Experiences with information provision and preferences for decision making of patients with acute stroke

Patient experience and satisfaction with shared decision-making: A cross-sectional study among outpatients

OBJECTIVES

This study aimed to investigate how doctor-patient communication, trust in doctors impacted patients' experience and satisfaction in shared decision-making (SDM).

METHODS

This study is based on the data from a cross-sectional survey (n = 12,401) conducted in 27 public specialist outpatient clinics in Hong Kong.

RESULTS

The multivariable regression models revealed that doctors' better communication skills were associated with lower decision-making involvement (odd ratio, 0.75 [95 % CI, 0.88-0.94], P < .001) but higher satisfaction with involvement (odd ratio, 6.88 [95 % CI, 5.99-7.93], P < .001). Similarly, longer consultation durations were associated with reduced involvement in decision-making (odd ratio, 0.71 [95 % CI, 0.66-0.73], P < .001) but increased satisfaction with involvement (odd ratio, 1.91 [95 % CI, 1.80-2.04], P < .001). Trust in doctors significantly mediated these associations, except for the association between consultation duration and patients' satisfaction with decision-making involvement.

CONCLUSION

Doctors' better communication skills and longer consultations might not necessarily increase patient involvement in SDM but correlated with increased satisfaction with involvement. Trust in doctors emerged as a mediator for participation and satisfaction in decision-making.

PRACTICE IMPLICATIONS

Clinics should consider patients' preferences and capabilities when tailoring communication strategies about decision-making and optimizing patient satisfaction.

What influences provision of information about recovery on stroke units? A focused ethnographic case study

OBJECTIVE

Patients and carers frequently report dissatisfaction with post-stroke information provision. This study aimed to develop an in-depth understanding of the factors influencing provision of information about recovery in stroke units.

METHODS

Focused ethnographic case-studies in two UK stroke units, including non-participant observations and semi-structured interviews with professionals, patients and carers, and documentary analysis. A Framework approach to analysis was undertaken.

RESULTS

Twenty patients, 17 carers and 47 professionals participated. The unpredictable recovery trajectory led professionals to present prognostic estimates as uncertain possibilities. The need to maintain patients' motivation limited sharing of negative predictions, and generic information over-emphasised the importance of therapy in recovery. A structured multidisciplinary team approach to delivering information improved consistency. Complex clinical reasoning was required to identify and meet patients' needs. Hospital environments and routines restricted opportunities for dialogue, particularly with carers.

CONCLUSIONS

The process of providing information about post-stroke recovery is complex, requiring enhanced clinical reasoning and communication. The challenges faced by professionals are numerous and if not addressed can result in suboptimal provision.

PRACTICE IMPLICATIONS

Professionals should develop a co-ordinated multidisciplinary approach to information provision; and engage in dialogue to ensure a tailored approach to identifying and meeting patients' and carers' information needs.

Impact of Interprofessional Collaborative Practice on Functional Improvements Among Post-Acute Stroke Survivors: A Retrospective Cross-Sectional Study

Background

Stroke survivors in post-acute care frequently experience physiological dysfunction and reduced quality of life. This study aims to assess the impact of the Post-Acute Care Interprofessional Collaborative Practice (PAC-IPCP) program across different care settings, and to identify sensitive tools for assessing physiological functions among post-acute stroke survivors.

Methods

This retrospective study involved 210 stroke survivors in Taiwan. Participants who self-selection for their preferred between hospital care setting and home care setting under PAC-IPCP. Multiple assessment tools were utilized, including the Barthel Index (BI), Functional Oral Intake Scale (FOIS), Mini Nutritional Assessment (MNA), EQ-5D-3L, and Instrumental Activities of Daily Living (IADL). The logistic regression was used to estimate the odds ratios of various functional assessment tools between hospital and home care settings. Additionally, the area under the ROC curves was used to determine which functional assessment tools had higher accuracy in measuring the association between care settings.

