The problematics of post-stroke disability assessment

Overview

The article introduces the issue of the post-stroke disability assessment. In the Czech Republic, there is a gradual decrease in the number of disability assessments of stroke patients, despite non-decreasing incidence of stroke. Specifically, the number of stroke patients treated in stroke centers per year remains consistent. This fact can be considered as the indirect evidence of good organization and improvement of complex medical care for stroke patients in the Czech Republic. Based on the fourteen-years old analysis of disability assessment criteria for nervous system dysfunctions, authors recommend using scoring scales such as the modified Rankin scale (mRS) and Barthel index (BI) for this purpose to ensure more accurate objectification in the post-stroke invalidity assessment.

Keywords:

stroke – medical assessment service – disability pension – post-stroke disability – disability assessment – stroke centers – quality of stroke care – RES-Q registry

This is an unauthorised machine translation into English made using the DeepL Translate Pro translator. The editors do not guarantee that the content of the article corresponds fully to the original language version.

 

Introduction

Stroke is a group of diseases with a high incidence and serious consequences on the health status of patients, their quality of life and socio-economic consequences for patients themselves, their families and society. In the Czech Republic, strokes account for 6% of all deaths in recent years [1,2]. The number of patients hospitalized in stroke centers and complex cerebrovascular centers has been similar for the last few years. The number of recanalization procedures for ischemic strokes – intravenous thrombolysis and mechanical thrombectomy - is increasing every year. Despite advances in primary prevention, the incidence of strokes is not declining, mainly due to the ageing of population, and the incidence of strokes is increasing. Invalidity is one of the major consequences of strokes. In the present study, we focused on the results of the disability assessment after stroke for the 5-year period between years 2016 and 2020 with the goal to approximate the issue and propose a refinement of the criteria for disability assessment and disability pensions.

 

Disability

The disability assessment criteria are regulated by Act .155/1995 Coll. on Pension Insurance and Decree No.359/2009 Coll. on disability assessment [3,4]. An insured person is invalid in the first degree of disability if the percentual rate of decline in the ability to work decreases by at least 35% but not more than 49%, in the second degree at least 50% but not more than 69% and in the third degree at least 70%. The decisive assessment for the recognition of invalidity is not only the fact

about the state of health, but also the functional impact of the disability on the use of work potential, including qualifications. The assessment is based on the finding of a long-term adverse health condition (LTADC), the establishment of a decisive diagnosis and an assessment of its functional impact on the person's ability to work.

For the purposes of the Pension Insurance act, a long-term adverse health condition is defined as a health condition that limits the insured person's physical, sensory or mental abilities relevant to his or her ability to work, if the condition lasts for more than 1 year or, according to medical science, can be expected to last for more than 1 year. The duration of the disability is calculated from the time when the adverse impact of the disability, i.e. the limitation of physical, sensory and mental abilities and thus the limitation or decline in the ability to work, starts to manifest itself [3,5].

In addition, the medical assessor may increase his or her assessment of the level of impairment by

up to 10 %, for example by concerning other conditions of a LTADC nature affecting education, experience, knowledge and the ability to continue previous gainful employment or the ability to requalify [5]. The general assessment principles for the assessment of nervous diseases are set out in

the annex to Decree No 359/2009 Coll. on the assessment of disability in Chapter VI Assessment of the nervous system: 'The assessment of the degree decline in working capacity is based on detailed

neurological findings, disorders of individual functional systems and structures, the extent and severity of motor, sensory, cognitive, expressive, sensory, bladder and rectal innervation disorders. In the assessment, the follow-up period, which is decisive for assessing the degree of decline in working

capacity, should normally last one year. The degree of impairment in nervous system diseases is determined by the range, degree and localization of the impairment, the impact of the impairment on mental and physical performance, the function of the musculoskeletal system and the ability to

manage daily activities,'. [4].

The criteria for disability assessing in persons with cerebral vascular accidents, as set out in the annex to the Disability Assessment Ordinance, are shown in Table 1. The assessment criteria listed in Table 1 were prepared in 2008 as part of a project of the Ministry of Labour and Social Affairs (MLSA),

which was led by the Czech Medical Society of J. E. Purkyně.

