A qualitative study exploring the experiences of individuals living with stroke and their caregivers with community-based poststroke services: A critical need for action

Background

Unmet poststroke service needs are common among people living in the community. Community-Based Stroke Services (CBSS) have the potential to address these unmet needs, yet there are no comprehensive guidelines to inform the design of CBSS, and they remain an understudied aspect of stroke care. This study aimed to describe the perceived barriers to accessing community-based stroke services, benefits from these programs and opportunities to address unmet needs.

Methods

This was a qualitative descriptive study with interviews and focus groups conducted with people living with stroke and caregivers. Data were transcribed and analyzed thematically.

Results

Eighty-five individuals with stroke and caregivers participated. Four key overarching themes were identified: facilitators and barriers to accessing and participating in community-based stroke services; components of helpful and unhelpful stroke services; perceived benefits of community-based stroke services; and opportunities to address unmet stroke service needs.

Interpretations

The findings resonate with and extend prior literature, suggesting a critical need for personalized and tailored stroke services to address persistent unmet needs. We call on relevant stakeholders, such as policymakers, providers, and researchers, to move these insights into action through comprehensive guidelines, practice standards and interventions to personalize and tailor CBSS.

Unmet Needs for Rehabilitative Management in Common Health-Related Problems Negatively Impact the Quality of Life of Community-Dwelling Stroke Survivors

Purpose: Community-dwelling stroke survivors have various unmet needs for rehabilitative management, but there is a lack of in-depth investigations on common health problems after stroke. Moreover, the association between unmet needs and health-related quality of life (HRQoL) has not been thoroughly investigated. This study aimed to investigate the unmet needs for rehabilitative management in common problems after stroke and their associations with HRQoL among community-dwelling stroke survivors. Methods: A face-to-face cross-sectional survey was conducted among community-dwelling stroke survivors visiting outpatient clinics of rehabilitation departments between June and October 2020 in three university-affiliated hospitals. Unmet needs for common problems after stroke were assessed across eight domains based on the post-stroke checklist: spasticity, dysphagia, communication, cognition, ambulation, pain/discomfort, anxiety/depression, and self-care. HRQoL was measured using the EuroQoL-5D three level (EQ-5D). The prevalence of unmet needs for rehabilitative management and their associations with the EQ-5D index were analyzed. Results: Among the 239 participants who responded to the survey, 63% (n = 150) were men. The mean age was 63 ± 13 years, and the mean duration of stroke onset was 55.6 months. Overall, 49% reported at least one unmet need, and the most frequently reported unmet needs were anxiety/depression (20.9%), self-care (20.9%), and pain/discomfort (18.0%). The highest proportion of unmet needs was in the anxiety/depression, communication, and cognition domains. Patients with unmet needs for cognition and pain/discomfort showed a significantly lower EQ-5D index, even after adjusting for age, sex, and modified Rankin scale scores. The total number of unmet needs was significantly correlated with a lower EQ-5D index (Pearson's r = -0.329, p < 0.001) in the multivariate linear regression model. Conclusions: Unmet rehabilitative needs are prevalent among community-dwelling stroke survivors, and the proportion of unmet needs was high among non-physical domains such as anxiety/depression. The number of unmet needs is an independent negative predictor of HRQoL. Systematic approaches to identify unmet needs and provide appropriate rehabilitative management are required in long-term stroke survivors.

Long-term unmet needs after stroke: systematic review of evidence from survey studies

OBJECTIVES

To synthesise evidence on longer term unmet needs perceived by stroke survivors, and psychometric properties of the tools used to evaluate unmet care needs after stroke.

DESIGN

Systematic review.

SETTING

Community or patients' home.

PARTICIPANTS

Stroke survivors.

METHODS

We searched PubMed, PsycINFO, CINAHL, EMBASE from inception to 31 March 2018 to identify survey studies that evaluated unmet needs perceived by stroke survivors after hospital discharge. Reported unmet needs were categorised under three domains: body functioning, activity/participation and environmental factors. Ranges of prevalence rates of unmet needs reported in studies were presented.

