L scores, and number and ratio of the score of EQ-5D-3L in patients with
stroke at admission and discharge.
EQ-5D-3L Admission Discharge p
dimensions mean  SD Level 1 Level 2 Level 3 mean  SD Level 1 Level 2 Level 3
EQ-5D:mobility 2.14  0.4 2 (2.11%) 78 (82.11%) 15 (15.79%) 1.74  0.4 26 (27.37%) 68 (71.58%) 1 (1.05%) 0.000a 0.000*
EQ-5D:self-care 2.21  0.41 0 (0%) 75 (78.95%) 20 (21.05%) 1.85  0.39 15 (15.79%) 79 (83.16%) 1 (1.05%) 0.000a 0.000*
EQ-5D:usual 2.19  0.38 0 (0%) 79 (83.16%) 16 (16.84%) 1.87  0.36 13 (13.68%) 81 (85.26%) 1 (1.05%) 0.000a 0.000*
activities
EQ-5D:pain/ 1.47  0.5 50 45 (47.37%) 0 (0%) 1.22  0.42 74 (77.89%) 21 (22.11%) 0 (0%) 0.000a 0.000*
discomfort (52.63%)
EQ-5D:anxiety/ 1.67  0.51 33 60 (63.16%) 2 (2.11%) 1.36  0.48 60 (63.83%) 34 (36.17%) 0 (0%) 0.000a 0.000*
depression (34.74%)
*p < 0.05. Pearson’s Chi-square test was used to compare changes in the ratio of the patient’s numbers from the EQ-5D-3L at admission
and discharge; ap < 0.05. Student’s t-test was used to compare the EQ-5D-3L mean scores between admission and discharge.

above 41 usually represent good balance. In this study, an
improvement was observed in the BBS mean scores from
20.5 at admission to 37.8 at discharge. Our study results are
in agreement with those of other studies that observed
changes in the BBS scales over time in patients with
stroke.27 This significant training effect transitioned the
balance function in most post-stroke patients from poor
balance to acceptable balance. Whether this training effect
can be transferred to a fall-down prevention effect still
needs further investigation.
Studies have shown that disability caused by stroke has a
great impact on quality of life (QoL) in both the stroke
patients themselves and their caregivers.28 The EQ-5D-3L is
a widely used self-reported instrument to describe the
health state and perceived problems in five dimensions
(mobility, self-care, usual activities, pain, and anxiety and
depression), each with 3 levels (no problems, some prob-
lems, and extreme problems).29 In this study, based on the
EQ-5D-3L descriptive scales (Table 3), we showed that
initially some patients exhibited extreme (levels 2 and 3)
problems in the mobility, self-care and performing usual
activities subcategories, whereas most of the patients had
less than moderate problems (levels 1 and 2) at admission in
the pain/discomfort and anxiety/depression subcategories.
This improvement was consistent with the accompanying
improvement in the mRS and BI at discharge. In the pain/
discomfort and anxiety/depression subcategories, the
changes occurred predominantly with a shift in case
numbers from level 2 to level 1 (p Z 0.000). In the mobility,
self-care, and usual activity subcategories, the major
changes from admission to discharge were reduced case
numbers in level 3 and increased case numbers in level 1.
The study of Graessel et al. showed that higher stroke
survivor EQ-5D scores at discharge were predictors of
staying at home after discharge.30 Although we did not
follow the returning home rate, our study results might
imply an increased rate of returning home after receiving
our PAC plan. Further investigation and follow up are
necessary to clarify this issue.
Few studies have been designed to evaluate the removal
rate of urinary catheters in patients after stroke. In Frost
et al.’s study about the removal of urinary catheters in
acute stroke patients, 175 of 432 patients had an IUC
removal event, and a 26% failure rate was noted.31 These
authors found that the factors associated with failed uri-
nary catheter removal included hemorrhagic stroke, a
lower level of physical function, and the hospital length of
stay. In our study, 10 patients had urinary catheters when
transferred to our PAC ward. At discharge, only 1 patient
still needed a urinary catheter; thus, the successful
removal rate was 90%. In this TNHI PAC program, an mRS
score of 3e4 and potential to gain improvement were the
essential enrollment criteria, which might explain our high
removal rate. Further observation is necessary to clarify
this post-stroke urinary catheter issue.
