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Magalhães JP, Faria-Fortini I, Menezes KK, Lara IA, Batista LR, Sant'anna R, Faria CD. Determinants of access to rehabilitation professionals by individuals with stroke in the first six months after hospital discharge in Brazil: a study based on the Andersen model. Top Stroke Rehabil 2024; 31:615-624. [PMID: 38319730 DOI: 10.1080/10749357.2024.2304969] [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: 10/24/2023] [Accepted: 12/29/2023] [Indexed: 02/08/2024]
Abstract
BACKGROUND determinants of access to rehabilitation professionals after stroke in middle-income countries, where the burden of this disease is higher, are little known. OBJECTIVES To identify the determinants of access to rehabilitation professionals by individuals with stroke at one, three, and six months after hospital discharge in Brazil and compare referral and access rates after discharge. METHODS Longitudinal and prospective study, with individuals with primary stroke, without previous disabilities. At hospital discharge, the number of rehabilitation professionals referred by the multidisciplinary team was recorded. The possible determinants of access, according to Andersen's model, were: a) predisposing factors: age, sex, education levels, and belief that they could improve with treatment; b) need factors: stroke severity, levels of disability; c) enabling factors: socioeconomic status, disposable income for health care, and quality of care provided by rehabilitation professionals. One, three, and six months after hospital discharge, individuals were contacted to identify which rehabilitation professionals were accessed. Multiple linear regression model and Wilcoxon tests were used (α=5%). RESULTS 201 individuals were included. Disability levels and stroke severity explained 31%, 34%, and 39% (p<0.01) of access at one, three, and six months after hospital discharge, respectively. In all periods, there was less access than that recommended at the time of hospital discharge (p<0.01). CONCLUSION Need factors (disability levels and stroke severity) were determinants of access in all assessed periods. In addition, in all periods, the comprehensiveness of care for individuals with stroke was compromised.
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Affiliation(s)
- Jordana P Magalhães
- Department of Physical Therapy, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Iza Faria-Fortini
- Department of Occupational Therapy, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Kênia Kp Menezes
- Department of Physical Therapy, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Isadora A Lara
- Department of Physical Therapy, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Ludmilla R Batista
- Department of Occupational Therapy, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Romeu Sant'anna
- Department of Neurology, Hospital Risoleta Tolentino Neves, Belo Horizonte, Brazil
| | - Christina Dcm Faria
- Department of Physical Therapy, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
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Li X, He Y, Wang D, Rezaei MJ. Stroke rehabilitation: from diagnosis to therapy. Front Neurol 2024; 15:1402729. [PMID: 39193145 PMCID: PMC11347453 DOI: 10.3389/fneur.2024.1402729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Accepted: 06/28/2024] [Indexed: 08/29/2024] Open
Abstract
Stroke remains a significant global health burden, necessitating comprehensive and innovative approaches in rehabilitation to optimize recovery outcomes. This paper provides a thorough exploration of rehabilitation strategies in stroke management, focusing on diagnostic methods, acute management, and diverse modalities encompassing physical, occupational, speech, and cognitive therapies. Emphasizing the importance of early identification of rehabilitation needs and leveraging technological advancements, including neurostimulation techniques and assistive technologies, this manuscript highlights the challenges and opportunities in stroke rehabilitation. Additionally, it discusses future directions, such as personalized rehabilitation approaches, neuroplasticity concepts, and advancements in assistive technologies, which hold promise in reshaping the landscape of stroke rehabilitation. By delineating these multifaceted aspects, this manuscript aims to provide insights and directions for optimizing stroke rehabilitation practices and enhancing the quality of life for stroke survivors.
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Affiliation(s)
- Xiaohong Li
- Department of Rehabilitation Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yanjin He
- Department of Rehabilitation Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Dawu Wang
- Department of Rehabilitation Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
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O'Callaghan G, Fahy M, O'Meara S, Lindblom S, von Koch L, Langhorne P, Galvin R, Horgan F. Experiences and preferences of people with stroke and caregivers, around supports provided at the transition from hospital to home: a qualitative descriptive study. BMC Neurol 2024; 24:251. [PMID: 39039456 PMCID: PMC11265157 DOI: 10.1186/s12883-024-03767-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Accepted: 07/16/2024] [Indexed: 07/24/2024] Open
Abstract
BACKGROUND Transitioning home from the structured hospital setting poses challenges for people with stroke (PWS) and their caregivers (CGs), as they navigate through complex uncertainties. There are gaps in our understanding of appropriate support interventions for managing the transition home. In this qualitative study, we explored the perspectives of PWS and their CGs regarding their support experiences and preferences during this period. METHODS Between November 2022 and March 2023, and within six months of hospital discharge, audio-recorded, semi-structured interviews were conducted with PWS and CGs. All interviews were transcribed, imported into NVivo software, and analysed using reflexive thematic analysis. RESULTS Sixteen interviews were conducted, nine with PWS and seven with CGs. Four themes relevant to their collective experiences and preferences were identified: (i) Need for tailored information-sharing, at the right time, and in the right setting; (ii) The importance of emotional support; (iii) Left in limbo, (iv) Inequity of access. Experiences depict issues such as insufficient information-sharing, communication gaps, and fragmented and inequitable care; while a multi-faceted approach is desired to ease anxiety and uncertainty, minimise delays, and optimise recovery and participation during transition. CONCLUSIONS Our findings highlight that regardless of the discharge route, and even with formal support systems in place, PWS and families encounter challenges during the transition period. The experiences of support at this transition and the preferences of PWS and CGs during this important period highlights the need for better care co-ordination, early and ongoing emotional support, and equitable access to tailored services and support. Experiences are likely to be improved by implementing a partnership approach with improved collaboration, including joint goal-setting, between PWS, CGs, healthcare professionals and support organisations.
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Affiliation(s)
- Geraldine O'Callaghan
- iPASTAR Collaborative Doctoral Award Programme, School of Physiotherapy, RCSI University of Medicine and Health Sciences, 123 St. Stephen's Green, Dublin, D02 YN77, Ireland.
- iPASTAR Collaborative Doctoral Award Programme, RCSI School of Population Health Sciences, RCSI University of Medicine and Health Sciences, 123 St. Stephen's Green, Dublin, D02 YN77, Ireland.
| | - Martin Fahy
- iPASTAR Collaborative Doctoral Award Programme, RCSI School of Population Health Sciences, RCSI University of Medicine and Health Sciences, 123 St. Stephen's Green, Dublin, D02 YN77, Ireland
| | - Sigrid O'Meara
- iPASTAR Collaborative Doctoral Award Programme, RCSI School of Population Health Sciences, RCSI University of Medicine and Health Sciences, 123 St. Stephen's Green, Dublin, D02 YN77, Ireland
| | - Sebastian Lindblom
- Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Alfred Nobels allé 23, Huddinge, Stockholm, Sweden
| | - Lena von Koch
- Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Alfred Nobels allé 23, Huddinge, Stockholm, Sweden
- Theme of Heart & Vascular and Neuro, Karolinska University Hospital, Stockholm, 14186, Sweden
| | - Peter Langhorne
- School of Cardiovascular and Metabolic Health (SCMH), University of Glasgow, 126 University Place, Glasgow, GT12 8TA, Scotland
| | - Rose Galvin
- School of Allied Health, Faculty of Education and Health Sciences, Ageing Research Centre, Health Research Institute, University of Limerick, Limerick, V94 T9PX, Ireland
| | - Frances Horgan
- iPASTAR Collaborative Doctoral Award Programme, School of Physiotherapy, RCSI University of Medicine and Health Sciences, 123 St. Stephen's Green, Dublin, D02 YN77, Ireland
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Barbosa PM, Szrek H, Ferreira LN, Cruz VT, Firmino-Machado J. Stroke rehabilitation pathways during the first year: A cost-effectiveness analysis from a cohort of 460 individuals. Ann Phys Rehabil Med 2024; 67:101824. [PMID: 38518399 DOI: 10.1016/j.rehab.2024.101824] [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: 07/03/2023] [Revised: 01/15/2024] [Accepted: 01/17/2024] [Indexed: 03/24/2024]
Abstract
BACKGROUND Stroke burden challenges global health, and social and economic policies. Although stroke recovery encompasses a wide range of care, including in-hospital, outpatient, and community-based rehabilitation, there are no published cost-effectiveness studies of integrated post-stroke pathways. OBJECTIVE To determine the most cost-effective rehabilitation pathway during the first 12 months after a first-ever stroke. METHODS A cohort of people in the acute phase of a first stroke was followed after hospital discharge; 51 % women, mean (SD) age 74.4 (12.9) years, mean National Institute of Health Stroke Scale score 11.7 (8.5) points, and mode modified Rankin Scale score 3 points. We developed a decision tree model of 9 sequences of rehabilitation care organised in 3 stages (3, 6 and 12 months) through a combination of public, semi-public and private entities, considering both the individual and healthcare service perspectives. Health outcomes were expressed as quality-adjusted life years (QALY) over a 1-year time horizon. Costs included healthcare, social care, and productivity losses. Sensitivity analyses were conducted on model input values. RESULTS From the individual perspective, pathway 3 (Short-term Inpatient Unit » Community Clinic) was the most cost-effective, followed by pathway 1 (Rehabilitation Centre » Community Clinic). From the healthcare service perspective, pathway 3 was the most cost-effective followed by pathway 7 (Outpatient Hospital » Private Clinic). All other pathways were considered strongly dominated and excluded from the analysis. The total 1-year mean cost ranged between €12104 and €23024 from the individual's perspective and between €10992 and €31319 from the healthcare service perspective. CONCLUSION Assuming a willingness-to-pay threshold of one times the national gross domestic product (€20633/QALY), pathway 3 (Short-term Inpatient Unit » Community Clinic) was the most cost-effective strategy from both the individual and healthcare service perspectives. Rehabilitation pathway data contribute to the development of a future integrated care system adapted to different stroke profiles.