RESULTS

We included 19 eligible studies, with considerable heterogeneity in patients, survey methods and results. Psychometric properties of two stroke-specific tools were formally evaluated, indicating their moderate reliability and content/concurrent validity. The median number of reported unmet needs per stroke survivor was from two to five, and the proportion of stroke survivors with at least one unmet needs was on average 73.8% (range 19.8%- 91.7%). Unmet needs perceived by stroke survivors included 55 records of unmet body functioning needs, 47 records of unmet activities/participatory needs and 101 records of unmet environmental needs. Common unmet service needs were unmet information needs (3.1%- 65.0%), transport (5.4%-53.0%), home help/personal care (4.7%-39.3%) and therapy (2.0%-35.7%).

CONCLUSIONS

The prevalence of unmet long-term needs is high among stroke survivors, and there is considerable heterogeneity in type and frequency of specific unmet needs. More research is required to link regular assessment of long-term unmet needs of stroke survivors with the provision of cost-effective patient-centred health and social care services.

Identifying Unmet Rehabilitation Needs in Patients After Stroke With a Graphic Rehab-CompassTM

BACKGROUND

Unmet rehabilitation needs are common among stroke survivors. We aimed to evaluate whether a comprehensive graphic "Rehab-Compass," a novel combination of structured patient-reported outcome measures, was feasible and useful in facilitating a capture of patients' rehabilitation needs in clinical practice.

METHODS

A new graphic overview of broad unmet rehabilitation needs covers deficits in functioning, daily activity, participation, and quality of life. It was constructed by using 5 patient-oriented, well-validated, and reliable existing instruments with converted data into a 0 (worst outcome) to 100 (best outcome) scale but unchanged in terms of variable properties. Satisfaction of the Rehab-Compass^TM was studied by a qualitative interview of 9 patients with stroke and 3 clinicians. Practical feasibility and capacity of the instrument were evaluated in a cross-sectionalstudy with 48 patients at 5-month follow-ups after subarachnoid hemorrhage.

RESULTS

The Rehab-Compass^TM identified and graphically visualized a panoramic view of the multidimensional needs over time which was completed before clinical consultation. The Rehab-Compass^TM appeared to be feasible and time-efficientin clinical use. The interviews of both patients and clinicians showed high satisfaction when using the Rehab-Compass^TM graph. In the studied stroke patients, the Rehab-Compass^TM identified memory and processing information, fatigue, mood, and pain after subarachnoid hemorrhage as the most common problems.

CONCLUSIONS

The graphic Rehab-Compass^TM seems to be a feasible, useful, and time-saving tool for identification of unmet rehabilitation needs among stroke survivors in clinical practice. Further research is needed to make the Rehab-Compass^TM more concise and evaluate the instrument among different stroke subgroups.

Rethinking Recovery: Incorporating Holistic Nursing Perspectives in Poststroke Care

Stroke is a life-changing experience. Current treatments focus on treating the condition, rather than the whole person. The goal of this report was to communicate the benefits of a holistic approach to the treatment and recovery of stroke. Our intent was to begin a conversation to transform our approach to stroke care to focus on the whole person, body, mind, and spirit. Wellness approaches are fiscally responsible ways of providing holistic care for patients and their family members to help them achieve optimal individualized recovery. Very few multidimensional programs for wellness exist for patients with stroke and brain injury. Given the changes in health care and the Call to Action set forth in the Institute of Medicine's 2010 report, it would behoove us to consider holistic approaches to stroke care and research programs. Nurses are uniquely positioned to implement multidisciplinary, innovative holistic approaches to address solutions for issues in stroke care. Wellness is a critically important area of stroke care and an opportunity for research. As advocates for patients, and nurses with personal experiences, we hope this commentary stimulates conversation around developing and testing multidimensional holistic programs of wellness for stroke prevention, treatment, and recovery.

Preventing muscular contractures through routine stroke patient care

The aim of this article is to elevate the standard of ward-based routine care by informing readers about the prevention and management of muscular contractures post-cerebrovascular accident (CVA). Musculoskeletal complications can develop at any time during the acute or latter stages of stroke care and rehabilitation; therefore, it is imperative that all nurses understand the importance of correct limb placement and some of the detrimental complications that can occur. By placing more onus on therapeutic positioning and earlier mobilisation, nurses, working alongside allied health professionals, can significantly improve morbidity-related outcomes.

