1. Łódź 26-27 February 2013
Healthcare policy in the area of
stroke: experiences of Tuscany
Francesco Benventi
Dipartimento Territorio-Fragilità
AUSL11 Empoli, Italy

2. Tuscany

3. Stroke in Tuscany

4. Stroke in Tuscany
Chronic Stroke Epidemiology
 Incidence: 190-220/100000
 Survival:
 1 year: 70-80%
 5 years: 50%
 10 years: >35%
 Prevalence: 600-800/100000
 Residual disability:
 Severe: 30-40%
 Moderate: 35-40%
 Mild or none: 20-35%

5. Hospital admissions for stroke (DRG14)
Stroke in Tuscany 600
500
400
number
300
200
100
0
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
years
Deaths after stroke
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Source 2002 2003 2004 2005 2006 2007 2008 2009 2010
AUSL11, 2012
year

6. Stroke: Hospital Home
End/FU
Integrated home care
Critical clinical instability Yes
adequate
no
Envirommental
and social conditions
History severe
yes
dementia+disability Not adequate
End
Nursing home
No
Rehabilitation DH
End/FU
or outpatient clinic
adequate
Envirommental
No Post stroke disability Mild/moderate
and social conditions
End Not adequate
If clinically unstable
Severe
Nursing Home or
Critical adverse clinical event
Residential extrahospital End/FU
rehabilitation
Intensive Hospital
Rehabilitation
No or mild Residual disability Moderate
Severe
End

7. Stroke: Hospital Home
End/FU
Integrated home care
Critical clinical instability Yes
adequate
no
25%andEnvirommental
social conditions
History severe
yes
dementia+disability Not adequate
End
Nursing home
No
Rehabilitation DH
End/FU
or outpatient clinic
adequate
15% Envirommental
No Post stroke disability Mild/moderate 28% and social conditions
End Not adequate
If clinically unstable
Severe
Nursing Home or
Critical adverse clinical event
Residential extrahospital End/FU
rehabilitation
Intensive Hospital
32%
Rehabilitation
No or mild Residual disability Moderate
Severe
End

8. Clinical Pathways
Sharing information
 Galileo
 Hospital
 Lab
 Radiology
 Hospital specialists outpatient clinics
 Patidok
 Community rehabilitation
 Millewin
 GP records
 Aster
 Home care
 Nursing homes

9. Clinical Pathways
Rehab Nursing Home
Hospital rehabilitation
Community rehabilitation
Acute Hospital are
Day Hospital
Home care Nursing Home

10. Stroke in Tuscany
Chronic Stroke Epidemiology
 Incidence: 220/100000
 Survival:
 1 year: 70-80%
 5 years: 50%
 10 years: >35%
 Prevalence: 600-800/100000
 Residual disability:
 Severe: 30-40%
 Moderate: 35-40%
 Mild or none: 20-35%

11. Stroke: Hospital Home
End/FU
Integrated home care
Critical clinical instability Yes
adequate
no
Envirommental
and social conditions
History severe
yes
dementia+disability Not adequate
End
Nursing home
No
Rehabilitation DH
End/FU
or outpatient clinic
adequate
Envirommental
No Post stroke disability Mild/moderate
and social conditions
End Not adequate
If clinically unstable
Severe
Nursing Home or
Critical adverse clinical event
Residential extrahospital End/FU
rehabilitation
Intensive Hospital
Rehabilitation
No or mild Residual disability Moderate
Severe
End

12. Clinical Pathways
Rehab Nursing Home
Hospital rehabilitation
Community rehabilitation
Acute Hospital Care
Upper limb care
CLEAR
Day Hospital
Home care Nursing Home
APA

