1
|
Sauvé-Schenk K, Duong P, Samonte-Brown S, Sheehy L, Trudelle M, Savard J. Supporting post-stroke access to services and resources for individuals with low income: understanding usual care practices in acute care and rehabilitation settings. Disabil Rehabil 2024; 46:1391-1399. [PMID: 37067052 DOI: 10.1080/09638288.2023.2199462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Accepted: 03/30/2023] [Indexed: 04/18/2023]
Abstract
PURPOSE Following stroke, individuals who live in a low-income or are at risk of living in a low-income situation face challenges with timely access to social services and community resources. Understanding the usual care practices of stroke teams, specifically, how they support this access to services and resources, is an important first step in promoting the implementation of practice change. METHOD A qualitative multiple-case study of acute care, inpatient, and outpatient rehabilitation stroke teams in an urban area of Canada. Semi-structured interviews and questionnaires about the workplace context were conducted with 19 professionals (social workers, occupational therapists, physiotherapists, speech-language pathologists) at four sites. RESULTS In their usual practice, stroke teams prioritized immediate care needs. The stroke team professionals did not address income or resources unless it directly affected discharge. Usual care was influenced by factors such as time constraints, lack of knowledge about services and resources, and social service system limitations. CONCLUSION To better support post-stroke access to social services and resource for low-income individuals, a multidisciplinary approach, with actions beginning earlier on and extending throughout the continuum of care, is recommended, in addition to system-level advocacy.
Collapse
Affiliation(s)
- Katrine Sauvé-Schenk
- School of Rehabilitation, University of Ottawa, Ottawa, Canada
- Institut du Savoir Montfort, Ottawa, Canada
| | - Patrick Duong
- School of Rehabilitation, University of Ottawa, Ottawa, Canada
| | | | | | | | - Jacinthe Savard
- School of Rehabilitation, University of Ottawa, Ottawa, Canada
- Institut du Savoir Montfort, Ottawa, Canada
| |
Collapse
|
2
|
Potter TBH, Tannous J, Pan AP, Bako A, Johnson C, Baig E, Kelly H, McCane CD, Garg T, Gadhia R, Misra V, Volpi J, Britz G, Chiu D, Vahidy FS. Stroke severity mediates the effect of socioeconomic disadvantage on poor outcomes among patients with intracerebral hemorrhage. Front Neurol 2023; 14:1176924. [PMID: 37384280 PMCID: PMC10293742 DOI: 10.3389/fneur.2023.1176924] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 05/08/2023] [Indexed: 06/30/2023] Open
Abstract
Background Socioeconomic deprivation drives poor functional outcomes after intracerebral hemorrhage (ICH). Stroke severity and background cerebral small vessel disease (CSVD) burden have each been linked to socioeconomic status and independently contribute to worse outcomes after ICH, providing distinct, plausible pathways for the effects of deprivation. We investigate whether admission stroke severity or cerebral small vessel disease (CSVD) mediates the effect of socioeconomic deprivation on 90-day functional outcomes. Methods Electronic medical record data, including demographics, treatments, comorbidities, and physiological data, were analyzed. CSVD burden was graded from 0 to 4, with severe CSVD categorized as ≥3. High deprivation was assessed for patients in the top 30% of state-level area deprivation index scores. Severe disability or death was defined as a 90-day modified Rankin Scale score of 4-6. Stroke severity (NIH stroke scale (NIHSS)) was classified as: none (0), minor (1-4), moderate (5-15), moderate-severe (16-20), and severe (21+). Univariate and multivariate associations with severe disability or death were determined, with mediation evaluated through structural equation modelling. Results A total of 677 patients were included (46.8% female; 43.9% White, 27.0% Black, 20.7% Hispanic, 6.1% Asian, 2.4% Other). In univariable modelling, high deprivation (odds ratio: 1.54; 95% confidence interval: [1.06-2.23]; p = 0.024), severe CSVD (2.14 [1.42-3.21]; p < 0.001), moderate (8.03 [2.76-17.15]; p < 0.001), moderate-severe (32.79 [11.52-93.29]; p < 0.001), and severe stroke (104.19 [37.66-288.12]; p < 0.001) were associated with severe disability or death. In multivariable modelling, severe CSVD (3.42 [1.75-6.69]; p < 0.001) and moderate (5.84 [2.27-15.01], p < 0.001), moderate-severe (27.59 [7.34-103.69], p < 0.001), and severe stroke (36.41 [9.90-133.85]; p < 0.001) independently increased odds of severe disability or death; high deprivation did not. Stroke severity mediated 94.1% of deprivation's effect on severe disability or death (p = 0.005), while CSVD accounted for 4.9% (p = 0.524). Conclusion CSVD contributed to poor functional outcome independent of socioeconomic deprivation, while stroke severity mediated the effects of deprivation. Improving awareness and trust among disadvantaged communities may reduce admission stroke severity and improve outcomes.