What is next after transfer of care from hospital to home for stroke patients? Evaluation of a community stroke care service based in a primary care clinic

Context:

Poststroke care in developing countries is inundated with poor concordance and scarce specialist stroke care providers. A primary care-driven health service is an option to ensure optimal care to poststroke patients residing at home in the community.

Aims:

We assessed outcomes of a pilot long-term stroke care clinic which combined secondary prevention and rehabilitation at community level.

Settings and Design:

A prospective observational study of stroke patients treated between 2008 and 2010 at a primary care teaching facility.

Subjects and Methods:

Analysis of patients was done at initial contact and at 1-year post treatment. Clinical outcomes included stroke risk factor(s) control, depression according to Patient Health Questionnaire (PHQ9), and level of independence using Barthel Index (BI).

Statistical Analysis Used:

Differences in means between baseline and post treatment were compared using paired t-tests or Wilcoxon-signed rank test. Significance level was set at 0.05.

Results:

Ninety-one patients were analyzed. Their mean age was 62.9 [standard deviation (SD) 10.9] years, mean stroke episodes were 1.30 (SD 0.5). The median interval between acute stroke and first contact with the clinic 4.0 (interquartile range 9.0) months. Mean systolic blood pressure decreased by 9.7 mmHg (t = 2.79, P = 0.007), while mean diastolic blood pressure remained unchanged at 80mmHg (z = 1.87, P = 0.06). Neurorehabilitation treatment was given to 84.6% of the patients. Median BI increased from 81 (range: 2−100) to 90.5 (range: 27−100) (Z = 2.34, P = 0.01). Median PHQ9 scores decreased from 4.0 (range: 0−22) to 3.0 (range: 0−19) though the change was not significant (Z= −0.744, P = 0.457).

Conclusions:

Primary care-driven long-term stroke care services yield favorable outcomes for blood pressure control and functional level.

Validation of the Longer-term Unmet Needs after Stroke (LUNS) monitoring tool: a multicentre study

Objective:

To evaluate the acceptability, test–retest reliability and validity of the Longer-term Unmet Needs after Stroke monitoring tool.

Design:

A questionnaire pack was posted to stroke survivors living at home three or six months after stroke. A second pack was sent two weeks after receipt of the completed first pack.

Setting:

Stroke survivors living at home across England.

Subjects:

Stroke survivors were recruited from 40 hospitals across England, in two phases. The first with an optimal cohort of patients, the second to capture a broader post-stroke population, including those with communication and/or cognitive difficulties. Patients were excluded if they required palliative care or if permanent discharge to a nursing or residential home was planned.

Main measures:

The questionnaire pack included the Longer-term Unmet Needs after Stroke tool, General Health Questionnaire-12, Frenchay Activities Index, and Short Form-12.

Results:

Interim analysis of phase 1 data ( n = 350) indicated that the tool was sufficiently robust to progress to phase 2 ( n = 500). Results are reported on the combined study population. Of 850 patients recruited, 199 (23%) had communication and/or cognitive difficulties. The median age was 73 years (range 28–98). Questionnaire pack return rate was 69%. For the new tool, there was 3.5% missing data and test–retest reliability was moderate to good (percentage item agreement 78–99%, kappa statistic 0.45–0.67). Identification of an unmet need was consistently associated with poorer outcomes on concurrent measures.

Conclusions:

The Longer-term Unmet Needs after Stroke tool is acceptable, reliable, can be self-completed, and used to identify longer-term unmet needs after stroke.

Feasibility of assessing the needs of stroke patients after six months using the GM-SAT

OBJECTIVE

To investigate the feasibility of administering the Greater Manchester Stroke Assessment Tool (GM-SAT), a structured evidence-based needs assessment tool, in a community setting and its acceptability to stroke patients and their carers.

SETTING

Community stroke services.

SUBJECTS

One hundred and thirty-seven stroke patients at six months post hospital discharge with no communication or cognitive difficulties residing in their own homes.

INTERVENTION

Patients' needs were assessed by information, advice and support (IAS) coordinators from the UK Stroke Association using the GM-SAT.