In 2008, diseases of the nervous system ranked as fifth among all recognized disabilities [6]. According to the data of the Czech Social Security Administration (CSSA) on disability pensions paid out, diseases of the nervous system were ranked as 4th in 2020 of all causes of disability. For decades, diseases of the skeletal and ligamentous system hold the first place. In 2016, the assessment for disability was revised as part of a public contract awarded by the Ministry of Labour and Social Affairs, the researcher was the Královské Vinohrady University Hospital.

In the researcher's opinion on Chapter VI Assessment of the nervous system, it is stated that in some cases some scales or tests can be used as an aid to assess the impact of the disease, but that these involve a degree of subjective judgement on the part of the assessor.

The decision-maker found that the general assessment principles and the specific assessment aspects for individual neurological diseases and disorders captured the relevant functional limitation and its impact on quality of life and ability to work, and therefore there was no need to change the design of Chapter VI [7,8].

Table 2, Figure 1 and Figure 2 show the number of disability assessments for people with stroke diagnoses I60 to I69 from 2016 to 2020. Table 2 shows that the number of disability assessments for stroke fell by 24% from 2016 to 2020. The number of unrecognized disabilities accounted for 8% in 2016 and increased to 12.5% in 2020. In all the years under review, the highest number of third degree disabilities were recognized.

 

Discussion

The Czech Republic is one of the countries with high estimated incidence, prevalence and mortality of stroke in Europe. Stroke is the third most common cause of death worldwide and is responsible for 3% of adult disability [10]. Krobot and others consider stroke to be one of the leading causes of chronic disability in populations in developed countries [11].

Neurological diseases are the fourth leading cause of disability in the Czech Republic, of which stroke is the first. The assessment of both disability and dependency is based on the assumption that the current functional impairment will last for at least 1 year or more. When assessing health status for the purposes of social security benefits, a determination of long-term adverse health status is a prerequisite.

Proof of a long-term adverse health condition is thus the first and necessary condition for further progress in the assessment of disability and degree of dependence. Several rating scales are used to assess neurological disability after stroke, most commonly the modified Rankin Scale (mRS), the Barthel Index (BI) and the The National Institutes of Health Stroke Scale (NIHSS) [12].