Collapse
Affiliation(s)
| | - Jonika Tannous
- Department of Neurosurgery, Houston Methodist, Houston, TX, United States
| | - Alan P. Pan
- Center for Health Data Science and Analytics, Houston Methodist, Houston, TX, United States
| | - Abdulaziz Bako
- Department of Neurosurgery, Houston Methodist, Houston, TX, United States
| | - Carnayla Johnson
- Department of Neurosurgery, Houston Methodist, Houston, TX, United States
| | - Eman Baig
- Department of Neurosurgery, Houston Methodist, Houston, TX, United States
| | - Hannah Kelly
- Department of Neurosurgery, Houston Methodist, Houston, TX, United States
| | - Charles D. McCane
- Department of Neurology, Houston Methodist, Houston, TX, United States
| | - Tanu Garg
- Department of Neurology, Houston Methodist, Houston, TX, United States
- Department of Neurology, Weill Cornell Medicine, White Plains, NY, United States
- Department of Neurology, Houston Methodist Academic Institute, Houston Methodist, Houston, TX, United States
| | - Rajan Gadhia
- Department of Neurology, Houston Methodist, Houston, TX, United States
- Department of Neurology, Weill Cornell Medicine, White Plains, NY, United States
- Department of Neurology, Houston Methodist Academic Institute, Houston Methodist, Houston, TX, United States
| | - Vivek Misra
- Department of Neurology, Houston Methodist, Houston, TX, United States
- Department of Neurology, Weill Cornell Medicine, White Plains, NY, United States
- Department of Neurology, Houston Methodist Academic Institute, Houston Methodist, Houston, TX, United States
| | - John Volpi
- Department of Neurology, Houston Methodist, Houston, TX, United States
- Department of Neurology, Weill Cornell Medicine, White Plains, NY, United States
- Department of Neurology, Houston Methodist Academic Institute, Houston Methodist, Houston, TX, United States
| | - Gavin Britz
- Department of Neurosurgery, Houston Methodist, Houston, TX, United States
- Department of Neurology, Weill Cornell Medicine, White Plains, NY, United States
- Department of Neurology, Houston Methodist Academic Institute, Houston Methodist, Houston, TX, United States
- Department of Neurological Surgery, Houston Methodist Neurological Institute, Houston Methodist, Houston, TX, United States
| | - David Chiu
- Department of Neurology, Houston Methodist, Houston, TX, United States
- Department of Neurology, Weill Cornell Medicine, White Plains, NY, United States
- Department of Neurology, Houston Methodist Academic Institute, Houston Methodist, Houston, TX, United States
| | - Farhaan S. Vahidy
- Department of Neurosurgery, Houston Methodist, Houston, TX, United States
- Center for Health Data Science and Analytics, Houston Methodist, Houston, TX, United States
- Department of Neurology, Weill Cornell Medicine, White Plains, NY, United States
- Department of Neurology, Houston Methodist Academic Institute, Houston Methodist, Houston, TX, United States
- Department of Neurological Surgery, Houston Methodist Neurological Institute, Houston Methodist, Houston, TX, United States
- Department of Population Health Sciences, Weill Cornell Medicine, White Plains, NY, United States
| |
Collapse
|
3
|
Everson J, Henderson SC, Cheng A, Senft N, Whitmore C, Dusetzina SB. Demand for and Occurrence of Medication Cost Conversations: A Narrative Review. Med Care Res Rev 2023; 80:16-29. [PMID: 35808853 DOI: 10.1177/10775587221108042] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
High medication prices can create a financial burden for patients and reduce medication initiation. To improve decision making, public policy is supporting development of tools to provide real-time prescription drug prices. We reviewed the literature on medication cost conversations to characterize the context in which these tools may be used. Our review included 42 articles: a median of 84% of patients across four clinical specialties reported a desire for cost conversations (n = 7 articles) but only 23% reported having held a cost conversation across six specialties (n = 16 articles). Non-White and older patients were less likely to report having held a cost conversation than White and younger patients in 9 of 13 and 5 of 9 articles, respectively, examining these associations. Our review indicates that tools providing price information may not result in improved decision making without complementary interventions that increase the frequency of cost conversations with a focus on protected groups.