13. UOC CURA E RIABILITAZIONE DELLE FRAGILITA’
EXTRAHOSPITAL
HOSPITAL COMMUNITY REHABILITATION
SEMI-RESIDENTIAL
REHABILITATION REHABILITATION NURSING HOME
REHABILITATION
PATHWAY FOR CHRONIC SPASTIC SYNDROMES
UOS RIABILITAZIONE TERRITORIALE
Director Dr. Antonio Taviani
REHABILITATION END
YES
PLATEAU
NO
IMPAIRMENTS FOLLOW
YES
CORRECTABLE? UP
NO
END
AFA+CLEAR

14. APAs
Physical activity programs, carried out in group,
adapted to chronic alterations of functional status
for tertiary prevention of disability

15. Disease or Syndrome
Adapted Physical Activity Primary Prevention Tertiary Prevention
Cancer (breast, colon, prostate) Yes No
Coronary artery disease Yes Yes
Chronic obstructive pulmonary disease No Yes
Dementia (different from multiinfarct dementia) No No
Depression Yes Yes
Diabetes type 2 Yes Yes
Mobility impairment, falls Yes Yes
Chronic renal failure Yes Yes
Peripheral vascular disease Yes Yes
Hypertension Yes Yes
Back pain No Yes
Congestive hearth failure No Yes
Obesity Yes Yes
Arthritis No Yes
Osteoporosis Yes Yes
Parkinson’s dis., CNS degenerative disorders No Yes
Stroke Yes Yes
Venous stasis disease Yes Yes
Fiatarone Singh MA, J Gerontol Med Sci 57A, M262-82, 2002

16. Adapted Physical Activity
Sarcopenia, altered joint
flexibility, cardiovascular Worse gait, endurance,
deconditioning, balance, manual dexterity,
osteoporosis, etc. etc.
Impairments
Sedentary life style Functional limitations
Disability
Depression,
lack of vocational pursuits,
higher family and social
support, etc. Decrements of AADLs,
IADLs, BADLs…

17. Adapted Physical Activity
Impairments
Mild Disability
Sedentary life style Functional limitations
Moderate Disability
Severe Disability
Disability

18. Adapted Physical Activity Better muscle and joint
function, endurance,
increased BMD, etc. Easier focused
interventions for
Impairments improving gait, balance,
manual dexterity, etc.
Active life-style Functional limitations
Disability
Better integration in the
community, lower family and
Less disability for
social support,
AADLs, IADLs, BADLs…
Preservation of vocational
pursuits, QoL, etc.

19. Adapted Physical Activity
Frequency
Low
High
Low
Physical activiti for recreatioal
Health
or health purposes
Life Style
Not top performance
Exercise opportunity
LR 35/03
agonistic sport activity
Top performance
sport activity
High

20. Adapted Physical Activity
Frequency
Low
High
Low
High disability APA
Low disability APA
DGR 459/09
DGR 595/05
Physical activiti for recreatioal
Health
or health purposes
Life Style
Not top performance
Exercise opportunity
LR 35/03
agonistic sport activity
Top performance
sport activity
High

21. Adapted Physical Activity
2.20 €
per session
( + = 2.20 € )

22. AUSL: APA classes
Adapted Physical Activity 300
250
200
Number
150
100 Residents 230000
50 Aged >65 22%
0
2003 12004 2005 2006 2007 2008 2009 2010 2011 2012 2013 Participants >6000
Cerreto Guidi Vinci
Capraia e Limite
Fucecchio
S. Croce S.A. Montelupo
Castelfranco Empoli
Montopoli
Montespertoli
S. Miniato
Castelfiorentino
Montaione
Certaldo
Gambassi
Low disability High disability

23. Adapted Physical Activity

24. FOR HYPOMOBILITY SYNDROMES AND OSTEOPOROSIS
AND CHRONIC SYNDROMES STABILIZED IN THE
OUTCOMES APA PROGRAMS ARE APPROPRIATE…..

