Higher comorbidity burden is associated with lower self-reported quality of life after stroke

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Higher comorbidity burden is associated with lower self-reported quality of life after stroke

Marlene Heinze^1*, Lisa Lebherz², David Leander Rimmele¹, Marc Frese³, Märit Jensen¹, Ewgenia Barow¹, Iris Lettow¹, Levente Kriston², Christian Gerloff¹, Martin Härter² and Götz Thomalla¹

• ¹Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
• ²Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
• ³Quality Management and Clinical Process Management, University Medical Center Hamburg-Eppendorf, Hamburg, Germany

Introduction: This study assesses the association of comorbidity burden and polypharmacy with self-reported quality of life after stroke.

Patients and methods: We performed a post-hoc analysis of a prospective, single-center, observational study of outcome evaluation by patient-reported outcome measures in stroke clinical practice. Consecutive patients with acute ischemic stroke (AIS) were enrolled and self-reported health–related quality of life (HrQoL) was assessed 90 days after acute stroke using the Patient-reported Outcomes Measurement Information System 10-Question Short-Form (PROMIS-10). Comorbidities at baseline were assessed by the Charlson Comorbidity Index (CCI). Polypharmacy was defined as medication intake of ≥5 at baseline. We used linear regression analysis to study the association of CCI, polypharmacy and other clinical covariates with HrQoL after stroke.

Results: Of 781 patients (median age 76 years, 48.4% female) enrolled, 30.2% had a CCI Score ≥2, and 31.5% presented with polypharmacy. At follow up, 71 (9.1%) had died. In 409 (52.4%) reached for outcome evaluation, Global Physical Health T-Score was 43.8 ± 10 and Global Mental Health T-Score was 43.5 ± 8.76, indicating lower HrQoL than the average population. A CCI Score ≥2, higher NIHSS Score, female sex, dependency on others for dressing, toileting and mobility before index stroke, atrial fibrillation and hypertension were independent predictors of worse physical and mental health outcomes, while polypharmacy was not.

Conclusion: In patients with AIS, high comorbidity burden and polypharmacy are frequent. Comorbidity burden at admission is independently associated with worse self-reported physical and mental health three months after stroke.

Introduction

Establishing predictive factors of health-related quality of life (HrQoL) after stroke is vitally important to ensure optimal post-stroke care. Index stroke severity (1, 2), bad functional outcome (3), female sex (4), and higher age (5) have been shown to have a detrimental effect on HrQoL after stroke. A high comorbidity burden at time of stroke has recently moved more to the center of interest as an independent predictor of mortality and functional outcome. Comorbidity burden was associated with higher in-hospital mortality (6, 7), length of hospital stay (8), and adverse clinical outcomes (9–11) in stroke patients, but very little data are available on the influence of high comorbidity load on HrQoL. Comorbidity burden is closely linked to polypharmacy, which is typically defined as an intake of ≥5 medications (12) and is considered a growing challenge in clinical practice (13). Stroke is associated with multiple cardiovascular risk factors and comorbidities (e.g., arterial hypertension, diabetes and atrial fibrillation) and preventative medical treatment of these conditions contributes to polypharmacy (14, 15). Polypharmacy has in turn been associated with lower HrQoL (16), an increased frequency of hospitalization, length of hospital stay, in-hospital mortality, disability and adverse drug reactions in population-based studies (17). Detrimental effects of stroke in domains of both physical and mental health are not well-represented in commonly used clinical rating and outcome scales (18), but can severely diminish quality of life (19). The effect of stroke on HrQoL can be assessed with the use of patient-reported outcome measures (PROMs), which have become increasingly important for outcome evaluation with regards to value-based health care (20, 21). A previous, ongoing study of outcome evaluation by PROMs in stroke clinical practice (EPOS) assessed the implementation of “The International Consortium for Health Outcome measurement Standard Set for Stroke (ICHOM-SSS)” in acute stroke care and identified impairments in physical and mental health across multiple domain (22). The EPOS study was registered at ClinicalTrials.gov, NCT03795948.

Data on the influence of comorbidity burden and polypharmacy on HrQoL after stroke are scarce. Here, we analyzed the prospective observational EPOS study with the aim to determine the strength of association of a high comorbidity burden and polypharmacy with self-reported quality of life after stroke in mental and physical health domains.

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