Collapse
Affiliation(s)
- Jordan Everson
- Vanderbilt University School of Medicine, Nashville, TN, USA
| | | | - Audrey Cheng
- Vanderbilt University School of Medicine, Nashville, TN, USA
| | | | | | - Stacie B Dusetzina
- Vanderbilt University School of Medicine, Nashville, TN, USA.,Vanderbilt-Ingram Cancer Center, Nashville, TN, USA
| |
Collapse
|
4
|
Mattingly TJ, Everson J, Besaw RJ, Whitmore CC, Henderson SC, Dusetzina SB. "Worth it if you could afford it": Patient perspectives on integrating real-time benefit tools into drug cost conversations. J Am Geriatr Soc 2023; 71:1627-1637. [PMID: 36637794 DOI: 10.1111/jgs.18226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 12/03/2022] [Accepted: 12/12/2022] [Indexed: 01/14/2023]
Abstract
BACKGROUND Medication costs can lead to financial burdens for patients, creating barriers to effective medication use. Health care provider use of real-time benefit tools (RTBTs) may facilitate cost conversations with patients. We sought to explicate patient views on how RTBTs could be used to improve cost considerations in prescribing decisions. METHODS We conducted focus groups to characterize patient perspectives on holding cost conversations with their physicians and to identify factors that would influence the value of RTBTs. We focused on adults aged 50+ who reported trouble paying for their prescriptions. Three groups included patients with conditions requiring high-cost treatments and one group included lower-income patients independent of their medical conditions. Focus groups were recorded, transcribed, coded, and categorized to salient themes employing inductive and deductive approaches using the Health Equity Implementation Framework. RESULTS Focus groups were conducted from 09/2020-12/2020 including 18 participants representing cancer (n = 6), diabetes (n = 6), rheumatoid arthritis (n = 3), and lower income (n = 3). Participants were between 50-74, eight self-identified as Black, 10 as White, and eight reported earning <$50,000/year. We identified five themes regarding cost conversations (medication cost importance, past experiences with cost/cost conversations, perception of physician's role and knowledge, knowledge of existing resources, and influence on decision-making) and four RTBT-use-specific themes (advantages/disadvantages, perceived relevance, data quality concerns, and implementation considerations). CONCLUSION Approaches that envision RTBTs as one-size-fits-all technological interventions may underestimate the complexity of incorporating price information into prescribing decisions. Nevertheless, patients highlighted the potential value of accurate, real-time information on medication costs to inform decision-making.
Collapse
Affiliation(s)
- T Joseph Mattingly
- Department of Pharmaceutical Health Services Research, University of Maryland School of Pharmacy, Baltimore, Maryland, USA
| | - Jordan Everson
- Department of Health and Human Services, Data Analysis Branch, Office of the National Coordinator for Health Information Technology, Washington, District of Columbia, USA
| | - Robert J Besaw
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Christine C Whitmore
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Sarah C Henderson
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Stacie B Dusetzina
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, Tennessee, USA.,Vanderbilt-Ingram Cancer Center, Nashville, Tennessee, USA
| |
Collapse
|
5
|
Ganesh A, Fladt J, Singh N, Goyal M. Efficacy and safety of mechanical thrombectomy in acute stroke patients with pre-morbid disability. Expert Rev Med Devices 2022; 19:641-648. [PMID: 36093630 DOI: 10.1080/17434440.2022.2124109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION – Patients with pre-morbid disability have been generally excluded from randomized controlled trials of mechanical thrombectomy for acute ischemic stroke. However, stroke physicians commonly encounter such patients in practice, and face challenging treatment decisions when caring for them. AREAS COVERED – We review the literature on the safety and efficacy of thrombectomy in patients with pre-morbid disability. Recent clinical-epidemiological studies have highlighted the adverse outcomes that come with each increment of additional post-stroke disability in these patients. Several observational studies - both case series and registry-based studies - have helped demonstrate the comparable safety of thrombectomy in patients with pre-morbid disability as in those without, complementing similar data on thrombolysis. These data also suggest similar rates of successful recanalization, symptomatic intracerebral hemorrhage, and return to pre-stroke level of disability when treated with mechanical thrombectomy, although they have higher mortality. EXPERT OPINION – In the absence of high-quality evidence, we recommend pursuing shared decision-making with patients or family members and being upfront about the uncertain evidence. Available observational data underline the potential for a substantial proportion of these patients to return to their pre-morbid state, do not indicate a greater rate of treatment-related complications, and do not support routinely excluding these patients from thrombectomy.
Collapse
Affiliation(s)
- Aravind Ganesh
- Calgary Stroke Program, Department of Clinical Neurosciences, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada.,Hotchkiss Brain Institute and the Mathison Centre for Mental Health Research and Education, University of Calgary, Calgary, Alberta, Canada.,Department of Community Health Sciences, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Joachim Fladt
- Calgary Stroke Program, Department of Clinical Neurosciences, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada.,Stroke Center and Department of Neurology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Nishita Singh
- Calgary Stroke Program, Department of Clinical Neurosciences, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Mayank Goyal
- Calgary Stroke Program, Department of Clinical Neurosciences, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada.,Hotchkiss Brain Institute and the Mathison Centre for Mental Health Research and Education, University of Calgary, Calgary, Alberta, Canada.,Department of Radiology, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| |
Collapse
|
6
|
Ganesh A, Fraser JF, Gordon Perue GL, Amin-Hanjani S, Leslie-Mazwi TM, Greenberg SM, Couillard P, Asdaghi N, Goyal M. Endovascular Treatment and Thrombolysis for Acute Ischemic Stroke in Patients With Premorbid Disability or Dementia: A Scientific Statement From the American Heart Association/American Stroke Association. Stroke 2022; 53:e204-e217. [PMID: 35343235 DOI: 10.1161/str.0000000000000406] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Patients with premorbid disability or dementia have generally been excluded from randomized controlled trials of reperfusion therapies such as thrombolysis and endovascular therapy for acute ischemic stroke. Consequently, stroke physicians face treatment dilemmas in caring for such patients. In this scientific statement, we review the literature on acute ischemic stroke in patients with premorbid disability or dementia and propose principles to guide clinicians, clinician-scientists, and policymakers on the use of acute stroke therapies in these populations. Recent clinical-epidemiological studies have demonstrated challenges in our concept and measurement of premorbid disability or dementia while highlighting the significant proportion of the general stroke population that falls under this umbrella, risking exclusion from therapies. Such studies have also helped clarify the adverse long-term clinical and health economic consequences with each increment of additional poststroke disability in these patients, underscoring the importance of finding strategies to mitigate such additional disability. Several observational studies, both case series and registry-based studies, have helped demonstrate the comparable safety of endovascular therapy in patients with premorbid disability or dementia and in those without, complementing similar data on thrombolysis. These data also suggest that such patients have a substantial potential to retain their prestroke level of disability when treated, despite their generally worse prognosis overall, although this remains to be validated in higher-quality registries and clinical trials. By pairing pragmatic and transparent decision-making in clinical practice with an active pursuit of high-quality research, we can work toward a more inclusive paradigm of patient-centered care for this often-neglected patient population.