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Affiliation(s)
- Pedro Maciel Barbosa
- Instituto de Saúde Pública, Universidade do Porto, Rua das Taipas 135, 4050-600 Porto, Portugal; Hospital Pedro Hispano, Unidade Local de Saúde, EPE, Rua de Alfredo Cunha 365, 4450-021 Matosinhos, Portugal; Centro de Investigação em Reabilitação, Escola Superior de Saúde, Instituto Politécnico do Porto, R. Dr. António Bernardino de Almeida, 4200-072 Porto, Portugal.
| | - Helena Szrek
- Centre for Economics and Finance, University of Porto, R. Dr. Roberto Frias, 4200-464 Porto, Portugal
| | - Lara Noronha Ferreira
- ESGHT, Universidade do Algarve, Estr. da Penha 139, 8005-246 Faro, Portugal; Centre for Health Studies and Research of the University of Coimbra, Avenida Dias da Silva 165, 3004-512 Coimbra, Portugal; Research Centre for Tourism, Sustainability and Well-Being (CinTurs), Portugal.
| | - Vitor Tedim Cruz
- Hospital Pedro Hispano, Unidade Local de Saúde, EPE, Rua de Alfredo Cunha 365, 4450-021 Matosinhos, Portugal; EPIUnit, Instituto de Saúde Pública, Universidade do Porto, Rua das Taipas 135, 4050-600 Porto, Portugal
| | - João Firmino-Machado
- EPIUnit, Instituto de Saúde Pública, Universidade do Porto, Rua das Taipas 135, 4050-600 Porto, Portugal; Centro Académico Clínico Egas Moniz, 810-193 Aveiro, Portugal; Centro Hospitalar Vila Nova de Gaia/Espinho, R. Conceição Fernandes S/N, 4434-502 Vila Nova de Gaia, Portugal
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Noé E, Gómez A, Bernabeu M, Quemada I, Rodríguez R, Pérez T, López C, Laxe S, Colomer C, Ríos M, Juárez-Belaúnde A, González C, Pelayo R, Ferri J. Guidelines: basic principles of neurorehabilitation for patients with acquired brain injury. Recommendations of the Spanish Society of Neurorehabilitation. Neurologia 2024; 39:261-281. [PMID: 37116696 DOI: 10.1016/j.nrleng.2023.04.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 06/27/2021] [Indexed: 04/30/2023] Open
Abstract
INTRODUCTION We present the Spanish Society of Neurorehabilitation's guidelines for adult acquired brain injury (ABI) rehabilitation. These recommendations are based on a review of international clinical practice guidelines published between 2013 and 2020. DEVELOPMENT We establish recommendations based on the levels of evidence of the studies reviewed and expert consensus on population characteristics and the specific aspects of the intervention or procedure under research. CONCLUSIONS All patients with ABI should receive neurorehabilitation therapy once they present a minimal level of clinical stability. Neurorehabilitation should offer as much treatment as possible in terms of frequency, duration, and intensity (at least 45-60minutes of each specific form of therapy that is needed). Neurorehabilitation requires a coordinated, multidisciplinary team with the knowledge, experience, and skills needed to work in collaboration both with patients and with their families. Inpatient rehabilitation interventions are recommended for patients with more severe deficits and those in the acute phase, with outpatient treatment to be offered as soon as the patient's clinical situation allows it, as long as intensity criteria can be maintained. The duration of treatment should be based on treatment response and the possibilities for further improvement, according to the best available evidence. At discharge, patients should be offered health promotion, physical activity, support, and follow-up services to ensure that the benefits achieved are maintained, to detect possible complications, and to assess possible changes in functional status that may lead the patient to need other treatment programmes.
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Affiliation(s)
- E Noé
- NEURORHB Servicio de Neurorrehabilitación de Hospitales Vithas, Fundación Hospitales Vithas, Valencia, Spain.
| | - A Gómez
- Centro Estatal de Atención al Daño Cerebral-CEADAC, Madrid, Spain
| | | | - I Quemada
- Red Menni de Daño Cerebral, Bilbao, Spain
| | | | - T Pérez
- Clínica San Vicente, Madrid, Spain
| | - C López
- Centro Lescer, Madrid, Spain
| | - S Laxe
- Hospital Clínic, Barcelona, Spain
| | - C Colomer
- NEURORHB Servicio de Neurorrehabilitación de Hospitales Vithas, Fundación Hospitales Vithas, Valencia, Spain
| | - M Ríos
- Unidad de Daño Cerebral, Hospital Beata María Ana, Madrid, Spain
| | | | - C González
- Centro Estatal de Atención al Daño Cerebral-CEADAC, Madrid, Spain
| | - R Pelayo
- Institut Guttmann, Barcelona, Spain
| | - J Ferri
- NEURORHB Servicio de Neurorrehabilitación de Hospitales Vithas, Fundación Hospitales Vithas, Valencia, Spain
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Brown C, Prusynski R, Baylor C, Humbert A, Mroz TM. Patient Characteristics and Treatment Patterns for Speech-Language Pathology Services in Skilled Nursing Facilities. AMERICAN JOURNAL OF SPEECH-LANGUAGE PATHOLOGY 2024; 33:912-936. [PMID: 38215225 DOI: 10.1044/2023_ajslp-23-00025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/14/2024]
Abstract
PURPOSE Skilled nursing facility (SNF) care has historically been influenced by systemic issues that could impact speech-language pathology (SLP) service provision. However, there has been little study specifically on factors associated with SLP service provision in SNFs. Large administrative data sets are rarely analyzed in SLP research but can be used to understand real-world SLP services. This study investigated associations between patient and facility characteristics and SLP services. METHOD Mixed-effects logistic regression models were used to evaluate factors associated with SLP service provision in 2018 Medicare administrative data representing 833,653 beneficiaries. RESULTS Beneficiaries had higher odds of receiving SLP services when they had neurologic diagnosis (odds ratio [OR] = 3.32), had SLP-related functional impairments (ORs = 1.19-3.41), and received other rehabilitative services (ORs = 3.11-3.78). Beneficiaries had lower odds of receiving SLP services when they received care from SNFs located in hospitals versus freestanding (OR = 0.45), with need for interpreter services (OR = 0.76) and with thresholding (OR = 0.68), a financially motivated practice. Direction of association varied across racial and ethnic groups and measures of location. Odds of being provided SLP services decreased with increasing communication impairment severity. CONCLUSIONS The results suggest that clinicians are identifying patients with diagnoses most likely to warrant SLP services. However, association disparities and weakening association of service provision with increasing impairment severity have concerning clinical implications. Health services research methods can be used to further explore SLP practices in SNFs to support equitable service provision.
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Affiliation(s)
- Cait Brown
- Department of Rehabilitation Medicine, University of Washington, Seattle
| | - Rachel Prusynski
- Department of Rehabilitation Medicine, University of Washington, Seattle
| | - Carolyn Baylor
- Department of Rehabilitation Medicine, University of Washington, Seattle
| | - Andrew Humbert
- Department of Rehabilitation Medicine, University of Washington, Seattle
| | - Tracy M Mroz
- Department of Rehabilitation Medicine, University of Washington, Seattle
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McGlinchey MP, Faulkner-Gurstein R, Sackley CM, McKevitt C. Factors guiding therapist decision making in the rehabilitation of physical function after severely disabling stroke - an ethnographic study. Disabil Rehabil 2024; 46:672-684. [PMID: 36734838 DOI: 10.1080/09638288.2023.2172463] [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: 05/30/2022] [Accepted: 01/20/2023] [Indexed: 02/04/2023]
Abstract
PURPOSE Whilst strong evidence supports rehabilitation to improve outcomes post-stroke, there is limited evidence to guide rehabilitation in the most severely disabled group. In an era of evidence-based practice, the aim of the study was to understand what factors guide physiotherapists (PTs) and occupational therapists (OTs) to select particular interventions in the rehabilitation of physical function after severely disabling stroke. MATERIAL AND METHODS An ethnographic study was undertaken over an 18-month period involving five London, UK stroke services. Seventy-nine primary participants (30 PTs, 22 OTs, and 27 stroke survivors) were recruited to the study. Over 400 h of observation, 52 semi-structured interviews were conducted. Study data were analysed through thematic analysis. RESULTS Key factors guiding therapist decision making were clinical expertise, professional role, stroke survivors' clinical presentation, therapist perspectives about stroke recovery, and clinical guidelines. Research evidence, stroke survivors' treatment preferences, organisational type, and pathway design were less influential factors. Therapy practice did not always address the physical needs of severely disabled stroke survivors. CONCLUSIONS Multiple factors guided therapist decision making after severely disabling stroke. Alternative ways of therapist working should be considered to address the physical needs of severely disabled stroke survivors more fully.Implications for rehabilitationMultiple factors guide therapist decision making after severely disabling stroke, some of which result in the use of interventions that do not fully address stroke survivors' clinical needs.Therapists should critically reflect upon their personal beliefs and attitudes about severely disabling stroke to reduce potential sources of bias on decision making.Therapists should consider the timing and intensity of therapy delivery as well as their treatment approach to optimise outcomes after severely disabling stroke.
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Affiliation(s)
- Mark P McGlinchey
- Neurorehabilitation Service, Integrated Local Services, Guy's and St Thomas' NHS Foundation Trust, London, UK
- School of Life Course and Population Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Rachel Faulkner-Gurstein
- School of Life Course and Population Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Catherine M Sackley
- Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
| | - Christopher McKevitt
- School of Life Course and Population Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
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Jones Berkeley SB, Johnson AM, Mormer ER, Ressel K, Pastva AM, Wen F, Patterson CG, Duncan PW, Bushnell CD, Zhang S, Freburger JK. Referral to Community-Based Rehabilitation Following Acute Stroke: Findings From the COMPASS Pragmatic Trial. Circ Cardiovasc Qual Outcomes 2024; 17:e010026. [PMID: 38189125 PMCID: PMC10997162 DOI: 10.1161/circoutcomes.123.010026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 10/13/2023] [Indexed: 01/09/2024]
Abstract
BACKGROUND Few studies on care transitions following acute stroke have evaluated whether referral to community-based rehabilitation occurred as part of discharge planning. Our objectives were to describe the extent to which patients discharged home were referred to community-based rehabilitation and identify the patient, hospital, and community-level predictors of referral. METHODS We examined data from 40 North Carolina hospitals that participated in the COMPASS (Comprehensive Post-Acute Stroke Services) cluster-randomized trial. Participants included adults discharged home following stroke or transient ischemic attack (N=10 702). In this observational analysis, COMPASS data were supplemented with hospital-level and county-level data from various sources. The primary outcome was referral to community-based rehabilitation (physical, occupational, or speech therapy) at discharge. Predictor variables included patient (demographic, stroke-related, medical history), hospital (structure, process), and community (therapist supply) measures. We used generalized linear mixed models with a hospital random effect and hierarchical backward model selection procedures to identify predictors of therapy referral. RESULTS Approximately, one-third (36%) of stroke survivors (mean age, 66.8 [SD, 14.0] years; 49% female, 72% White race) were referred to community-based rehabilitation. Rates of referral to physical, occupational, and speech therapists were 31%, 18%, and 10%, respectively. Referral rates by hospital ranged from 3% to 78% with a median of 35%. Patient-level predictors included higher stroke severity, presence of medical comorbidities, and older age. Female sex (odds ratio, 1.24 [95% CI, 1.12-1.38]), non-White race (2.20 [2.01-2.44]), and having Medicare insurance (1.12 [1.02-1.23]) were also predictors of referral. Referral was higher for patients living in counties with greater physical therapist supply. Much of the variation in referral across hospitals remained unexplained. CONCLUSIONS One-third of stroke survivors were referred to community-based rehabilitation. Patient-level factors predominated as predictors. Variation across hospitals was notable and presents an opportunity for further evaluation and possible targets for improved poststroke rehabilitative care. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT02588664.