Results

Of the study population, 138 stroke survivors (65.71%) selection hospital care setting and 72 stroke survivors (34.29%) selection home care setting. The PAC-IPCP program was equally effective in both care settings for physical function status and quality of life improvements. Specifically, the BI emerged as the most sensitive tool for assessing care settings, with an adjusted OR of 1.04 (95% CI:1.02-1.07, p < 0.0001; AUC = 0.7557). IPCP-based hospital and home care models are equally effective in facilitating improved functional outcomes in post-acute stroke survivors.

Conclusion

The PAC-IPCP program is versatile and effective across care settings. The BI stands out as a robust assessment tool for physiological functions, endorsing its broader clinical application. Future studies should also consider swallowing and nutritional status for a more holistic approach to rehabilitation.

Shared decision making in older people after severe stroke

Stroke is a major cause of death and lifelong disability. Although stroke treatments have improved, many patients are left with life-changing deficits. Shared decision making and consent are fundamental to good medical practice. This is challenging because stroke often causes mental incapacity, prior views might not be known and prognosis early after stroke is often uncertain. There are no large trials of shared decision making after severe stroke, so we need to rely on observational data to inform practice. Core ethical principles of autonomy, beneficence, non-maleficence and justice must underpin our decision making. 'Surrogate' decision makers will need to be involved if a patient lacks capacity, and prior expressed views and values and beliefs need to be taken into account in decision making. Patients and surrogates often feel shocked at the sudden nature of stroke, and experience grief including anticipatory grief. Health care professionals need to acknowledge these feelings and provide support, be clear about what decisions need to be made and provide sufficient information about the stroke, and the risks and benefits of treatments being considered. Shared decision making can be emotionally difficult for health care professionals and so working in a supportive environment with compassionate leadership is important. Further research is needed to better understand the nature of grief and what sort of psychological support would be most helpful. Large randomised trials of shared decision making are also needed.

A tension between surrendering and being involved: An interview study on person-centeredness in clinical reasoning in the acute stroke setting

OBJECTIVE

To explore how stroke survivors experience and prefer to participate in clinical reasoning processes in the acute phase of stroke care.

METHODS

An explorative qualitative design was used. Individual interviews were conducted with 11 stroke survivors in the acute phase of care and analyzed using reflexive thematic analysis.

RESULTS

The analysis identified five themes: What's going on with me?; Being a recipient of care and treatment; The need to be supported to participate; To be seen and strengthened; and Collaboration and joint understanding.

CONCLUSION

Stroke survivors experience many attributes of person-centeredness in the acute phase of care but, according to their stories, their participation in clinical reasoning can be further supported. The tension between surrendering and the desire to be more actively involved in the care needs to be considered to facilitate participation in clinical reasoning.

PRACTICE IMPLICATIONS

Stroke survivors' participation in clinical reasoning in the acute phase can be facilitated by health professionals noticing signs prompting a shift towards increased willingness to participate. Furthermore, health professionals need to take an active role, sharing their expertise and inviting the stroke survivors to share their perspective. The findings can contribute to further develop person-centered care in acute settings.

Stroke intervention and pharmacotherapy guidelines: Knowledge-to-practice translation gaps among the emergency resident physicians in Riyadh, Saudi Arabia

Translating the updated medical guidelines into routine clinical practice is an important initiative to improve the population's health and decrease disease outcomes. A cross-sectional survey-based study was conducted in Riyadh City, Saudi Arabia, to evaluate the knowledge and degree of application (practice) of the stroke management guidelines among emergency resident physicians. An interview-based self-administered questionnaire was used to survey the emergency resident doctors in Riyadh hospitals from May 2019 to January 2020. Of 129 participants, 78 valid, complete responses were obtained (60.5% response rate). Descriptive statistics, principle component, and correlation analyses were used. Most resident doctors were men(69.4%) with a mean age of 28.4±3.37 years. More than 60% of the residents were satisfied with their knowledge of the stroke guidelines; meanwhile, 46.2% were satisfied with their application of the guidelines. Both Knowledge and practice compliance components were significantly and positively correlated. Also, both components were significantly correlated with being updated, aware of, and strictly following these guidelines. The mini-test challenge showed a negative result with a mean knowledge score of 1.03±0.88. Even though the majority of participants utilized different tools of education and were aware of the American Stroke Association Guidelines. It was concluded that a considerable gap in the residents' knowledge regarding the current stroke management guidelines was present in Saudi hospitals. Also, it was reflected on their actual implementation and application into clinical practice. Continuous medical education, training, and follow-up of the emergency resident doctors, administered as a part of the government health programs, are crucial to improve the health care delivery for acute stroke patients.