Collapse
|
7
|
Dharma KK, -Rahayu H. [The effective post-stroke adaptation behavior model requires a family support system]. ENFERMERIA CLINICA (ENGLISH EDITION) 2022; 32:123-130. [PMID: 35577409 DOI: 10.1016/j.enfcle.2020.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 11/20/2020] [Indexed: 06/15/2023]
Abstract
PURPOSE This study aimed to explain the effective post-stroke adaptation behavior based on the Roy's adaptation model (RAM) through the patient experiences when undergoing the adaptation process after stroke. METHODS This study was qualitative used a phenomenological approach. The participants were patients undergoing post-stroke recovery at home with the following inclusion criteria: post-discharge from the hospital 2-3 months, and in stable medical condition. The data were collected through in-depth interviews. The data analysis was performed through content analysis. We used Lincoln and Guba's criteria to establish the trustworthiness of the study. RESULTS Three thematic categories structured the meaning of the stroke survivor's experience: (1) Problems after stroke; (2) Adaptive coping strategies and (3) Effective adaptation response. CONCLUSION A thematic analysis integrated with Roy's adaptation model generated an effective post-stroke adaptation model. We recommend the development of a family empowerment intervention framework to improve the adaptation behavior of stroke survivors.
Collapse
Affiliation(s)
- Kelana-Kusuma Dharma
- School of Nursing, Politeknik Kesehatan Kementerian Kesehatan Pontianak, Indonesia.
| | - Halina -Rahayu
- School of Nursing, Politeknik Kesehatan Kementerian Kesehatan Pontianak, Indonesia
| |
Collapse
|
8
|
Beck M, Engelke E, Birkelund R, Martinsen B. Aesthetics sets patients 'free' to recover during hospitalization with a neurological disease. A qualitative study. Int J Qual Stud Health Well-being 2021; 16:1992843. [PMID: 34747349 PMCID: PMC8583855 DOI: 10.1080/17482631.2021.1992843] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/08/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Patients with neurological symptoms are particularly sensitive to the quality of the sensory impressions to which they are exposed to during hospitalization. AIM To understand the meaning of aesthetic experiences to patients afflicted with neurological diseases during hospitalization on a neurological unit. METHOD Fifteen patients were invited to "walk and talk" supplemented by semi-structured interviews conducted in newly established aesthetic tableaus within the neurology unit. Data analysis was inspired by the hermeneutic phenomenological methodology of van Manen. RESULT The data analysis identified three overarching themes that unfolded in the patients' experiences of a more aesthetic environment. The themes were: 1) A safe place to avoid noisiness, 2) An invitation to homey activities, 3) A thoughtful consideration for being ill. CONCLUSION Aesthetic elements can enable a thoughtful and needed consideration that withholds momentarily imaginative and hopeful experiences to patients in a vulnerable situation. Thus, aesthetics, together with peace and quietness, can set vulnerable patients free to retreat and recover from the symptoms of neurological diseases.