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Affiliation(s)
- Sara B Jones Berkeley
- Department of Epidemiology, University of North Carolina at Chapel Hill, Gillings School of Global Public Health (S.B.J.B., A.M.J., F.W., S.Z.)
| | - Anna M Johnson
- Department of Epidemiology, University of North Carolina at Chapel Hill, Gillings School of Global Public Health (S.B.J.B., A.M.J., F.W., S.Z.)
| | - Elizabeth R Mormer
- Department of Physical Therapy, University of Pittsburgh, School of Health and Rehabilitation Sciences (E.R.M., K.R., C.G.P., J.K.F.)
| | - Kristin Ressel
- Department of Physical Therapy, University of Pittsburgh, School of Health and Rehabilitation Sciences (E.R.M., K.R., C.G.P., J.K.F.)
| | - Amy M Pastva
- Department of Orthopaedic Surgery, Doctor of Physical Therapy Division and Center for the Study of Aging and Human Development, Duke University School of Medicine (A.M.P.)
| | - Fang Wen
- Department of Epidemiology, University of North Carolina at Chapel Hill, Gillings School of Global Public Health (S.B.J.B., A.M.J., F.W., S.Z.)
| | - Charity G Patterson
- Department of Physical Therapy, University of Pittsburgh, School of Health and Rehabilitation Sciences (E.R.M., K.R., C.G.P., J.K.F.)
- Department of Neurology, Wake Forest School of Medicine (P.W.D., C.D.B.)
| | - Pamela W Duncan
- Department of Neurology, Wake Forest School of Medicine (P.W.D., C.D.B.)
| | | | - Shuqi Zhang
- Department of Epidemiology, University of North Carolina at Chapel Hill, Gillings School of Global Public Health (S.B.J.B., A.M.J., F.W., S.Z.)
| | - Janet K Freburger
- Department of Physical Therapy, University of Pittsburgh, School of Health and Rehabilitation Sciences (E.R.M., K.R., C.G.P., J.K.F.)
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9
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Chou HY, Ma SC, Tsai YW, Shih CL, Yeh CT. Effects of functional performance and national health insurance cost on length of hospitalization for postacute care in stroke: a retrospective observational study. BMC Neurol 2023; 23:343. [PMID: 37770846 PMCID: PMC10540458 DOI: 10.1186/s12883-023-03396-z] [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: 07/24/2023] [Accepted: 09/17/2023] [Indexed: 09/30/2023] Open
Abstract
BACKGROUND The postacute care for cerebrovascular disease (PAC-CVD) program was launched in Taiwan nearly a decade ago. However, no clear regulations regarding length of stay (LOS) in the program and extension standards exist. Thus, the allocation of limited medical resources such as hospital beds is a major issue. METHODS This novel study retrospectively investigated the effects of functional performance and national health insurance (NHI) costs on PAC-CVD LOS. Data for 263 patients with stroke who participated in the PAC-CVD program were analysed. Hierarchical multiple regression was used to estimate the effects of functional performance and NHI costs on LOS at three time points: weeks 3, 6, and 9. RESULTS At week 3, age, NHI costs, modified Rankin scale score, and Barthel index significantly affected LOS, whereas at week 6, age and NHI costs were significant factors. However, functional performance and NHI costs were not significant factors at week 9. CONCLUSIONS The study provides crucial insights into the factors affecting LOS in the PAC-CVD program, and the results can enable medical decision-makers and health care teams to develop inpatient rehabilitation plans or provide transfer arrangements tailored to patients. Specifically, this study highlights the importance of early functional recovery and consideration of NHI costs when managing LOS in the PAC-CVD program.
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Affiliation(s)
- Hsiang-Yun Chou
- Department of Rehabilitation, An Nan Hospital, China Medical University, No. 66, Sec. 2, Changhe Rd., Annan Dist, Tainan, 709204, Taiwan
| | - Shang-Chun Ma
- Institute of Physical Education, Health & Leisure Studies, National Cheng Kung University, No. 1, Daxue Rd., East Dist, Tainan, 701401, Taiwan.
| | - Ya-Wen Tsai
- Department of Rehabilitation, An Nan Hospital, China Medical University, No. 66, Sec. 2, Changhe Rd., Annan Dist, Tainan, 709204, Taiwan.
| | - Chia-Li Shih
- Department of Rehabilitation, An Nan Hospital, China Medical University, No. 66, Sec. 2, Changhe Rd., Annan Dist, Tainan, 709204, Taiwan
| | - Chieh-Ting Yeh
- Department of Nursing, An Nan Hospital, China Medical University, No. 66, Sec. 2, Changhe Rd., Annan Dist, Tainan, 709204, Taiwan
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Camardella C, Germanotta M, Aprile I, Cappiello G, Curto Z, Scoglio A, Mazzoleni S, Frisoli A. A Decision Support System to Provide an Ongoing Prediction of Robot-Assisted Rehabilitation Outcome in Stroke Survivors. IEEE Int Conf Rehabil Robot 2023; 2023:1-6. [PMID: 37941244 DOI: 10.1109/icorr58425.2023.10304700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2023]
Abstract
Clinicians often deal with complex robotic platform and serious games in stroke patients rehabilitation contexts, and they face two main problems: 1) the interpretation of either the performance in game or measures of a robotic system from the motor recovery point of view, and 2) the duration and complexity of clinical scales administration that makes repetitive assessments during the therapy unpractical. In this paper, a Random Tree Forest based system was trained and tested to provide a prediction of different clinical outcomes (i.e. FMA, ARAT, and MI) along the whole therapy duration, having non-clinical measures only as inputs, acting as a simulated decision support system. The dataset includes 30 post-stroke patients, that underwent a 30-session robot-assisted rehabilitation treatment. Results have shown that the system is able to produce very accurate and reliable predictions about the motor recovery of the patient at the end of the therapy, already in the first phases of the rehabilitation (i40% of therapy execution), just using robotic platform measures. Such a tool would provide a great benefit in terms of rehabilitation objectives planning, as a decision support tool for highly personalized rehabilitation treatments.
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Blair EM, Reale BK, Zahuranec DB, Forman J, Langa KM, Giordani BJ, Plassman BL, Welsh-Bohmer KA, Wang J, Kollman CD, Levine DA. Influence of mild cognitive impairment on patient and care partner decision-making for acute ischemic stroke. J Stroke Cerebrovasc Dis 2023; 32:107068. [PMID: 37004301 PMCID: PMC10499500 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 02/28/2023] [Accepted: 03/02/2023] [Indexed: 04/03/2023] Open
Abstract
GOALS Evidence suggests that patients with mild cognitive impairment (MCI) receive fewer treatments for acute ischemic stroke and other cardiovascular diseases than patients with normal cognition. Little is known about how patient and care partner preferences for ischemic stroke treatment differ between the patient population with MCI and the population with normal cognition. This study aimed to understand how patient MCI diagnosis influences patient and care partner decision-making for acute ischemic stroke treatments. METHODS Multi-center qualitative study using in-person semi-structured interviews with 20 MCI and normal cognition patient-care partner dyads using a standard guide. The present study reports results on patient and care partner preferences for a clinical vignette patient to receive three non-invasive treatments (intravenous tissue plasminogen activator, inpatient rehabilitation, and secondary preventive medications) and two invasive treatments (feeding tube and carotid endarterectomy) after acute ischemic stroke. We used qualitative content analysis to identify themes. FINDINGS We identified three major themes: (1) Patients with MCI desired non-invasive treatments after stroke, similar to patients with normal cognition and for similar reasons; (2) Patients with MCI expressed different preferences than patients with normal cognition for two invasive treatments after stroke: carotid endarterectomy and feeding tube placement; and (3) Patients with MCI expressed more skepticism of the stroke treatment options and less decisiveness in decision-making than patients with normal cognition. CONCLUSIONS These results suggest that patient MCI diagnosis may contribute to differences in patient and care partner preferences for invasive treatments after stroke, but not for non-invasive treatments.