MAIN MEASURES

Number and nature of unmet needs identified and actions required to address these; patient/carer feedback; and IAS coordinator feedback.

RESULTS

The mean number of unmet needs identified was 3 (min 0, max 14; SD 2.5). The most frequently identified unmet needs related to fatigue (34.3%), memory, concentration and attention (25.5%), secondary prevention non-lifestyle (21.9%) and depression (19.0%). It was found that 50.4% of unmet needs could be addressed through the provision of information and advice. Patients/carers found the assessment process valuable and IAS coordinators found the GM-SAT easy to use.

CONCLUSIONS

Results demonstrate that the GM-SAT is feasible to administer in the community using IAS coordinators and is acceptable to patients and their carers, as well as staff undertaking the assessments. Further research is needed to determine whether the application of the GM-SAT at six months improves outcomes for patients.

A lifestyle intervention as supplement to a physical activity programme in rehabilitation after stroke: a randomized controlled trial

OBJECTIVE

To evaluate the effectiveness of lifestyle group intervention on well-being, occupation and social participation.

DESIGN

A randomized controlled trial.

SETTING

Senior centres in the community.

SUBJECTS

Of 204 stroke survivors screened, 99 (49%) were randomized three months after stroke whereby 86 (87%) participants (mean (SD) age 77.0 (7.1) years) completed all assessments (39 in the intervention group and 47 in the control group).

INTERVENTION

A lifestyle course in combination with physical activity (intervention group) compared with physical activity alone (control group). Both programmes were held once a week for nine months.

MAIN OUTCOME MEASURE

The Short Form Questionnaire (SF-36), addressing well-being and social participation. Assessments were performed at baseline and at nine months follow-up.

RESULTS

We found no statistically significant differences between the groups at the nine months follow-up in the SF-36. Adjusted mean differences in change scores in the eight subscales of SF-36 were; 'mental health' (+1.8, 95% confidence interval (CI) -4.0, +7.6), 'vitality' (-3.0, 95% CI -9.6, +3.6), 'bodily pain' (+3.3, 95% CI -7.8, +14.4), 'general health' (-1.6, 95% CI -8.4, +5.1), 'social functioning' (-2.5, 95% CI -12.8, +7.8), 'physical functioning' (+1.0, 95% CI -6.7, +8.6), 'role physical' (-7.1, 95% CI -22.7, +8.4), 'role emotional' (+11.8, 95% CI -4.4, +28.0).

CONCLUSIONS

Improvements were seen in both groups, but no statistically significant differences were found in the intervention group compared to controls. An intervention comprising regular group-based activity with peers may be sufficient in the long-term rehabilitation after stroke.

Self-Reported Long-Term Needs After Stroke

Background and Purpose—

Development of interventions to manage patients with stroke after discharge from the hospital requires estimates of need. This study estimates the prevalence of self-reported need in community-dwelling stroke survivors across the United Kingdom.

Methods—

We conducted a survey of stroke survivors 1 to 5 years poststroke recruited through Medical Research Council General Practice Research Framework general practices and 2 population-based stroke registers. Levels and type of need were calculated with comparisons among sociodemographic groups, disability level, and cognitive status using the χ 2 test or Fisher exact test, as appropriate.

Results—

From 1251 participants, response rates were 60% (national sample) and 78% (population registers sample) with few differences in levels of reported need between the 2 samples. Over half (51%) reported no unmet needs; among the remainder, the median number of unmet needs was 3 (range, 1 to 13). Proportions reporting unmet clinical needs ranged from 15% to 59%; 54% reported an unmet need for stroke information; 52% reported reduction in or loss of work activities, significantly more from black ethnic groups ( P =0.006); 18% reported a loss in income and 31% an increase in expenses with differences by age, ethnic group, and deprivation score. In multivariable analysis, ethnicity ( P =0.032) and disability ( P =0.014) were associated with total number of unmet needs.

Conclusions—

Multiple long-term clinical and social needs remain unmet long after incident stroke. Higher levels of unmet need were reported by people with disabilities, from ethnic minority groups, and from those living in the most deprived areas. Development and testing of novel methods to meet unmet needs are required.