Collapse
Affiliation(s)
- Malene Beck
- Department of Neurology,Zealand University Hospital, Roskilde, Denmark
| | - Eileen Engelke
- College of Health Professions, Lienhard School of Nursing, Pace Universityr, Teachers College, Columbia University, New York City, NY, USA
| | - Regner Birkelund
- Department of Regional Health Research, Institute of Health Service Research (IRS), University of Southern Denmark, Odense, Denmark
| | - Bente Martinsen
- Institute of Health, Department of Nursing Science, Aarhus University, Campus Emdrup, Copenhagen, NV, Denmark
| |
Collapse
|
9
|
The Comparison and Interpretation of Machine-Learning Models in Post-Stroke Functional Outcome Prediction. Diagnostics (Basel) 2021; 11:diagnostics11101784. [PMID: 34679482 PMCID: PMC8534424 DOI: 10.3390/diagnostics11101784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 09/18/2021] [Accepted: 09/23/2021] [Indexed: 11/24/2022] Open
Abstract
Prediction of post-stroke functional outcomes is crucial for allocating medical resources. In this study, a total of 577 patients were enrolled in the Post-Acute Care-Cerebrovascular Disease (PAC-CVD) program, and 77 predictors were collected at admission. The outcome was whether a patient could achieve a Barthel Index (BI) score of >60 upon discharge. Eight machine-learning (ML) methods were applied, and their results were integrated by stacking method. The area under the curve (AUC) of the eight ML models ranged from 0.83 to 0.887, with random forest, stacking, logistic regression, and support vector machine demonstrating superior performance. The feature importance analysis indicated that the initial Berg Balance Test (BBS-I), initial BI (BI-I), and initial Concise Chinese Aphasia Test (CCAT-I) were the top three predictors of BI scores at discharge. The partial dependence plot (PDP) and individual conditional expectation (ICE) plot indicated that the predictors’ ability to predict outcomes was the most pronounced within a specific value range (e.g., BBS-I < 40 and BI-I < 60). BI at discharge could be predicted by information collected at admission with the aid of various ML models, and the PDP and ICE plots indicated that the predictors could predict outcomes at a certain value range.
Collapse
|
10
|
Ganesh A, Ospel JM, Marko M, van Zwam WH, Roos YBWEM, Majoie CBLM, Goyal M. From Three-Months to Five-Years: Sustaining Long-Term Benefits of Endovascular Therapy for Ischemic Stroke. Front Neurol 2021; 12:713738. [PMID: 34381418 PMCID: PMC8350336 DOI: 10.3389/fneur.2021.713738] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 06/28/2021] [Indexed: 11/28/2022] Open
Abstract
Background and Purpose: During the months and years post-stroke, treatment benefits from endovascular therapy (EVT) may be magnified by disability-related differences in morbidity/mortality or may be eroded by recurrent strokes and non-stroke-related disability/mortality. Understanding the extent to which EVT benefits may be sustained at 5 years, and the factors influencing this outcome, may help us better promote the sustenance of EVT benefits until 5 years post-stroke and beyond. Methods: In this review, undertaken 5 years after EVT became the standard of care, we searched PubMed and EMBASE to examine the current state of the literature on 5-year post-stroke outcomes, with particular attention to modifiable factors that influence outcomes between 3 months and 5 years post-EVT. Results: Prospective cohorts and follow-up data from EVT trials indicate that 3-month EVT benefits will likely translate into lower 5-year disability, mortality, institutionalization, and care costs and higher quality of life. However, these group-level data by no means guarantee maintenance of 3-month benefits for individual patients. We identify factors and associated “action items” for stroke teams/systems at three specific levels (medical care, individual psychosocioeconomic, and larger societal/environmental levels) that influence the long-term EVT outcome of a patient. Medical action items include optimizing stroke rehabilitation, clinical follow-up, secondary stroke prevention, infection prevention/control, and post-stroke depression care. Psychosocioeconomic aspects include addressing access to primary care, specialist clinics, and rehabilitation; affordability of healthy lifestyle choices and preventative therapies; and optimization of family/social support and return-to-work options. High-level societal efforts include improving accessibility of public/private spaces and transportation, empowering/engaging persons with disability in society, and investing in treatments/technologies to mitigate consequences of post-stroke disability. Conclusions: In the longtime horizon from 3 months to 5 years, several factors in the medical and societal spheres could negate EVT benefits. However, many factors can be leveraged to preserve or magnify treatment benefits, with opportunities to share responsibility with widening circles of care around the patient.
Collapse
Affiliation(s)
- Aravind Ganesh
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | | | - Martha Marko
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada.,Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Wim H van Zwam
- Department of Radiology, Maastricht University Medical Centre, Maastricht, Netherlands
| | | | | | - Mayank Goyal
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada.,Department of Radiology, University of Calgary, Calgary, AB, Canada.,Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
| |
Collapse
|
11
|
Dharma KK, Halina-Rahayu. The effective post-stroke adaptation behavior model requires a family support system. ENFERMERIA CLINICA 2021; 32:S1130-8621(20)30550-7. [PMID: 33455844 DOI: 10.1016/j.enfcli.2020.11.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 10/30/2020] [Accepted: 11/20/2020] [Indexed: 01/01/2023]
Abstract
PURPOSE This study aimed to explain the effective post-stroke adaptation behavior based on the Roy's adaptation model (RAM) through the patient experiences when undergoing the adaptation process after stroke. METHODS This study was qualitative used a phenomenological approach. The participants were patients undergoing post-stroke recovery at home with the following inclusion criteria: post-discharge from the hospital 2-3 months, and in stable medical condition. The data were collected through in-depth interviews. The data analysis was performed through content analysis. We used Lincoln and Guba's criteria to establish the trustworthiness of the study. RESULTS Three thematic categories structured the meaning of the stroke survivor's experience: (1) Problems after stroke; (2) Adaptive coping strategies and (3) Effective adaptation response. CONCLUSION A thematic analysis integrated with Roy's adaptation model generated an effective post-stroke adaptation model. We recommend the development of a family empowerment intervention framework to improve the adaptation behavior of stroke survivors.