25. Participants
Adapted Physical Activity
25000
20000
Number
15000
10000
5000
0
2008 2009 2010 2011 2012
Classes
1500
1200
Number
900
600
300
0
2008 2009 2010 2011 2012
Low disability High disability

26. Gyms/pools
800
Number
600
400
200
0
2008 2009 2010 2011 2012
Municipalities
100%
80%
60%
40%
20%
0%
2008 2009 2010 2011 2012

27. Conferenze Stato Regioni ed Unificata

28. Adapted Physical Activity
for chronic stroke survivors

29. APA Stroke
Rehabilitation
Acute &
Subacute
Recovery plateau
Rehabilitation
Chronic
Rehabilitation
Time from stroke
Rehabilitation

30. APA Stroke
Recovery plateau
Conventional rehabilitation
"Task-oriented" exercise
Community-based exercise program
Acute & Chronic
Subacute Time from stroke

31. 23:726-734;2009

32. APA Stroke
Inclusion criteria
 Time from stroke >8 months
 Age >40 years
 Able to walk independently for 6 minutes
(also with walking aids) at a velocity 0,2-0,6
stature/sec
 No critical comorbidity or severe dementia

33. APA Stroke
METHODS
 Duration 6 months
 APA group recruited in Empoli Health
Authority area
 Usual care group (control group) recruited
in Pisa and Florence Health Authorities
 Project approved by Local Ethical
Committee

34. ISS project:
APA Stroke “Obtaining Optimal Functional Recovery and Efficient Managed
Care for the Chronic Stroke Population”
Community gyms or social clubs
Trainers not Health Professionals
Cerreto Guidi Vinci
Capraia e Limite
Fucecchio
S. Croce S.A. Montelupo
Castelfranco Empoli
Montopoli
Montespertoli
S. Miniato
Castelfiorentino
Montaione
Certaldo
Gambassi
Coordination Center
Stroke APA courses

35. APA Stroke
1,90 €
per session
No transportation provided by LHA
( + = 1.90 € )

36. APA Stroke
Safety
No adverse clinical
event in gymnasiums

37. APA Stroke
APA Functional ∆ > Control Functional
∆
80
70
60
50
40
APA Baseline
30
APA Post 6 months
20
10 Control Baseline
Control Post 6 months
0
Group x time
P < .005 for
all

38. Baseline and Post APA Intervention Mean Glucose and Insulin
APA Stroke Curves in Individuals without IGT or DM
Glucose
160,0
120,0
mg/dL
Before
80,0
After 6 months
40,0
0,0
0 +30 +60
minutes +90 +120
Insulin
160,0
120,0
mU/L
Before
80,0
After 6 months
40,0
0,0
1mU/L =7,217 pMol/L 0 +30 +60 +90 +120
minutes

39. 1 year after the end of the study… telephone interview
APA Stroke
How do you rate your…
as compared to one year ago?
Variation Gait
gait velocity N=38 N=38
100%
80% >26%
60%
40% 1-25%
20%
0%
<0%
APA group observed APA group reported Usual care group reported
Better or cured
same Health
worse
100%
N=38 N=38
80%
60%
40%
20%
0%
APA group Usual care group

40. APA Stroke Continuity with rehabilitation?
(DIS)CONTINUITY
Acute Chronic
phase phase
Rehabilitation APA
OVERLAPPING
Acute Chronic
phase phase
Rehabilitation APA

41. APA Stroke Can further interventions on
impairments in the chronic phase
of the disease improve outcome?
GAIT VELOCITY
0,5
stature/sec
0,4
0,3
0,2
0,1
0
0 1 2 3 4 5 6 7 8 9 10 11 12
N=81 Months in APA

42. Can we improve adherence?
APA Stroke
Baseline assessment
130
Excluded:
20 refused FU interview
(8 continuing APA)
3 not found
6 dead
1 year FU interview
101
Self reported causes of
interruption: N.
Continuing APA Interrupted APA Lack of motivation 15
70 30
Health 6
Family/work 2
Transportation 4
Cost 0
Other 3

44. Thanks
f.benvenuti@usl11.toscana.it
www.usl11.toscana.it