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Affiliation(s)
- Emilie M Blair
- Department of Internal Medicine and Cognitive Health Services Research Program, U-M Medical School, Ann Arbor, MI, USA
| | - Bailey K Reale
- Department of Internal Medicine and Cognitive Health Services Research Program, U-M Medical School, Ann Arbor, MI, USA; Lake Erie College of Osteopathic Medicine at Seton Hill, LECOM, Greensburg, PA, USA
| | | | - Jane Forman
- Department of Internal Medicine and Cognitive Health Services Research Program, U-M Medical School, Ann Arbor, MI, USA; VA Ann Arbor Healthcare System, Ann Arbor, MI, USA; Institute for Social Research, U-M, Ann Arbor, MI, USA
| | - Kenneth M Langa
- Department of Internal Medicine and Cognitive Health Services Research Program, U-M Medical School, Ann Arbor, MI, USA; Institute for Healthcare Policy and Innovation, U-M, Ann Arbor, MI, USA; VA Ann Arbor Healthcare System, Ann Arbor, MI, USA; Institute for Social Research, U-M, Ann Arbor, MI, USA
| | - Bruno J Giordani
- Department of Psychiatry and Michigan Alzheimer's Disease Center, U-M, Ann Arbor, MI, USA
| | - Brenda L Plassman
- Department of Psychiatry and Behavioral Science, Duke University School of Medicine, Durham, NC, USA
| | - Kathleen A Welsh-Bohmer
- Department of Psychiatry and Behavioral Science, Duke University School of Medicine, Durham, NC, USA
| | - Jing Wang
- Department of Psychiatry and Behavioral Science, Duke University School of Medicine, Durham, NC, USA
| | | | - Deborah A Levine
- Department of Internal Medicine and Cognitive Health Services Research Program, U-M Medical School, Ann Arbor, MI, USA; Department of Neurology and Stroke Program, U-M, Ann Arbor, MI, USA; VA Ann Arbor Healthcare System, Ann Arbor, MI, USA.
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Biel M, Haley KL. Motivation in Aphasia Treatment: Self-Determination Theory Applied to the FOURC Model. AMERICAN JOURNAL OF SPEECH-LANGUAGE PATHOLOGY 2023; 32:1016-1036. [PMID: 36889681 DOI: 10.1044/2022_ajslp-22-00251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
PURPOSE Although the importance of motivation to successful rehabilitation is frequently acknowledged in the aphasia literature, little evidence-based guidance has been provided on how to support it. The purpose of this tutorial is to introduce a well-validated theory of motivation, self-determination theory (SDT); explain its role as the foundation for the FOURC model of collaborative goal setting and treatment planning; and explain how it may be applied during rehabilitation to support the motivation of people with aphasia. METHOD We provide an overview of SDT, explore the link between motivation and psychological wellness, and discuss how psychological needs are addressed in SDT and the FOURC model. Concrete examples from aphasia therapy are used to illustrate main concepts. CONCLUSIONS SDT offers tangible guidance for supporting motivation and wellness. SDT-based practices support positive forms of motivation, which is one of the targets of FOURC. An understanding of SDT's theoretical foundation will help clinicians maximize the impact of collaborative goal setting and aphasia therapy more generally.
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Affiliation(s)
- Michael Biel
- Department of Communication Disorders and Sciences, California State University, Northridge
| | - Katarina L Haley
- Department of Health Sciences, School of Medicine, The University of North Carolina at Chapel Hill
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Gledhill K, Bucknall TK, Lannin NA, Hanna L. Defining ready for discharge from sub-acute care: a qualitative exploration from multiple stakeholder perspectives. BMC Health Serv Res 2023; 23:425. [PMID: 37131178 PMCID: PMC10153031 DOI: 10.1186/s12913-023-09285-y] [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: 08/25/2022] [Accepted: 03/14/2023] [Indexed: 05/04/2023] Open
Abstract
BACKGROUND Planning discharges from subacute care facilities is becoming increasingly complex due to an ageing population and a high demand on services. The use of non-standardised assessments to determine a patient's readiness for discharge places a heavy reliance on a clinician's judgement which can be influenced by system pressures, past experiences and team dynamics. The current literature focusses heavily on discharge-readiness from clinicians' perspectives and in the acute care setting. This paper aimed to explore the perceptions of discharge-readiness from the perspectives of key stakeholders in subacute care: inpatients, family members, clinicians and managers. METHODS A qualitative descriptive study was conducted, exploring the views of inpatients (n = 16), family members (n = 16), clinicians (n = 17) and managers (n = 12). Participants with cognitive deficits and those who did not speak English were excluded from this study. Semi-structured interviews and focus groups were conducted and audio-recorded. Following transcription, inductive thematic analysis was completed. RESULTS Participants identified that there are both patient-related and environmental factors that influence discharge-readiness. Patient-related factors discussed included continence, functional mobility, cognition, pain and medication management skills. Environmental factors centred around the discharge (home) environment, and were suggested to include a safe physical environment alongside a robust social environment which was suggested to assist to fill any gaps in functional capabilities (i.e. patient-related factors). CONCLUSIONS These findings make a unique contribution to the literature by providing a thorough exploration of determining discharge-readiness as a combined narrative from the perspectives from key stakeholders. Findings from this qualitative study identified key personal and environmental factors influencing patients' discharge-readiness, which may allow health services to streamline the determination of discharge-readiness from subacute care. Understanding how these factors might be assessed within a discharge pathway warrants further attention.
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Affiliation(s)
- Kate Gledhill
- School of Health and Social Development, Deakin University, Geelong, Australia.
- School of Primary and Allied Healthcare, Monash University, Frankston, Australia.
- Department of Occupational Therapy, School of Primary Health and Allied Care, Faculty of Medicine, Nursing and Health Sciences, Monash University, Peninsula Campus, Frankston, VIC, 3199, Australia.
| | - Tracey K Bucknall
- School of Nursing and Midwifery, Deakin University, Melbourne, Australia
- Alfred Health, Melbourne, Australia
- Centre for Quality and Patient Safety Research, Institute for Health Transformation, Deakin University, Melbourne, Australia
| | - Natasha A Lannin
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Australia
- Alfred Health, Melbourne, Australia
| | - Lisa Hanna
- School of Health and Social Development, Deakin University, Geelong, Australia
- Institute of Health Transformation, Deakin University, Geelong, Australia
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Déry J, de Guise É, Lamontagne ME. Identifying prioritization criteria for patients with mtbi waiting for multidisciplinary rehabilitation services: A Delphi study. Brain Inj 2023; 37:563-571. [PMID: 37114975 DOI: 10.1080/02699052.2023.2205662] [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: 04/29/2023]
Abstract
INTRODUCTION Rehabilitation service providers must take into account prognostic factors when making clinical decisions, which includes using these factors as prioritization criteria. The goal of this study was to establish consensus on patient prioritization criteria based on prognostic factors related to persistent symptoms for patients with mild traumatic brain injury (mTBI) waiting for outpatient specialized rehabilitation services. MATERIALS AND METHODS We conducted a Delphi survey involving clinicians, researchers, decision makers, and patients. Before the survey, we presented the results of an overview of systematic reviews summarizing the evidence on prognostic factors related to post-concussion symptoms. RESULTS After two rounds, the 17 experts reached consensus on the inclusion of 12 prioritization criteria: acute stress disorder, anxiety and depression, baseline mental and physical health, functional impacts and difficulties in performing daily habits after the trauma, motivation to receive services, multiple concussions, prior neurological problems, PTSD, quality of sleep, return to work failures, somatic complaints, suicidal ideation. CONCLUSION Healthcare stakeholders must consider a wide range of factors to guide clinical decision-making, including about access to care and patient prioritization. This study shows that the Delphi technique can be used to reach consensus on such decisions regarding patients with mTBI who are waiting for outpatient specialized rehabilitation services.
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Affiliation(s)
- Julien Déry
- Department of Rehabilitation, Université Laval, Québec, Canada
- Centre interdisciplinaire de recherche en réadaptation et intégration sociale (Cirris), Centre intégré universitaire de santé et de services sociaux de la Capitale-Nationale,Québec, Canada
| | - Élaine de Guise
- Department of Psychology, Université de Montréal, Montréal, Canada
- Research Institute of the McGill University Health Centre (RI-MUHC), Montréal, Canada
- Centre de recherche interdisciplinaire en réadaptation du Montréal métropolitain (CRIR), Montréal, Canada
| | - Marie-Eve Lamontagne
- Department of Rehabilitation, Université Laval, Québec, Canada
- Centre interdisciplinaire de recherche en réadaptation et intégration sociale (Cirris), Centre intégré universitaire de santé et de services sociaux de la Capitale-Nationale,Québec, Canada
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Li S, Lu Y, Fang S, Wang L, Peng B. Inpatient rehabilitation therapy in stroke patients with reperfusion therapy: a national prospective registry study. BMC Neurol 2023; 23:146. [PMID: 37020194 PMCID: PMC10073784 DOI: 10.1186/s12883-023-03144-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2022] [Accepted: 02/27/2023] [Indexed: 04/07/2023] Open
Abstract
BACKGROUND Little is known about the rate of real-world inpatient rehabilitation therapy (IRT) after stroke. We aimed to determine the rate of inpatient rehabilitation therapy and its associated factors in patients who undergo reperfusion therapy in China. METHODS This national prospective registry study included hospitalized ischemic stroke patients aged 14-99 years with reperfusion therapy between January 1, 2019, and June 30, 2020, collecting hospital-level and patient-level demographic and clinical data. IRT included acupuncture or massage, physical therapy, occupational therapy, speech therapy, and others. The primary outcome was the rate of patients receiving IRT. RESULTS We included 209,189 eligible patients from 2191 hospitals. The median age was 66 years, and 64.2% were men. Four in five patients received only thrombolysis, and the rest 19.2% underwent endovascular therapy. The overall rate of IRT was 58.2% (95% CI, 58.0-58.5%). Differences in demographic and clinical variables existed between patients with and without IRT. The rates of acupuncture or massage, physical therapy, occupational therapy, speech therapy, and other rehabilitation interventions were 38.0%, 28.8%, 11.8%, 14.4%, and 22.9%, respectively. The rates of single and multimodal interventions were 28.3% and 30.0%, respectively. A lower likelihood of receiving IRT was associated with being 14-50 or 76-99 years old, female, from Northeast China, from Class-C hospitals, receiving only thrombolysis, having severe stroke or severe deterioration, a short length of stay, Covid-19 pandemic and having intracranial or gastrointestinal hemorrhage. CONCLUSION Among our patient population, the IRT rate was low with limited use of physical therapy, multimodal interventions, and rehabilitation centers and varied by demographic and clinical features. The implementation of IRT remains a challenge for stroke care, warranting urgent and effective national programs to enhance post-stroke rehabilitation and the adherence to guidelines.