Collapse
Affiliation(s)
- Kelana-Kusuma Dharma
- School of Nursing, Politeknik Kesehatan Kementerian Kesehatan Pontianak, Indonesia.
| | - Halina-Rahayu
- School of Nursing, Politeknik Kesehatan Kementerian Kesehatan Pontianak, Indonesia
| |
Collapse
|
12
|
Sauvé-Schenk K, Duong P, Savard J, Durand F. A systematic review of social service and community resource interventions following stroke. Disabil Rehabil 2020; 44:2948-2957. [PMID: 33280453 DOI: 10.1080/09638288.2020.1851780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
PURPOSE Finding and accessing social services and community resources are a challenge for stroke survivors and care partners. The purpose of this systematic review was to identify and review interventions that aimed to increase access and use of such services and resources post stroke. METHOD A systematic review of the published literature was performed using MEDLINE, CINAHL, PsycINFO, and ProQuest Nursing and Allied Health (January 2008 to May 2020). Studies were included if they were quantitative designs and reported on outcomes of interventions addressing post-stroke access to social services or community resources. Results were synthesised narratively. RESULTS 3566 titles and abstracts were reviewed. Ten articles met the inclusion criteria. The interventions included in this review varied in terms of target group, timing, and type of support provided (passive or active tailored information provision, referral service, navigation assistance). Outcome measures, for social service and community resource access, included discharge preparedness measures, service counts, observations, satisfaction evaluations, interviews, and open-ended questions. CONCLUSION Overall, interventions demonstrated some improvements in information received and access to social services and community resources following stroke. Future research should focus on carrying out high quality studies that examine the effectiveness of various social service and community resource interventions, and on setting valid and reliable outcome measures.IMPLICATIONS FOR REHABILITATIONStroke survivors and care partners have unmet social service and community resource needs.Stroke survivors and care partners can benefit from interventions that provide information, referrals, and ongoing support to access services and resources.Clearly identifying social service and community resource needs is important for tailoring interventions to individual situations.Interventions should ideally be provided throughout the hospital stay, in acute care and rehabilitation, and continue on in the community.
Collapse
Affiliation(s)
- Katrine Sauvé-Schenk
- School of Rehabilitation Sciences, Faculty of Health Sciences, University of Ottawa, Ottawa, Canada.,Institut du Savoir Montfort, Ottawa, Canada
| | - Patrick Duong
- School of Rehabilitation Sciences, Faculty of Health Sciences, University of Ottawa, Ottawa, Canada
| | - Jacinthe Savard
- School of Rehabilitation Sciences, Faculty of Health Sciences, University of Ottawa, Ottawa, Canada.,Institut du Savoir Montfort, Ottawa, Canada
| | - François Durand
- Institut du Savoir Montfort, Ottawa, Canada.,Telfer School of Management, University of Ottawa, Ottawa, Canada
| |
Collapse
|
13
|
Ganesh A, Luengo-Fernandez R, Rothwell PM. Late functional improvement and 5-year poststroke outcomes: a population-based cohort study. J Neurol Neurosurg Psychiatry 2020; 91:831-839. [PMID: 32576613 PMCID: PMC7402458 DOI: 10.1136/jnnp-2019-322365] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Revised: 03/24/2020] [Accepted: 05/27/2020] [Indexed: 11/06/2022]
Abstract
BACKGROUND Late functional improvement between 3 and 12 months poststroke occurs in about one in four patients with ischaemic stroke, more commonly in lacunar strokes. It is unknown whether this late improvement is associated with better long-term clinical or health economic outcomes. METHODS In a prospective, population-based cohort of 1-year ischaemic stroke survivors (Oxford Vascular Study; 2002-2014), we examined changes in functional status (modified Rankin Scale (mRS), Rivermead Mobility Index (RMI), Barthel Index (BI)) from 3 to 12 months poststroke. We used Cox regressions adjusted for age, sex, 3-month disability and stroke subtype (lacunar vs non-lacunar) to examine the association of late improvement (by ≥1 mRS grades, ≥1 RMI points and/or ≥2 BI points between 3 and 12 months) with 5-year mortality and institutionalisation. We used similarly adjusted generalised linear models to examine association with 5-year healthcare/social-care costs. RESULTS Among 1288 one-year survivors, 1135 (88.1%) had 3-month mRS >0, of whom 319 (28.1%) demonstrated late functional improvement between 3 and 12 months poststroke. Late improvers had lower 5-year mortality (aHR per mRS=0.68, 95% CI 0.51 to 0.91, p=0.009), institutionalisation (aHR 0.48, 0.33 to 0.72, p<0.001) and healthcare/social care costs (margin US$17 524, -24 763 to -10 284, p<0.001). These associations remained on excluding patients with recurrent strokes during follow-up (eg, 5-year mortality/institutionalisation: aHR 0.59, 0.44 to 0.79, p<0.001) and on examining late improvement per RMI and/or BI (eg, 5-year mortality/institutionalisation with RMI/BI: aHR 0.73, 0.58 to 0.92, p=0.008). CONCLUSION Late functional improvement poststroke is associated with lower 5-year mortality, institutionalisation rates and healthcare/social care costs. These findings should motivate patients and clinicians to maximise late recovery in routine practice, and to consider extending access to proven rehabilitative therapies during the first year poststroke.