For the purposes of assessing functional disability from the perspective of the post-assessment evaluation for social security benefits, we focused on the Rankin Scale, which from our perspective is the most relevant to the needs of the post-assessment evaluation. With the recommended post-stroke follow-up at 3 months after the event and the mRS assessment [13], the development of the health status is already prognostically predictable. From the third stage of mRS, a recognition of disability is likely and an award of care allowance is virtually certain. Although it is not possible to directly compare the degree of mRS with the degree of disability, it is clear that this information is not taken into account in the assessment of functional status after a stroke, despite the fact that the 2016 project investigators recommend the use of various measurement scales or tests in the assessment of disability. The assessment should not focus solely on the diagnosis, but should take into account the functional impairment that the mRS adequately reflects. If we compare the Czech Republic's assessment criteria with the systems in developed Western countries, only Slovakia has a similar system of disability assessment, which is due to historical reasons. Annex 4 of Act No. 461/2003 of the Collection of Laws of the Slovak Republic on Social Insurance lists the types of disability and the degree of decline in earning capacity. For comparison, we attach Table 3, according to which disability is assessed, with the difference from the Czech Republic that it is full and partial disability. Partial disability requires the presence of a long-term adverse health condition and a reduction in working capacity of at least 40%, while full disability requires a 70% reduction. While the Czech assessment criteria differentiate between minimal, mild, moderate and severe functional impairment, in Slovakia only 3 forms are assessed, namely mild, moderate and severe with impaired integrity of brain functions. In other EU countries, the criteria for assessing disability are derived from the country's social system and historical experience. In Germany, for example, under the so-called Social Code, a full invalidity pension is granted to persons who, as a result of illness or incapacity, are unable to work for at least 3 hours a day in the unsupported labour market. A partial invalidity pension is granted to persons who, as a result of illness or incapacity, are unable to work for 6 hours a day in the unsupported labour market. Disabled persons who are able to engage in gainful activity for a minimum of 3 hours per day but not more than 6 hours per day are thus entitled to a full invalidity pension.  In addition, in Germany, so-called 'participation benefits', i.e. benefits for rehabilitation care, take precedence over the award of an invalidity pension. Pensions on the grounds of reduced earning capacity are to be awarded only after rehabilitation benefits have been granted. The exception is where the success of rehabilitation cannot be predicted. This is a big difference from the Czech Republic, where undergoing rehabilitation before applying for a disability pension is not enshrined in legislation. In France, disability is defined by the Social Security Code and a person becomes disabled if, as a result of an illness or accident, their earning capacity is reduced by at least two-thirds. He is therefore unable to earn, in any occupation, a wage higher than one third of the normal wage paid to workers in the same occupational category in the same region. Disability pensions are classified into one of three categories which determine the amount of the disability pension. In the first category, the invalid is able to engage in gainful activity; in the second category, he or she is totally unable to engage in any occupation; and in the third category, he or she is not only unable to engage in any occupation but also relies on the assistance of a third person for normal life activities [14 - 16]. Except for the Czech Republic and Slovakia, the assessment criteria are not so rigidly bound by legislation in Western countries. Moreover, in the Czech Republic there is no legal link to the obligation to undergo rehabilitation before applying for an invalidity pension. Also, the amount of earnings and working time of persons receiving an invalidity pension is not monitored. This fact was pointed out by the researchers of the Ministry of Labour and Social Affairs' public contract 'Incorporating advances in medical science into the assessment of health, work capacity and disability', who recommended that the Ministry should look into the possibility of reintroducing the control of the concurrence of the invalidity pension and income from gainful employment. On the issue of legislatively set assessment criteria, they took the view that the legally regulated medicine from the point of view of clinicians leads to problems, contradictions and schematic application, which in turn causes difficulties for assessing physicians in the interpretation of individual findings and their transformation into an assessment conclusion [17,18].

Therefore, we believe that the creation of assessment criteria containing assessment scales commonly used in neurological practice, such as the aforementioned mRS classification, would provide an objective and clear assessment criterion. Alternatively, other scales such as BI could be used. There has been a gradual decline in the number of disability assessments for strokes since 2016. This decline does not correspond to their increasing incidence in the population. If the criteria for disability assessment remain unchanged over this time period, the gradual decrease in the number of disability assessments for people after stroke can be considered indirect evidence of the increasing quality of stroke care in the Czech Republic [19 - 22].

For a more detailed overview of disability due to stroke, a tool similar to the Multiple Sclerosis Patient Registry (ReMuS) could be used. For these patients, it is mandatory to track data on incapacity for work, long-term incapacity for work and disability of the appropriate degree [23]. Consideration is being given to adding an annual check to the international register Registry of Stroke Care Quality (RES-Q) [13], including the above items. This would also allow comparisons of outcome and disability after stroke across countries.

 

Conclusion

While the incidence of stroke and the number of patients treated in stroke centers and comprehensive cerebrovascular centers in the Czech Republic were without significant changes between 2016 and 2020, there was a clear decrease in the number of disability assessments for people after stroke during this period. This fact can be considered as indirect evidence of the increasing quality of health care for stroke patients, especially the organization of acute stroke care in the Czech Republic. Regarding the actual assessment of long-term adverse health status (LTADC) and disability, it would be advisable to use common assessment scales used, for example, in the international RES-Q registry, such as mRS, BI, which assess and objectify the functional status of patients in a relatively simple but sufficiently accurate way. The use of these scales would also make it possible to determine the degree of decline in the incapacity to work of persons after a stroke and would contribute to avoiding inaccurate predictions of the medical assessors about the development of the health status of persons when assessing disability.

 

 

Financial support

Supported by the Institutional Research Project of the Ministry of Health of the Czech Republic - FNPI, 00669806 and the Programme for the Development of Scientific Disciplines of Charles University (Progres Q39).

 

Conflict of interest

The authors declare that they have no conflict of interest in relation to the subject of the study.