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Affiliation(s)
- Shengde Li
- Department of Neurology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Shuaifuyuan1, Dong Cheng District, Beijing, 100730, China
| | - Yixiu Lu
- Department of Neurology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Shuaifuyuan1, Dong Cheng District, Beijing, 100730, China
| | - Shiyuan Fang
- Department of Neurology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Shuaifuyuan1, Dong Cheng District, Beijing, 100730, China
| | - Longde Wang
- The General Office of Stroke Prevention Project Committee, National Health Commission of the People's Republic of China, No. 118, Guang'anmen Inner Street, Beijing, 100053, China.
| | - Bin Peng
- Department of Neurology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Shuaifuyuan1, Dong Cheng District, Beijing, 100730, China.
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Additional therapy promotes a continued pattern of improvement in upper-limb function and independence post-stroke. J Stroke Cerebrovasc Dis 2023; 32:106995. [PMID: 36681009 DOI: 10.1016/j.jstrokecerebrovasdis.2023.106995] [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: 09/01/2022] [Revised: 12/29/2022] [Accepted: 01/13/2023] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Upper-limb motor impairment after stroke is common and disabling. Growing evidence suggests that rehabilitation is effective in the chronic period. However, there is limited knowledge on the effects of ongoing targeted rehabilitation programs on patient outcomes. OBJECTIVES This study investigated the effects of delivering two programs of dose-matched evidence-based upper-limb rehabilitation to community-dwelling post-acute stroke patients with low, moderate and high motor-function. MATERIALS AND METHODS 12 patients (2 female) aged 50.5±18.2 years and 13.8±10.8 months post-stroke completed 2-weeks of modified-Constraint-Induced Movement Therapy followed by 2-weeks of Wii-based Movement Therapy after a mean interval of 9.6±1.1 months (range 6-19months). Function was assessed at 6 time points (i.e. before and after each therapy program and 6-month follow-up after each program). Primary outcome measures were the Wolf Motor Function Test timed-tasks (WMFT-tt), upper-limb Fugl-Meyer Assessment (F-M) and the Motor Activity Log Quality of Movement Scale (MALQOM). Improvement and maintenance was analyzed using Paired T-Tests and Wilcoxon Signed Rank Tests. RESULTS Upper-limb function significantly improved on all primary outcome measures with the first therapy program (WMFT-tt p=0.008, F-M p=0.007 and MALQOM p<0.0001). All scores continued to improve with the second therapy program with significant improvements in the F-M (p=0.048) and the MALQOM (p=0.001). CONCLUSIONS All patients showed a pattern of continued improvement in upper-limb motor-function and independence in activities of daily living. These improvements demonstrate the benefit of ongoing post-stroke rehabilitation for community-dwelling stroke survivors for individuals of varying baseline functional status.
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Chou HY, Tsai YW, Ma SC, Ma SM, Shih CL, Yeh CT. Efficacy and Cost over 12 Hospitalization Weeks of Postacute Care for Stroke. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:1419. [PMID: 36674170 PMCID: PMC9859483 DOI: 10.3390/ijerph20021419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 01/07/2023] [Accepted: 01/11/2023] [Indexed: 06/17/2023]
Abstract
Few studies have investigated changes in functional outcomes and economic burden in patients in the postacute care cerebrovascular disease (PAC-CVD) program. We, for the first time, retrospectively investigated changes in functional performance and the national health insurance (NHI) cost over 12 PAC-CVD hospitalization weeks and evaluated the therapeutic effects of the PAC-CVD program on the NHI cost. Specifically, the functional outcomes and NHI cost of 263 stroke patients in the PAC-CVD program were analyzed. The repeated measures t test was used to compare functional performance over 0-3 weeks, and a one-way repeated measures multivariate analysis of variance was used to compare functional performance and NHI costs during weeks 0-6 and 0-9. The Wilcoxon signed-rank test was used to compare functional performance over weeks 9-12. Hierarchical multiple regression was used to estimate the effects of functional performance on NHI costs during weeks 3, 6, and 9. Over weeks 0-12, all functional performance measures demonstrated significant improvements. Changes in NHI costs varied depending on whether hospitalization was extended. At any time point, functional performance did not have a significant impact on NHI cost. Therefore, the PAC-CVD program may aid patients with stroke in sustainably regaining functional performance and effectively controlling economic burden.
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Affiliation(s)
- Hsiang-Yun Chou
- Department of Rehabilitation, An Nan Hospital, China Medical University, Tainan 709204, Taiwan
| | - Ya-Wen Tsai
- Department of Rehabilitation, An Nan Hospital, China Medical University, Tainan 709204, Taiwan
| | - Shang-Chun Ma
- Institute of Physical Education, Health & Leisure Studies, National Cheng Kung University, Tainan 701401, Taiwan
| | - Shang-Min Ma
- Department of Recreational Sport & Health Promotion, National Pingtung University of Science & Technology, Pingtung 912301, Taiwan
| | - Chia-Li Shih
- Department of Rehabilitation, An Nan Hospital, China Medical University, Tainan 709204, Taiwan
| | - Chieh-Ting Yeh
- Department of Nursing, An Nan Hospital, China Medical University, Tainan 709204, Taiwan
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Chen B, Zhou Y, Chen C, Sayeed Z, Hu J, Qi J, Frush T, Goitz H, Hovorka J, Cheng M, Palacio C. Volitional control of upper-limb exoskeleton empowered by EMG sensors and machine learning computing. ARRAY 2023. [DOI: 10.1016/j.array.2023.100277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
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Deschasse G, Drumez E, Visade F, Charpentier A, Delecluse C, Loggia G, Lescure P, Attier-Żmudka J, Bloch J, Gaxatte C, Bloch F, Puisieux F, Beuscart JB. Factors Associated with Transfer from an Acute Geriatric Unit to a Post-Acute Care Facility among Community-Dwelling Patients: Results from the DAMAGE Cohort. Clin Interv Aging 2022; 17:1821-1832. [DOI: 10.2147/cia.s370562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 09/14/2022] [Indexed: 12/13/2022] Open
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Successful Community Discharge Among Older Adults With Traumatic Brain Injury Admitted to Inpatient Rehabilitation Facilities. Arch Rehabil Res Clin Transl 2022; 4:100241. [PMID: 36545522 PMCID: PMC9761303 DOI: 10.1016/j.arrct.2022.100241] [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] [Indexed: 11/06/2022] Open
Abstract
Objective To identify admission characteristics that predict a successful community discharge from an inpatient rehabilitation facility (IRF) among older adults with traumatic brain injury (TBI). Design In a retrospective cohort study, we leveraged probabilistically linked Medicare Administrative, IRF-Patient Assessment Instrument, and National Trauma Data Bank data to build a parsimonious logistic model to identify characteristics associated with successful discharge. Multiple imputation methods were used to estimate effects across linked datasets to account for potential data linkage errors. Setting Inpatient Rehabilitation Facilities in the U.S. Participants The sample included a mean of 1060 community-dwelling adults aged 66 years and older across 30 linked datasets (N=1060). All were hospitalized after TBI between 2011 and 2015 and then admitted to an IRF. The mean age of the sample was 79.7 years, and 44.3% of the sample was women. Interventions Not applicable. Main Outcome Measures Successful discharge home. Results Overall, 64.6% of the sample was successfully discharged home. A logistic model including 4 predictor variables: Functional Independence Measure motor (FIM-M) and cognitive (FIM-C) scores, pre-injury chronic conditions, and pre-injury living arrangement, that were significantly associated with successful discharge, resulted in acceptable discrimination (area under the curve: 0.76, 95% confidence interval [CI]: 0.72-0.81). Higher scores on the FIM-M (odds ratio [OR]:1.07, 95% CI: 1.05-1.09) and FIM-C (OR: 1.05, 95% CI: 1.02-1.08) were associated with greater odds of successful discharge, whereas living alone vs with others (OR: 0.46, 95% CI: 0.30-0.71) and a greater number of chronic conditions (OR: 0.94, 95% CI: 0.90-0.99) were associated with lower odds of successful discharge. Conclusions The results provide a parsimonious model for predicting successful discharge among older adults admitted to an IRF after a TBI-related hospitalization and provide clinically useful information to inform discharge planning.
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Lam Wai Shun P, Bottari C, Dubé S, Grondin M, Swaine B. Factors influencing clinicians' referral or admission decisions for post-acute stroke or traumatic brain injury rehabilitation: A scoping review. PM R 2022; 14:1388-1405. [PMID: 34387943 DOI: 10.1002/pmrj.12691] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 07/05/2021] [Accepted: 08/05/2021] [Indexed: 12/31/2022]
Abstract
Demand for post-acute stroke and traumatic brain injury (TBI) rehabilitation outweighs resource availability. Every day, clinicians face the challenging task of deciding which patient will benefit or not from rehabilitation. The objectives of this scoping review were to map and compare factors reported by clinicians as influencing referral or admission decisions to post-acute rehabilitation for stroke and TBI patients, to identify most frequently reported factors and those perceived as most influential. We searched four major databases for articles published between 1946 and January 2021. Articles were included if they reported clinicians' perceptions, investigated referral or admission decisions to post-acute rehabilitation, and focused on patients with stroke or TBI. Twenty articles met inclusion criteria. The International Classification of Functioning, Disability and Health framework was used to guide data extraction and summarizing. Patient-related factors most frequently reported by clinicians were age, mental status prior to stroke or TBI, and family support. The two latter were ranked among the most influential by clinicians working with stroke patients, whereas age was ranked of low importance. Organizational factors were reported to influence decisions (particularly the availability of post-acute care services) as well as clinicians' characteristics (eg, knowledge). Moreover, clinicians' prediction of patient outcome ranked among the most important driver of referral or admission decisions by clinicians working with stroke patients. Findings highlight the complex nature of decision-making regarding patient selection for rehabilitation and provide insight on important factors that frontline clinicians need to consider when having to make rapid decisions in high-pressured acute care environments.