Collapse
Affiliation(s)
- Aravind Ganesh
- Wolfson Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK.,Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - Ramon Luengo-Fernandez
- Wolfson Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Peter Malcolm Rothwell
- Wolfson Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| |
Collapse
|
14
|
Exploring the Determinants and Experiences of Senior Stroke Patients with Virtual Care. Can J Neurol Sci 2020; 48:87-93. [PMID: 32713397 DOI: 10.1017/cjn.2020.162] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
OBJECTIVE The study sought to explore the experiences of participants affected by stroke with home video visit (HVV) for follow-up visits in order to understand the determinants, barriers, and benefits associated with HVVs. METHODS Semi-structured interviews were conducted with (n = 23) participants to gather insight and descriptive information about patients' experiences with HVV. Specifically, we sought to collect descriptions about the (1) costs and time associated with in-person visits, (2) facilitators and barriers to in-person and virtual visits, and (3) their values attached to traditional and virtual forms of patient care. RESULTS HVVs were perceived to be a mode of healthcare that is time-saving and convenient for both participants and physicians. However, our study also found some participants felt uncomfortable using technology to conduct medical visits while others still supported a positive view of traditional forms of in-person visits because they valued the in-person interactions and safe environment of the hospital. CONCLUSION While HVVs were considered to be useful in addressing geographical barriers to health care, technological and digital health literacy may serve to impede seniors from using the service, with some of them opting to go to the hospital despite geographical barriers. Resultantly, HVVs may serve both to alleviate and exacerbate certain determinants to health care.
Collapse
|
15
|
Sauvé-Schenk KML, Egan MY, Dubouloz-Wilner CJ, Kristjansson E. Influence of low income on return to participation following stroke. Disabil Rehabil 2019; 42:2726-2734. [PMID: 30763524 DOI: 10.1080/09638288.2019.1570355] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Purpose: Low income is known to influence participation post stroke, but the process by which this occurs is poorly understood.Methods: A qualitative multiple case study approach, focusing on the experience of returning to participation in personal projects among eight low-income francophone stroke survivors living in eastern Ontario (Canada). Data included semi-structured interviews with the stroke survivors and with their care partners, participant observations, assessment measures, and chart reviews.Results: Healthcare professionals inconsistently gave the stroke survivors needed information and assistance to access entitlements during discharge planning. Income support programs were difficult to access and once obtained, were not completely adequate to support essential necessities (food, medication) in addition to other goods and services related to valued activities. Housing was an important monthly expense that limited available monies for personal projects. Only in instances where participants were assisted with housing by informal networks were there adequate funds to pursue personal projects.Conclusion: This case study demonstrated that even in a universal healthcare system, post-stroke participation for those with low incomes was severely restricted. Changes at the clinical level and at the public policy level could facilitate participation.Implications for rehabilitationIncome influenced the experience of return to participation for the low-income stroke survivors by limiting their ability to afford housing, goods, and services.The macro environment, which regulates the healthcare and social service systems, was the strongest influence on return to participation for low income stroke survivors.Findings point to actions at the clinical and policy levels to help address this inequity.
Collapse
Affiliation(s)
| | - Mary Y Egan
- Faculty of Health Sciences, University of Ottawa, Ottawa, ON, Canada.,Bruyère; Research Institute, Ottawa, ON, Canada
| | | | | |
Collapse
|
16
|
Hassankhani H, Soheili A, Vahdati SS, Mozaffari FA, Fraser JF, Gilani N. Treatment Delays for Patients With Acute Ischemic Stroke in an Iranian Emergency Department: A Retrospective Chart Review. Ann Emerg Med 2018; 73:118-129. [PMID: 30318375 DOI: 10.1016/j.annemergmed.2018.08.435] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2018] [Revised: 08/11/2018] [Accepted: 08/16/2018] [Indexed: 10/28/2022]
Abstract
STUDY OBJECTIVE We evaluate the extent and nature of treatment delays and the contributing factors influencing them for patients with acute ischemic stroke, as well as main barriers to stroke care in an Iranian emergency department (ED). METHODS A retrospective chart review was conducted on 394 patients with acute ischemic stroke who were referred to the ED of a tertiary academic medical center in northwest Iran from March 21 to June 21, 2017. The steps of this review process included instrument development, medical records retrieval, data extraction, and data verification. Primary outcomes were identified treatment delays and causes of loss of eligibility for intravenous recombinant tissue plasminogen activator (r-tPA). RESULTS Of patients with acute ischemic stroke, 80.2% did not meet intravenous r-tPA eligibility; the most common cause was delayed (>4.5 hours) ED arrival after symptom onset (71.82%; n=283). Of 19.8% of subjects for whom the stroke code was activated, intravenous r-tPA was administered in only 5.3%. The average time from patients' arrival to first emergency medicine resident visit, notification of acute stroke team, presence of neurology resident, and computed tomography scan interpretation was lower for patients who met criteria of intravenous r-tPA than for those who lost eligibility for fibrinolytic therapy. The average door-to-needle time was 69 minutes (interquartile range 46 to 91 minutes). CONCLUSION Our ED and acute stroke team had a favorable clinical performance meeting established critical time goals of inhospital care for potentially eligible patients, but a poor clinical performance for the majority of patients who were not candidates for fibrinolytic therapy.