Swallowing problems are a common symptom following
an acute stroke, but the occurrence frequency varies
considerably.32 Typically, a nasogastric tube is used to
prevent or reduce complications, such as pneumonia,
malnutrition, and dehydration.33 However, nasogastric
tubes are not well tolerated by patients and may be
frequently dislodged. In this study, at admission 21 patients
(22.1%) had a nasogastric tube when transferred to our PAC
ward. At discharge, 7 patient still needed a nasogastric
tube for feeding due to dysphagia; thus, the successful
removal rate was 66.7%. Arnold et al. showed that patients
with dysphagia had a lower chance of being discharged
home.34 Removal of indwelling tubes, such as a nasogastric
tube or urinary catheter, may increase the rate of early
discharge and returning home.
This study has some limitations. Although the charac-
teristics and clinical outcomes of the patients were
assessed regularly and routinely based on the TNHI PAC
rules, the retrospective study design was a drawback.
Another limitation was that our enrolled patients were all
from central Taiwan and from a single PAC rehabilitation
unit; thus, the results may have geographic variations and
may not represent the whole current situation in Taiwan.
Conclusion
In summary, this study showed that the PAC rehabilitation
unit was beneficial for patients with first-ever acute stroke
who had functional impairments in terms of not only
improvement in ADL function but also improvement in
quality of life and balance function. This PAC program also
had a high success rate for removal of urinary catheters and
A functional recovery profile for patients with stroke
nasogastric tubes. The study results may call for further
investigations to identify and develop better models for
delivery of rehabilitation in the stroke PAC unit.
Conflict of interest
The authors have no conflicts of interest relevant to this
article.
Acknowledgements
This research (grant No. TTCRD105-03) was supported from
Taichung Tzu Chi Hospital, Buddhist Tzu Chi Medical
Foundation.
Appendix A. Supplementary data
Supplementary data to this article can be found online at
https://doi.org/10.1016/j.jfma.2019.05.013.
References
1. Murray CJ, Vos T, Lozano R, Naghavi M, Flaxman AD, Michaud C,
et al. Disability-adjusted life years (dalys) for 291 diseases and
injuries in 21 regions, 1990e2010: a systematic analysis for the
global burden of disease study 2010. Lancet 2012;380:2197e223.
2. Feigin VL, Forouzanfar MH, Krishnamurthi R, Mensah GA,
Connor M, Bennett DA, et al. Global and regional burden of
stroke during 1990e2010: findings from the global burden of
disease study 2010. Lancet 2014;383:245e54.
3. Lee HC, Chang KC, Huang YC, Hung JW, Chiu HH, Chen JJ, et al.
Readmission, mortality, and first-year medical costs after
stroke. J Chin Med Assoc 2013;76:703e14.
4. Buntin MB, Colla CH, Deb P, Sood N, Escarce JJ. Medicare
spending and outcomes after postacute care for stroke and hip
fracture. Med Care 2010;48:776e84.
5. Ayis SA, Coker B, Bhalla A, Wellwood I, Rudd AG, Di Carlo A,
et al. Variations in acute stroke care and the impact of
organised care on survival from a european perspective: the
european registers of stroke (eros) investigators. J Neurol
Neurosurg Psychiatry 2013;84:604e12.
6. Buntin MB. Access to postacute rehabilitation. Arch Phys Med
Rehabil 2007;88:1488e93.
7. Stone DA, Dickensheets BA, Poisal JA. Comparison of medicaid
payments relative to medicare using inpatient acute care
claims from the medicaid program: fiscal year 2010-fiscal year
2011. Health Serv Res 2018;53:326e40.
8. Heuschmann PU, Wiedmann S, Wellwood I, Rudd A, Di Carlo A,
Bejot Y, et al. Three-month stroke outcome: the european reg-
isters of stroke (eros) investigators. Neurology 2011;76:159e65.
9. Putman K, De Wit L. European comparison of stroke rehabili-
tation. Top Stroke Rehabil 2009;16:20e6.
10. Duncan PW, Bushnell CD, Rosamond WD, Jones Berkeley SB,
Gesell SB, D’Agostino Jr RB, et al. The comprehensive post-acute
stroke services (compass) study: design and methods for a
cluster-randomized pragmatic trial. BMC Neurol 2017;17:133.
11. Wang CY, Chen YR, Hong JP, Chan CC, Chang LC, Shi HY.
Rehabilitative post-acute care for stroke patients delivered by
per-diem payment system in different hospitalization paths: a
taiwan pilot study. Int J Qual Health Care 2017;29:779e84.