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Affiliation(s)
- Priscilla Lam Wai Shun
- School of Rehabilitation, Faculty of Medicine, Université de Montréal, Montréal, Québec, Canada.,Centre for Interdisciplinary Research in Rehabilitation of Greater Montreal (CRIR), Montréal, Québec, Canada
| | - Carolina Bottari
- School of Rehabilitation, Faculty of Medicine, Université de Montréal, Montréal, Québec, Canada.,Centre for Interdisciplinary Research in Rehabilitation of Greater Montreal (CRIR), Montréal, Québec, Canada
| | - Sandra Dubé
- School of Rehabilitation, Faculty of Medicine, Université de Montréal, Montréal, Québec, Canada
| | - Myrian Grondin
- Marguerite-d'Youville Library, Université de Montréal, Montréal, Québec, Canada
| | - Bonnie Swaine
- School of Rehabilitation, Faculty of Medicine, Université de Montréal, Montréal, Québec, Canada.,Centre for Interdisciplinary Research in Rehabilitation of Greater Montreal (CRIR), Montréal, Québec, Canada
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22
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Biel M, Enclade H, Richardson A, Guerrero A, Patterson J. Motivation Theory and Practice in Aphasia Rehabilitation: A Scoping Review. AMERICAN JOURNAL OF SPEECH-LANGUAGE PATHOLOGY 2022; 31:2421-2443. [PMID: 36264648 DOI: 10.1044/2022_ajslp-22-00064] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
PURPOSE In the aphasia literature, motivation has been described as potentially influencing rehabilitation outcomes, and there are reports that researchers and clinicians have acted to promote it. However, studies directly investigating the range of beliefs and practices surrounding motivation do not exist currently. The purpose of this scoping review is to develop themes related to the beliefs and practices appearing in the recent aphasia literature. METHOD Four databases (CINAHL, PsycINFO, PubMed, and Google Scholar) were searched using keywords aphasia and motivation (including derivatives such as motiv*) for articles published between 2009 and 2020. Searches returned 19,731 articles; after deleting duplicates and applying inclusionary criteria, 365 articles remained. In each article, text surrounding the term motivation was highlighted and thematic analysis was applied to these quotations. RESULTS Sixteen themes were developed through thematic analysis and placed into two groups. The first group contained five themes suggesting that researchers believed that motivation should be studied and recognized the value of motivation in person(s) with aphasia when participating in research or clinical activities. The second group contained 11 themes reporting diverse beliefs and practices in how motivation is incorporated in research and clinical activities. CONCLUSIONS Results from this scoping review suggest that aphasia researchers, clinicians, and persons with aphasia hold beliefs about motivation that can influence clinical and research decisions. In general, beliefs and decisions related to motivation appeared to be guided by intuition rather than theories of motivation. These themes are discussed within the context of three psychological needs proposed by self-determination theory: competency, autonomy, and relatedness. Applying theories of motivation to future study in aphasia rehabilitation will guide work that can provide empirical support for these beliefs.
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Souto SDR, Anderle P, Goulart BNGD. [Racial inequalities in access to rehabilitation after a stroke: study of the Brazilian population]. CIENCIA & SAUDE COLETIVA 2022; 27:1919-1928. [PMID: 35544819 DOI: 10.1590/1413-81232022275.09452021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 07/02/2021] [Indexed: 11/22/2022] Open
Abstract
This article aims to verify the association between race/skin color and access to post-stroke rehabilitation services. It is a cross-sectional population-based study including 966 post-stroke adults (≥18 years) that responded to the National Health Survey (PNS). The outcome, access to rehabilitation, and exposure (race/skin color) were collected in a self-reported manner. Socio-demographic variables, clinical history, healthcare plan and post-stroke limitation were considered for the adjustment. Poisson regression with robust variance estimation was used to estimate the association in the crude and adjusted analyses. Based on the sample, 51.8% are self-declared black and 61.4% require rehabilitation, with only 20% having access to the rehabilitation service. Difficulty in accessing rehabilitation was reported by 57.5% of other self-declared races, 43% blacks, and 35.4% whites. In the adjusted analysis, 4% of self-declared black (PR 1.04, CI95%1.00-1.08) and 17% of self-declared yellow and indigenous (PR 1.17, IC95%1.13-1.20) have less access to rehabilitation than their white peers. In Brazil, self-declared black and yellow and indigenous people have worst access to post-stroke rehabilitation in comparison with self-declared white people, highlighting racial inequities in rehabilitation in stroke survivors.
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Affiliation(s)
- Shayze da Rosa Souto
- Departamento de Saúde e Comunicação Humana, Instituto de Psicologia, Universidade Federal do Rio Grande do Sul (UFRGS). R. Ramiro Barcelos 2777, Santa Cecília. 90035-003 Porto Alegre RS Brasil.
| | - Paula Anderle
- Programa de Pós-Graduação em Epidemiologia, Faculdade de Medicina, UFRGS. Porto Alegre RS Brasil
| | - Bárbara Niegia Garcia de Goulart
- Departamento de Saúde e Comunicação Humana, Instituto de Psicologia, Universidade Federal do Rio Grande do Sul (UFRGS). R. Ramiro Barcelos 2777, Santa Cecília. 90035-003 Porto Alegre RS Brasil.
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Saverino A, Sonabend R, Wong S, Symeon C. The Wolfson Assessment Matrix: a potential tool to support clinicians in establishing access to specialized neuro rehabilitation by capturing important prognostic factors. Sharing more equitable and transparent criteria. Eur J Phys Rehabil Med 2022; 58:161-170. [PMID: 34823336 PMCID: PMC9981235 DOI: 10.23736/s1973-9087.21.07022-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Specialized Rehabilitation Services (SRSs) are designed to offer intensive multidisciplinary rehabilitation to patients with complex needs, who are expected to make significant functional gains in their ADLs over a relatively limited period of time. Although national guidelines offer a guidance on how to band patients by complexity, there is no consensus on how to screen patients with regard to rehabilitation prognosis. AIM The aim of this study was to improve the selection of patients admitted to an SRS, defining transparent and equitable prognostic criteria to guide clinicians' decision making. DESIGN This is a retrospective observational study SETTING: an SRS in the UK. POPULATION We included 121 patients affected by a neurological condition consecutively admitted for multidisciplinary rehabilitation. METHODS Rehabilitation Complexity Scale Extended is used to describe rehabilitation complexity. A short list of potential barriers to rehabilitation was analysed to predict the functional outcome measured by the Functional Independent Measure and the Barthel Index. RESULTS Older age, a heavier burden of co-morbidities, pre-morbid cognitive difficulties or dementia and a lower function level at admission were the most important variables to predict a lower functional gain. CONCLUSIONS We have used this list of barriers to create the Wolfson Assessment Matrix as a potential support tool to guide clinicians navigating through the different rehabilitation service options when assessing complex patients for eligibility to an SRS. CLINICAL REHABILITATION IMPACT SRSs are highly expensive services representing a possible step along the rehabilitation pathway for patients with complex needs. A tool such as the Wolfson Assessment Matrix would represent a step forward to help consistency in decision making regarding appropriateness for SRSs. It would also help to set realistic long-term goals with patients and families and support Health Services in the further development of alternative rehabilitation settings.
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Affiliation(s)
- Alessia Saverino
- Wolfson Neuro Rehabilitation Center, St George's Hospital, London, UK - .,Maugeri Clinical Scientific Institute, Genoa, Italy -
| | - Raphael Sonabend
- Department of Statistical Science, University College London, London, UK
| | - Sancho Wong
- Wolfson Neuro Rehabilitation Center, St George's Hospital, London, UK
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Guerra S, Lambe K, Manolova G, Sadler E, Sheehan KJ. Multidisciplinary team healthcare professionals' perceptions of current and optimal acute rehabilitation, a hip fracture example A UK qualitative interview study informed by the Theoretical Domains Framework. PLoS One 2022; 17:e0277986. [PMID: 36399456 PMCID: PMC9674178 DOI: 10.1371/journal.pone.0277986] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 11/07/2022] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE To understand multidisciplinary team healthcare professionals' perceptions of current and optimal provision of acute rehabilitation, perceived facilitators and barriers to implementation, and their implications for patient recovery, using hip fracture as an example. METHODS A qualitative design was adopted using semi-structured telephone interviews with 20 members of the acute multidisciplinary healthcare team (occupational therapists, physiotherapists, physicians, nurses) working on orthopaedic wards at 15 different hospitals across the UK. Interviews were audio-recorded, transcribed verbatim, anonymised, and then thematically analysed drawing on the Theoretical Domains Framework to enhance our understanding of the findings. RESULTS We identified four themes: conceptualising a model of rehabilitative practice, which reflected the perceived variability of rehabilitation models, along with facilitators and common patient and organisational barriers for optimal rehabilitation; competing professional and organisational goals, which highlighted the reported incompatibility between organisational goals and person-centred care shaping rehabilitation practices, particularly for more vulnerable patients; engaging teams in collaborative practice, which related to the expressed need to work well with all members of the multidisciplinary team to achieve the same person-centred goals and share rehabilitation practices; and engaging patients and their carers, highlighting the importance of their involvement to achieve a holistic and collaborative approach to rehabilitation in the acute setting. Barriers and facilitators within themes were underpinned by the lack or presence of adequate ways of communicating with patients, carers, and multidisciplinary team members; resources (e.g. equipment, staffing, group classes), and support from people in leadership positions such as management and senior staff. CONCLUSIONS Cornerstones of optimal acute rehabilitation are effective communication and collaborative practices between the multidisciplinary team, patients and carers. Supportive management and leadership are central to optimise these processes. Organisational constraints are the most commonly perceived barrier to delivering effective rehabilitation in hospital settings, which exacerbate silo working and limited patient engagement.