Collapse
Affiliation(s)
- Hadi Hassankhani
- Research Center for Evidence-Based Medicine, Department of Medical Surgical Nursing, School of Nursing and Midwifery, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Amin Soheili
- Student Research Committee, Department of Medical Surgical Nursing, School of Nursing and Midwifery, Tabriz University of Medical Sciences, Tabriz, Iran.
| | - Samad S Vahdati
- Neurosciences Research Center, Department of Emergency Medicine, School of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Farough A Mozaffari
- Department of Social Sciences, School of Law and Social Sciences, University of Tabriz, Tabriz, Iran
| | - Justin F Fraser
- Department of Neurological Surgery, Neurology, Radiology, and Neuroscience, University of Kentucky, Lexington, KY
| | - Neda Gilani
- Road Traffic Injury Research Center, Department of Statistics and Epidemiology, School of Health, Tabriz University of Medical Sciences, Tabriz, Iran
| |
Collapse
|
17
|
Kulhawy-Wibe S, King-Shier KM, Barnabe C, Manns BJ, Hemmelgarn BR, Campbell DJT. Exploring structural barriers to diabetes self-management in Alberta First Nations communities. Diabetol Metab Syndr 2018; 10:87. [PMID: 30524507 PMCID: PMC6276258 DOI: 10.1186/s13098-018-0385-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Accepted: 11/09/2018] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Type 2 diabetes is highly prevalent in Canadian First Nations (FN) communities. FN individuals with diabetes are less likely to receive guideline recommended care and access specialist care. They are also less likely to be able to engage in optimal self-management behaviours. While the systemic and racial contributors to this problem have been well described, individuals' experiences with structural barriers to care and self-management remain under-characterized. METHODS We utilized qualitative methods to gain insight into the structural barriers to self-management experienced by FN individuals with diabetes. We conducted a qualitative descriptive analysis of a subcohort of patients with diabetes from FN communities (n = 5) from a larger qualitative study. Using detailed semi-structured telephone interviews, we inquired about participants' diabetes and barriers to diabetes self-management. Inductive thematic analysis was performed in duplicate using NVivo 10. RESULTS The structural barriers faced by this population were substantial yet distinct from those described by non-FN individuals with diabetes. For example, medication costs, which are usually cited as a barrier to care, are covered for FN persons with status. The barriers to diabetes self-management that were commonly experienced in this cohort included transportation-related difficulties, financial barriers to uninsured health services, and lack of accessible diabetes education and resultant knowledge gaps. CONCLUSIONS FN Albertans with diabetes face a myriad of barriers to self-management, which are distinct from the Non-FN population. In addition to the barriers introduced by colonialism and historical injustices, finances, geographic isolation, and lack of diabetes education each impede optimal management of diabetes. Programs targeted at addressing FN-specific barriers may improve aspects of diabetes self-management in this population.
Collapse
Affiliation(s)
- Stephanie Kulhawy-Wibe
- Department of Medicine, Cumming School of Medicine, University of Calgary, North Tower, 9th Floor, 3330 Hospital Drive NW, Calgary, AB T2N 4N1 Canada
| | - Kathryn M. King-Shier
- Department of Community Health Sciences, Cumming School of Medicine, O’Brien Institute for Public Health, Libin Cardiovascular Institute of Alberta, Faculty of Nursing, University of Calgary, TRW 3rd Floor, 3330 Hospital Drive NW, Calgary, AB T2N 4N1 Canada
| | - Cheryl Barnabe
- Departments of Medicine and Community Health Sciences, Cumming School of Medicine, O’Brien Institute for Public Health, Libin Cardiovascular Institute of Alberta, University of Calgary, North Tower, 9th Floor, 3330 Hospital Drive NW, Calgary, AB T2N 4N1 Canada
| | - Braden J. Manns
- Departments of Medicine and Community Health Sciences, Cumming School of Medicine, O’Brien Institute for Public Health, Libin Cardiovascular Institute of Alberta, University of Calgary, North Tower, 9th Floor, 3330 Hospital Drive NW, Calgary, AB T2N 4N1 Canada
| | - Brenda R. Hemmelgarn
- Departments of Medicine and Community Health Sciences, Cumming School of Medicine, O’Brien Institute for Public Health, Libin Cardiovascular Institute of Alberta, University of Calgary, North Tower, 9th Floor, 3330 Hospital Drive NW, Calgary, AB T2N 4N1 Canada
| | - David J. T. Campbell
- Department of Medicine, Cumming School of Medicine, University of Calgary, 1820 Richmond Road SW, Calgary, AB T2N 4N1 Canada
| |
Collapse
|