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Association of patient quality of life with the degree of agreement in the perceptions of patient disability within the stroke patient-rehabilitation therapist dyad: a cross-sectional study in postdischarge rehabilitation setting

Takashi, Naoki 京都大学 DOI:10.14989/doctor.k23612

2022.01.24

概要

【背景】
立場や考え方の相違から生じる医療提供者と患者の間のミスコミュニケーションは、長い間、患者中心の医療における課題の一つとされてきた。リハビリテーションの領域においても同様であり、特に脳卒中後のリハビリテーションでは、障害に関する認識や治療の目標について、患者と療法士の間で食い違いが存在し、それがリハビリテーションプロセスを阻害することが指摘されてきた。しかし、これまでの知見の多くは入院患者を対象としたものであり、退院後のリハビリテーションサービスをセッティングとして、患者-療法士間の認識の一致の定量的評価や患者アウトカムとの関連を検討した研究はほとんど存在しない。そこで、退院後のリハビリテーションにおける患者-療法士間の障害に関する認識の一致の程度と患者の身体的・心理的Qualityof Life(QOL)との関連を探索することを目的に本研究を実施した。

【方法】
本研究は、介護保険のリハビリテーションサービスを利用している在宅の男性脳卒中患者と、リハビリテーションを担当する療法士(理学療法士または作業療法士)のペアを対象とした横断的研究である(実施期間は2019 年3 月~2020 年2 月)。研究協力が得られた通所または訪問リハビリサービスを実施している施設17 か所から対象ペアを簡易的に選定し、タブレット内に電子化された構造化質問票を使用してデータ収集を行った。患者の身体的・心理的 QOL は日本語版 WHOQOL-BREF を、患者と療法士の持つ患者の障害の程度に関する認識は 12-itemWHO Disability Assessment Schedule2.0 (DAS) を用いて測定した。患者と療法士から得られたDAS スコアをそれぞれ2 区分(低・高)と3 区分(低・中・高)に分け、その組み合わせで、認識の一致の程度を表す多区分変数(6 区分 [ DAS 患者スコア低・療法士スコア低、低中、低高、高高、 高中、高低])を作成した。また、患者と療法士の特性として、患者の年齢や脳卒中発症後の年数、発症回数、併存疾患の有無、療法士の年齢と職種、さらに患者を担当している期間などを測定した。統計解析では、一般化推定方程式を用いて共変量とクラスター効果を調整した上で、認識の一致の程度を表す多区分変数と患者の身体的・心理的QOL スコアの関連を評価した。共変量は、患者と療法士の特性のうち、患者の身体的・心理的QOL スコアとの単変量解析でP<0.2 となったものを選んだ。

【結果】
81 ペア(患者81 名、療法士45 名)の参加が得られた。患者の平均年齢は72.6 で、74.1%が初回発症であり、90%以上で発症から一年以上が経過していた。療法士の平均年齢は32.7 であり、60%が理学療法士で、約90%が患者を担当して3 年未満であった。障害の程度について、48 ペア(約60%)で認識の不一致が確認された。一般化推定方程式の結果、身体的QOL を従属変数とするモデルにおいて、DAS 低低、低中、低高の回帰係数はそれぞれ、0、₋7.9、₋16.0 であり、DAS 高高、高中、高低の回帰係数はそれぞれ、₋18.5、₋22.4、₋19.6 であった。一方、心理的QOL を従属変数とするモデルでは、DAS 低低、低中、低高の回帰係数はそれぞれ、0、₋12.4、₋10.6 であり、DAS 高高、高中、高低の回帰係数はそれぞれ、₋18.0、₋23.5、₋20.8 であった。

【結論】
参加したペアの約60%で患者の障害についての認識に乖離が見られた。さらに、患者のDAS スコアが低い場合(自身の障害を軽度であると認識している場合)、認識の不一致が大きいほど、身体的・心理的QOL が低かった。自宅生活を送る脳卒中患者の身体的・心理的QOL を考える上で、患者の障害に関する患者‐療法士間の認識の乖離は留意すべき要因の一つと考えられる。

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