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Affiliation(s)
- Stefanny Guerra
- Department of Population Health Sciences, School of Life Course and Population Sciences, King’s College London, London, United Kingdom
| | - Kate Lambe
- Department of Population Health Sciences, School of Life Course and Population Sciences, King’s College London, London, United Kingdom
| | - Gergana Manolova
- Department of Population Health Sciences, School of Life Course and Population Sciences, King’s College London, London, United Kingdom
| | - Euan Sadler
- Faculty of Environmental and Life Sciences, School of Health Sciences, University of Southampton, and Southern Health NHS Foundation Trust, Southampton, United Kingdom
| | - Katie J. Sheehan
- Department of Population Health Sciences, School of Life Course and Population Sciences, King’s College London, London, United Kingdom
- * E-mail:
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Lam Wai Shun P, Swaine B, Bottari C. Clinical reasoning underlying acute care occupational therapists' assessment of rehabilitation potential after stroke or brain injury: A constructivist grounded theory study. Aust Occup Ther J 2021; 69:177-189. [PMID: 34939206 DOI: 10.1111/1440-1630.12781] [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: 07/09/2021] [Revised: 12/02/2021] [Accepted: 12/05/2021] [Indexed: 11/28/2022]
Abstract
INTRODUCTION In acute care hospitals, clinicians are expected to rapidly provide recommendations regarding patients' rehabilitation potential and candidacy for postacute rehabilitation. Some studies have investigated factors influencing referral to rehabilitation, but few have examined clinical reasoning underlying referral decisions. This study aimed to investigate what occupational therapists were thinking about (factors influencing reasoning), how they reasoned (thought processes) when evaluating stroke or traumatic brain injury patients' rehabilitation potential, and how they decided on referral to postacute rehabilitation. METHODS Using a constructivist grounded theory approach, the clinical reasoning of 10 acute care occupational therapists working in a large Canadian city was examined. Participant recruitment, data collection, and analysis were performed simultaneously following theoretical sampling procedures. Therapists' thoughts on patients' rehabilitation potential were collected twice (during chart consultation and initial patient assessment) using think-aloud protocols and semi-structured interviews. Constant comparison, memoing, and diagramming methods were employed during coding to help categorisation and conceptualisation. FINDINGS Numerous patient, clinician, and organisation-related factors were found to influence clinical reasoning. Occupational therapists interpreted these factors in an attempt to (1) predict recovery, (2) estimate rehabilitation potential, and (3) determine rehabilitation candidacy. They used two types of thought processes: (1) building a representation of patients' rehabilitation potential (involving eight steps including gathering and interpreting factors); (2) activating bottom-up and top-down scripts (comparing the expected impact of impairments on activity performance to behaviours observed during activity performance). Furthermore, an algorithm was developed describing how occupational therapists decide on referral to postacute rehabilitation. CONCLUSION Findings can be used to teach students and novice occupational therapists how to identify and interpret key factors in the assessment of stroke or traumatic brain injury patients' rehabilitation potential. Results also provide insight on cognitive processes that can be taught for efficient assessment of rehabilitation potential and decision-making regarding referral to postacute rehabilitation.
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Affiliation(s)
- Priscilla Lam Wai Shun
- Occupational Therapy, School of Rehabilitation, Faculty of Medicine, Université de Montréal, Montréal, Québec, Canada.,Centre for Interdisciplinary Research in Rehabilitation of Greater Montreal, Montréal, Québec, Canada
| | - Bonnie Swaine
- Occupational Therapy, School of Rehabilitation, Faculty of Medicine, Université de Montréal, Montréal, Québec, Canada.,Centre for Interdisciplinary Research in Rehabilitation of Greater Montreal, Montréal, Québec, Canada
| | - Carolina Bottari
- Occupational Therapy, School of Rehabilitation, Faculty of Medicine, Université de Montréal, Montréal, Québec, Canada.,Centre for Interdisciplinary Research in Rehabilitation of Greater Montreal, Montréal, Québec, Canada
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Conic RRZ, Geis C, Vincent HK. Social Determinants of Health in Physiatry: Challenges and Opportunities for Clinical Decision Making and Improving Treatment Precision. Front Public Health 2021; 9:738253. [PMID: 34858922 PMCID: PMC8632538 DOI: 10.3389/fpubh.2021.738253] [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: 07/08/2021] [Accepted: 10/11/2021] [Indexed: 11/15/2022] Open
Abstract
Physiatry is a medical specialty focused on improving functional outcomes in patients with a variety of medical conditions that affect the brain, spinal cord, peripheral nerves, muscles, bones, joints, ligaments, and tendons. Social determinants of health (SDH) play a key role in determining therapeutic process and patient functional outcomes. Big data and precision medicine have been used in other fields and to some extent in physiatry to predict patient outcomes, however many challenges remain. The interplay between SDH and physiatry outcomes is highly variable depending on different phases of care, and more favorable patient profiles in acute care may be less favorable in the outpatient setting. Furthermore, SDH influence which treatments or interventional procedures are accessible to the patient and thus determine outcomes. This opinion paper describes utility of existing datasets in combination with novel data such as movement, gait patterning and patient perceived outcomes could be analyzed with artificial intelligence methods to determine the best treatment plan for individual patients in order to achieve maximal functional capacity.
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Affiliation(s)
- Rosalynn R Z Conic
- Department of Family Medicine and Public Health, University of California, San Diego, San Diego, CA, United States
| | - Carolyn Geis
- Department of Physical Medicine and Rehabilitation, University of Florida, Gainesville, FL, United States
| | - Heather K Vincent
- Department of Physical Medicine and Rehabilitation, University of Florida, Gainesville, FL, United States
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Washida K, Kitajima E, Tanaka T, Ikeda S, Chiba T, Noda K, Yoshimoto T, Fukuma K, Saito S, Ihara M. A Nationwide Multi-Center Questionnaire Survey on the Real-World State and Clinical Management of Poststroke Dementia in Japan. J Alzheimers Dis 2021; 84:1103-1114. [PMID: 34633324 PMCID: PMC8673533 DOI: 10.3233/jad-215006] [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] [Indexed: 11/20/2022]
Abstract
Background: Poststroke dementia (PSD) is a serious problem for stroke survivors. However, there is still limited data on the real-world state and clinical management of PSD worldwide, and several countries already have a super-aged society. Objective: We conducted a nationwide questionnaire survey to examine the real-world state and management of PSD in Japan. Methods: A survey was conducted in the top 500 Japanese hospitals regarding the number of stroke patients treated between July 2018 and August 2019. Thirteen questions regarding PSD were mailed to doctors responsible for stroke management. Results: Responses were obtained from 251 hospitals (50.2%). The chief doctors responsible for stroke management answered the questionnaires. The median numbers of patients admitted annually with stroke in the departments of neurology and neurosurgery in the hospitals were 281.0 (interquartile range [IQR], 231.8–385.3) and 253.5 (IQR, 210.0–335.3), respectively, and most hospitals were acute care hospitals. Executive dysfunction was the most common cognitive dysfunction (10.9%), followed by amnesia (9.5%) and apathy (4.1%). Surprisingly, many stroke survivors lived alone at home (23.7%). Montreal Cognitive Assessment was significantly uncommon compared to Mini-Mental State Examination (p < 0.01). Furthermore, objective evaluation tests for behavioral and psychological symptoms of dementia were not often performed. Cognitive rehabilitation treatments were performed more often and earlier than drug treatments. The first drug of choice for PSD was predominantly donepezil (79.1%), followed by galantamine (6.1%), cilostazol (4.9%), memantine (2.5%), and rivastigmine (1.8%). Conclusion: Our study provides real-world evidence for the state of clinical practice related to PSD in Japan.
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Affiliation(s)
- Kazuo Washida
- Department of Neurology, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Erika Kitajima
- Department of Neurology, National Cerebral and Cardiovascular Center, Osaka, Japan.,Department of Medical Engineering, Faculty of Healthcare Sciences, Himeji Dokkyo University, Hyogo, Japan
| | - Tomotaka Tanaka
- Department of Neurology, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Shuhei Ikeda
- Department of Neurology, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Tetsuya Chiba
- Department of Neurology, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Kotaro Noda
- Department of Neurology, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Takeshi Yoshimoto
- Department of Neurology, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Kazuki Fukuma
- Department of Neurology, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Satoshi Saito
- Department of Neurology, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Masafumi Ihara
- Department of Neurology, National Cerebral and Cardiovascular Center, Osaka, Japan
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Noé E, Gómez A, Bernabeu M, Quemada I, Rodríguez R, Pérez T, López C, Laxe S, Colomer C, Ríos M, Juárez-Belaúnde A, González C, Pelayo R, Ferri J. Guía: Principios básicos de la neurorrehabilitación del paciente con daño cerebral adquirido. Recomendaciones de la Sociedad Española de Neurorrehabilitación. Neurologia 2021. [DOI: 10.1016/j.nrl.2021.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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In the Aftermath of Acute Hospitalization for Traumatic Brain Injury: Factors Associated with the Direct Pathway into Specialized Rehabilitation. J Clin Med 2021; 10:jcm10163577. [PMID: 34441872 PMCID: PMC8397212 DOI: 10.3390/jcm10163577] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 08/10/2021] [Accepted: 08/11/2021] [Indexed: 11/26/2022] Open
Abstract
Previous research has demonstrated that early initiation of rehabilitation and direct care pathways improve outcomes for patients with severe traumatic brain injury (TBI). Despite this knowledge, there is a concern that a number of patients are still not included in the direct care pathway. The study aim was to provide an updated overview of discharge to rehabilitation following acute care and identify factors associated with the direct pathway. We analyzed data from the Oslo TBI Registry—Neurosurgery over a five-year period (2015–2019) and included 1724 adults with intracranial injuries. We described the patient population and applied multivariable logistic regression to investigate factors associated with the probability of entering the direct pathway. In total, 289 patients followed the direct pathway. For patients with moderate–severe TBI, the proportion increased from 22% to 35% during the study period. Significant predictors were younger age, low preinjury comorbidities, moderate–severe TBI and disability due to TBI at the time of discharge. In patients aged 18–29 years, 53% followed the direct pathway, in contrast to 10% of patients aged 65–79 years (moderate–severe TBI). This study highlights the need for further emphasis on entering the direct pathway to rehabilitation, particularly for patients aged >64 years.