Ability of patients with acute ischemic stroke to recall given information on intravenous thrombolysis: Results of a prospective multicenter study

Introduction:

Intravenous thrombolysis (IVT) is an on label treatment for selected patients with acute ischemic stroke (AIS). As major bleeding or allergic shock may occur, the need to ensure patients’ informed consent for IVT is a matter of debate.

Patients and methods:

Prospective investigator-initiated multi-center observational study to assess the ability of AIS patients to recall information, provided by a physician during a standardized educational talk (SET) on IVT use. The recall of 20 pre-defined items was assessed in AIS after 60–90 min ( n = 93) or 23–25 h ( n = 40) after SET. About 40 patients with subacute stroke, 40 non-stroke patients, and 23 relatives of AIS patients served as controls, and were surveyed 60–90 min after SET.

Results:

Within 60–90 min after SET, AIS patients (median age 70 years, 31% female, median NIHSS score on admission 3 points) who were considered capable to provide informed consent recalled 55% (IQR 40%–66.7%) of the provided SET items. In multivariable linear regression analysis recapitulation by AIS patients was associated with their educational level (β = 6.497, p < 0.001), self-reported excitement level (β = 1.879, p = 0.011) and NIHSS score on admission (β = −1.186, p = 0.001). Patients with subacute stroke (70 years, 40% female, median NIHSS = 2) recalled 70% (IQR 55.7%–83.6%), non-stroke patients (75 years, 40% female) 70% (IQR 60%–78.7%), and AIS relatives (58 years, 83% female) 70% (IQR 60%–85%). Compared to subacute stroke patients, AIS patients less often recalled the frequency of IVT-related bleeding (21% vs 43%), allergic shock (15% vs 39%), and bleeding-related morbidity and mortality (44% vs 78%). AIS patients recalled 50% (IQR 42.3%–67.5%) of the provided items 23–25 h after SET.

Conclusion:

AIS patients eligible for IVT remember about half of all SET-items after 60–90 min or 23–25 h, respectively. The fact that the recapitulation of IVT-associated risks is particularly poor should be given special consideration.

What do stroke survivors want in stroke education and information provision in Australia?

Despite evidence that stroke education is important and effective, low rates of stroke education are reported worldwide. Many stroke survivors and carers report that current stroke information does not meet their needs. The aim of the current study was to explore the perceptions of stroke survivors and carers towards stroke education in an Australian health context. A qualitative descriptive approach using focus groups was used to explore education received and preferred content, format and timing of education. Data were analysed inductively using qualitative content analysis to identify key categories, sub-categories and an overarching theme. Fifteen stroke survivors and four carers participated. Four categories emerged: the timing of stroke education, the content of stroke education, the format of stroke education, and reactions to stroke education. Each category contained a number of sub-categories. One overarching theme was woven through the transcripts: everyone is different and has different needs. Overall, participants generally expressed positive attitudes towards stroke education. Participants reported that education should occur at multiple timepoints and in a mixed format. All participants reported receiving stroke education in hospital, but not in the community. Stroke survivors preferred group education, while carers did not share this preference. Both stroke survivors and carers desired information about post-stroke physical changes and computer use; however, stroke survivors desired additional information spanning a variety of areas such as motivation and driving. Tailoring of stroke education for each individual is critical to ensure that education meets the needs of stroke survivors and carers from the hospital to the community.