Our study revealed that 60% of neurological patients receiving inpatient rehabilitation improved their QoL during the rehabilitation period. This finding is consistent with the findings from studies by Manimmanakorn, et al. and Piravej, et al.. Both of those studies performed a multicenter study in stroke patients admitted to 9 centers in Thailand, and both reported significantly improved QoL in stroke patients after rehabilitation. In addition, Ploypetch and Dajpratham performed a single-center study in QoL among disabled patients receiving inpatient rehabilitation in a general rehabilitation ward of a tertiary hospital. They reviewed 200 charts for QoL information using the WHOQOL-BREF-THAI questionnaire, and they found that all domains of QoL had improved at discharge except the social domain .
This study also found that 15% of patients had decreased QoL from admission to discharge. This outcome may due to some of our patients not being ready to undertake a rehabilitation program (non-intensive goal of admission of 42.0%), and approximately 30% had complications during the rehabilitation period.3 Moreover, almost 50% of our subjects were SCI, which is associated with complicated physical disabilities, including motor impairment, difficulty with urination and defecation, and sexual dysfunction, that can adversely impact QoL , and some self-evaluated themselves as having poor QoL [18–20].
A prospective observational study was conducted by Coleman, et al. in 32 geriatric patients admitted to an inpatient rehabilitation ward . They studied patient QoL as one of their main outcomes, and they found that QoL evaluated by EQ-VAS significantly improved after 6 weeks of rehabilitation. Their study confirmed the benefits of rehabilitation, even in frail older adults (mean age of 82.9 years). In contrast, Gupta, et al. in 2008 investigated QoL in 30 neurological patients receiving rehabilitation using the WHOQOL-BREF assessment tool, and they found impaired QoL among their study subjects that affected all domains . This finding may be due to the fact that most of the participants in Gupta’s study were SCI (18/30), younger age (mean age: 34.6 ± 11.9), and 9 (30%) and 3 (10%) patients had moderate to severe anxiety and depression, respectively. Neither our KPI project nor this study aimed to evaluate the effect of psychological distress on QoL. Further study to investigate the effects of psychological factors on patient QoL are recommended.
Regarding factors that affect QoL during the rehabilitation period, intensive goal of admission and OAI of less than 3 months were both found to be predictors of improved QoL during the rehabilitation period. The fact that intensive rehabilitation was identified may be explained by these patients being ready and eager to participate in a program that will help to improve their ability to function independently, and this would have a resulting positive effect on QoL. Ploypetch and Dajpratham reported improved QoL after rehabilitation in patients admitted for intensive rehabilitation . In 2016, Kuptniratsaikul, et al. conducted a multicenter study in 2,081 rehabilitation inpatients that revealed the most efficient type of admission to be intensive rehabilitation, which could improve functional score better than other types of admission . A 2012 study showed association between better patient QoL perceptions and the level of patient independence . They also found that older adults that considered themselves to be unhealthy had a tendency to report a worse QoL than the QoL reported by healthy older adults. Our intensive rehabilitation program aims to improve physical functions and the level of patient independence. Accordingly, it could be anticipated that patients admitted for intensive rehabilitation would realize improvement in their QoL.
Regarding onset to rehabilitation admission interval, we found a duration less than 3 months to be associated with improvement in QoL. This finding is consistent with that reported by Piravej and colleague . They studied QoL among stroke with onset of less than 1 month compared to stroke with onset of more than or equal to 1 month, and they found that an interdisciplinary intensive rehabilitation program could improve QoL in these stroke populations, but that early interdisciplinary intensive rehabilitation was preferred. The 1999 Copenhagen Stroke Study reported that neurological recovery is greatest within 3 months after stroke onset . Taken together, these results suggest that the earlier the rehabilitation is started, the more QoL benefit the patient will gain.
The present study is part of the first prospective multicenter study with a large sample size to report on rehabilitation services in Thailand, however, it has some mentionable limitations. First, there was no long-term follow-up of the patients included in this study. The reported effect on patient QoL reflected the difference in QoL between admission and discharge. It is, therefore, possible that improvements in QoL at the end of rehabilitation may not have been sustained after the patient was discharged. Longer-term follow-up is needed to evaluate the level of sustained effect of rehabilitation after discharge. Second, this study was performed in tertiary hospitals that could provide patients with care delivered by a multidisciplinary team. Since we do not know the effect of other disciplines on changes in patient QoL, our results may not be generalizable to other rehabilitation hospitals with different contexts that could not deliver multidisciplinary care. Third, there are many assessment tools that can be used to evaluate QoL. We chose EQ-5D, which is a non-specific tool, but it is a simple to use tool that we felt would be suitable in our context. Moreover, since the inpatient rehabilitation wards in Thailand are general wards that can treat any kind of condition that requires rehabilitation, we selected EQ-5D since it can be applied in every one of the conditions treated in this study. Fourth, factors related to QoL were analyzed among the entire study cohort. As such, we do not know the effects of the studied factors on each included condition. In addition and as mentioned earlier in this section, the factors affecting QoL that were investigated in this study were mainly physical factors. Further study that includes the effect of psychological and socioeconomic factors on patient QoL should be conducted so that we can gain a more comprehensive understanding of what influences changes in QoL in this patient population.