12. Lai CL, Tsai MM, Luo JY, Liao WC, Hsu PS, Chen HY. Post-acute
care for stroke - a retrospective cohort study in taiwan. Pa-
tient Prefer Adherence 2017;11:1309e15.
259
13. Hsieh CY, Tsao WC, Lin RT, Chao AC. Three years of the
nationwide post-acute stroke care program in taiwan. J Chin
Med Assoc 2018;81:87e8.
14. Kramer AM, Kowalsky JC, Lin M, Grigsby J, Hughes R,
Steiner JF. Outcome and utilization differences for older per-
sons with stroke in hmo and fee-for-service systems. J Am
Geriatr Soc 2000;48:726e34.
15. Duncan PW, Jorgensen HS, Wade DT. Outcome measures in
acute stroke trials: a systematic review and some recommen-
dations to improve practice. Stroke 2000;31:1429e38.
16. Banks JL, Marotta CA. Outcomes validity and reliability of the
modified rankin scale: implications for stroke clinical trials: a
literature review and synthesis. Stroke 2007;38:1091e6.
17. Lai SM, Duncan PW. Stroke recovery profile and the modified
rankin assessment. Neuroepidemiology 2001;20:26e30.
18. Mahoney FI, Barthel DW. Functional evaluation: the barthel
index. Md State Med J 1965;14:61e5.
19. Collin C, Wade DT, Davies S, Horne V. The barthel adl index: a
reliability study. Int Disabil Stud 1988;10:61e3.
20. Sinoff G, Ore L. The barthel activities of daily living index: self-
reporting versus actual performance in the old-old (> or Z 75
years). J Am Geriatr Soc 1997;45:832e6.
21. Caro JJ, Huybrechts KF, Kelley HE. Predicting treatment costs
after acute ischemic stroke on the basis of patient characteristics
at presentation and early dysfunction. Stroke 2001;32:100e6.
22. Batchelor FA, Mackintosh SF, Said CM, Hill KD. Falls after
stroke. Int J Stroke 2012;7:482e90.
23. Cheng PT, Chen CL, Wang CM, Hong WH. Leg muscle activation
patterns of sit-to-stand movement in stroke patients. Am J
Phys Med Rehabil 2004;83:10e6.
24. Harris JE, Eng JJ, Marigold DS, Tokuno CD, Louis CL. Rela-
tionship of balance and mobility to fall incidence in people
with chronic stroke. Phys Ther 2005;85:150e8.
25. Blum L, Korner-Bitensky N. Usefulness of the berg balance
scale in stroke rehabilitation: a systematic review. Phys Ther
2008;88:559e66.
26. Wang YH, Yang YR, Pan PJ, Wang RY. Modeling factors pre-
dictive of functional improvement following acute stroke. J
Chin Med Assoc 2014;77:469e76.
27. English CK, Hillier SL, Stiller K, Warden-Flood A. The sensitivity
of three commonly used outcome measures to detect change
amongst patients receiving inpatient rehabilitation following
stroke. Clin Rehabil 2006;20:52e5.
28. Lou S, Carstensen K, Jorgensen CR, Nielsen CP. Stroke patients’
and informal carers’ experiences with life after stroke: an
overview of qualitative systematic reviews. Disabil Rehabil
2017;39:301e13.
29. Andrew NE, Busingye D, Lannin NA, Kilkenny MF, Cadilhac DA.
The quality of discharge care planning in acute stroke care:
influencing factors and association with postdischarge out-
comes. J Stroke Cerebrovasc Dis 2018;27:583e90.
30. 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;37:212e9.
31. Frost FS, Fan Y, Harrison A, Modlin T, Samuel S, Thompson N, et al.
Failed removal of indwelling urinary catheters in patients with
acute stroke: incidence and risk factors. PM R 2018;10:160e7.
32. Mann G, Hankey GJ, Cameron D. Swallowing disorders
following acute stroke: prevalence and diagnostic accuracy.
Cerebrovasc Dis 2000;10:380e6.
33. Virvidaki IE, Nasios G, Kosmidou M, Giannopoulos S, Milionis H.
Swallowing and aspiration risk: a critical review of non instru-
mental bedside screening tests. J Clin Neurol 2018;14:265e74.
34. Arnold M, Liesirova K, Broeg-Morvay A, Meisterernst J, Schlager M,
Mono ML, et al. Dysphagia in acute stroke: incidence, burden
and impact on clinical outcome. PLoS One 2016;11:e0148424.