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Predicting Independence 6 and 18 Months after Ischemic Stroke Considering Differences in 12 Countries: A Secondary Analysis of the IST-3 Trial. Stroke Res Treat 2021; 2021:5627868. [PMID: 34373778 PMCID: PMC8349276 DOI: 10.1155/2021/5627868] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 07/11/2021] [Indexed: 11/17/2022] Open
Abstract
Objectives This study is aimed at identifying the best clinical model to predict poststroke independence at 6 and 18 months, considering sociodemographic and clinical characteristics, and then identifying differences between countries. Methods Data was retrieved from the International Stroke Trial 3 study. Nine clinical variables (age, gender, severity, rt-PA, living alone, atrial fibrillation, history of transient ischemic attack/stroke, and abilities to lift arms and walk) were measured immediately after the stroke and considered to predict independence at 6 and 18 months poststroke. Independence was measured using the Oxford Handicap Scale. The adequacy, predictive capacity, and discriminative capacity of the models were checked. Countries were added to the final models. Results At 6 months poststroke, 35.8% (n = 1088) of participants were independent, and at 18 months, this proportion decreased to 29.9% (n = 747). Both 6 and 18 months poststroke predictive models obtained fair discriminatory capacities. Gender, living alone, and rt-PA only reached predictive significance at 18 months. Poststroke patients from Poland and Sweden showed greater chances to achieve independence at 6 months compared to the UK. Poland also achieved greater chances at 18 months. Italy had worse chances than the UK at both follow-ups. Discussion. Six and eight variables predicted poststroke independence at 6 and 18 months, respectively. Some variables only reached significance at 18 months, suggesting a late influence in stroke patients' rehabilitation. Differences found between countries in achieving independence may be related to healthcare system organization or cultural characteristics, a hypothesis that must be addressed in future studies. These results can allow the development of tailored interventions to improve the outcomes.
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Cummins C, Payne D, Kayes NM. Governing neurorehabilitation. Disabil Rehabil 2021; 44:4921-4928. [PMID: 33989096 DOI: 10.1080/09638288.2021.1918771] [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: 10/21/2022]
Abstract
PURPOSE Person centred approaches to rehabilitation are promoted as an ethical means of addressing paternalistic power relations in clinician dominated medical encounters and improving outcomes. However, they fail to account for the complex nature of power. We sought alternative ways to explain the use of power in health service provision. METHODS A poststructural discourse analysis using the view of power offered by Michel Foucault was undertaken. Foucault's concept of governmentality is useful to explain the way health services deploy technologies of power to achieve objectives of the state. Governmentality refers to not just political structures but all the strategies and procedures for directing human behaviour. RESULTS Our investigation uncovered a web of strategic relationships operating that were both potentially productive and problematic and illuminate how client centred approaches in neurorehabilitation intertwines its subjects in strategic power relationships that involve webs of obligations and responsibilities. CONCLUSION The client-professional relationship promoted in neurorehabilitation as a moral way to practice can be a tool for mastery of one over the other, and assist the client to achieve their desired ends, but also has the potential to marginalise others who are unable to shape themselves into the desired ideal client.Implications for rehabilitationThis analysis shows how power is subtle and productive in that it produces knowledge and roles for both clients and practitioners.It demonstrates how neurorehabilitation's disciplinary practices assist the client to achieve their recovery goals.It reveals how certain clients might be marginalised when they cannot shape themselves into the ideal rehabilitation client.As a final point we hope that by being aware of how power works in neurorehabilitation, practitioners can become aware of opportunities for challenging disciplinary practices that do not serve the best interest of the client.
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Affiliation(s)
- Christine Cummins
- Centre for Person Centred Research, Auckland University of Technology, Auckland, New Zealand
| | - Deborah Payne
- Centre for Person Centred Research, Auckland University of Technology, Auckland, New Zealand.,Centre for Midwifery and Women's Health Research, Auckland University of Technology, Auckland, New Zealand
| | - Nicola M Kayes
- Centre for Person Centred Research, Auckland University of Technology, Auckland, New Zealand
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Marnane K, Gustafsson L, Bennett S, Rosbergen I, Grimley R. "Everyone needs rehab, but…": exploring post-stroke rehabilitation referral and acceptance decisions. Disabil Rehabil 2021; 44:4717-4728. [PMID: 33974463 DOI: 10.1080/09638288.2021.1918770] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
PURPOSE To explore the decision-making processes and experiences of acute and rehabilitation clinicians, regarding referral and acceptance of patients to rehabilitation after stroke. MATERIALS AND METHODS Multi-site rapid ethnography, involving observation of multidisciplinary case conferences, interviews with acute stroke and rehabilitation clinicians, and review of key documents within five (5) acute stroke units (ASUs) in Queensland, Australia. A cyclical, inductive content analysis was performed. RESULTS Seven key themes were identified, revealing the complex nature of post-stroke rehabilitation referral and acceptance decision making. Although the majority of clinicians felt that all patients could benefit from rehabilitation, they acknowledged this could not always be the case. Rehabilitation potential and goals were considered by clinicians, but decision making was impacted by ASU context and team processes, rehabilitation service availability and access procedures, and the relationships between the acute and rehabilitation clinicians. Patients and families were not actively involved in the decision-making processes. CONCLUSIONS Post-stroke rehabilitation decision making in Queensland, Australia involves complex processes and compromise. Decisions are not based solely on patients' rehabilitation needs, and patients and families are not actively involved in the decision-making process. Mechanisms are required to streamline access procedures, and improve shared decision making with patients.IMPLICATIONS FOR REHABILITATIONReferral decision making for post-stroke rehabilitation is complex and not always based solely on patients' needs.Clear and straightforward access procedures and positive relationships between acute and rehabilitation clinicians have a positive impact on referral decision making.Stroke services should review their processes to ensure shared decision making is facilitated when patients require access to rehabilitation.
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Affiliation(s)
- Kerry Marnane
- School of Health and Rehabilitation Sciences, The University of Queensland, St Lucia, Australia.,Community and Oral Health Directorate, Metro North Hospital and Health Service, Herston,Australia
| | - Louise Gustafsson
- School of Health and Rehabilitation Sciences, The University of Queensland, St Lucia, Australia.,School of Allied Health Sciences, Griffith University, Nathan, Australia
| | - Sally Bennett
- School of Health and Rehabilitation Sciences, The University of Queensland, St Lucia, Australia
| | - Ingrid Rosbergen
- Conjoint Research Fellow Physiotherapy, STARS Education and Research Alliance, Surgical Treatment and Rehabilitation Service (STARS), The University of Queensland and Metro North Hospital and Health Service, Australia
| | - Rohan Grimley
- School of Medicine, Griffith University, Sunshine Coast, Australia
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Vélez-Guerrero MA, Callejas-Cuervo M, Mazzoleni S. Artificial Intelligence-Based Wearable Robotic Exoskeletons for Upper Limb Rehabilitation: A Review. SENSORS 2021; 21:s21062146. [PMID: 33803911 PMCID: PMC8003246 DOI: 10.3390/s21062146] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 03/04/2021] [Accepted: 03/06/2021] [Indexed: 12/14/2022]
Abstract
Processing and control systems based on artificial intelligence (AI) have progressively improved mobile robotic exoskeletons used in upper-limb motor rehabilitation. This systematic review presents the advances and trends of those technologies. A literature search was performed in Scopus, IEEE Xplore, Web of Science, and PubMed using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) methodology with three main inclusion criteria: (a) motor or neuromotor rehabilitation for upper limbs, (b) mobile robotic exoskeletons, and (c) AI. The period under investigation spanned from 2016 to 2020, resulting in 30 articles that met the criteria. The literature showed the use of artificial neural networks (40%), adaptive algorithms (20%), and other mixed AI techniques (40%). Additionally, it was found that in only 16% of the articles, developments focused on neuromotor rehabilitation. The main trend in the research is the development of wearable robotic exoskeletons (53%) and the fusion of data collected from multiple sensors that enrich the training of intelligent algorithms. There is a latent need to develop more reliable systems through clinical validation and improvement of technical characteristics, such as weight/dimensions of devices, in order to have positive impacts on the rehabilitation process and improve the interactions among patients, teams of health professionals, and technology.
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Affiliation(s)
- Manuel Andrés Vélez-Guerrero
- Software Research Group, Universidad Pedagógica y Tecnológica de Colombia, Tunja 150002, Colombia
- Correspondence: ; Tel.: +57-320-820-6832
| | - Mauro Callejas-Cuervo
- School of Computer Science, Universidad Pedagógica y Tecnológica de Colombia, Tunja 150002, Colombia;
| | - Stefano Mazzoleni
- Department of Electrical and Information Engineering, Polytechnic University of Bari, 70126 Bari, Italy;
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Oyesanya TO. Selection of discharge destination for patients with moderate-to-severe traumatic brain injury. Brain Inj 2020; 34:1222-1228. [PMID: 32715771 DOI: 10.1080/02699052.2020.1797172] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVES To investigate criteria acute care interdisciplinary providers use to select discharge destination for patients with traumatic brain injury (TBI). DESIGN Cross-sectional, exploratory survey study. METHODS Data were collected from interdisciplinary providers at a U.S. Level I trauma centre via electronic survey. We invited 199 providers to participate and 27 responded (13.5% response rate). Responses were received from physicians and physical, occupational, and speech therapists. RESULTS Findings showed variability in standard criteria and clinical judgment criteria providers used to select discharge destination for patients with TBI receiving acute care. There was limited agreement on standard criteria used to select discharge destination. Findings showed some agreement between providers on clinical judgment criteria used to select home as discharge destination and to prevent discharge to home. Most common clinical judgment criteria included therapists' recommendations on discharge location, patient's level of independence in activities of daily living, planned family support and ventilator dependence. Agreement on clinical judgment criteria became more limited when stratifying by discipline, frequency of patient care and experience. CONCLUSIONS Findings on clinical judgment criteria providers use to select acute care discharge destination for patients with TBI are inconclusive.
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Affiliation(s)
- Tolu O Oyesanya
- Duke University, School of Nursing , Durham, North Carolina, USA
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Lam Wai Shun P, Swaine B, Bottari C. Combining scoping review and concept analysis methodologies to clarify the meaning of rehabilitation potential after acquired brain injury. Disabil Rehabil 2020; 44:817-825. [PMID: 32551986 DOI: 10.1080/09638288.2020.1779825] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Purpose: Clinicians make judgments about patients' rehabilitation potential because it is considered by many as a prerequisite for referral to rehabilitation. However, the concept is rarely defined. This research aimed to clarify the concept of rehabilitation potential in the context of acquired brain injury patient referral to post-acute rehabilitation.Method: Literature search (conducted in Medline, CINAHL and Embase) and article selection followed a scoping review methodology while a concept analysis methodology guided data extraction and analysis.Results: Eighteen documents met inclusion criteria. Findings suggest four defining attributes of the concept. Rehabilitation potential (1) emerges from clinicians' interpretation of patient characteristics and is influenced by the health care environment, (2) involves the prediction of how a patient might improve with rehabilitation interventions, (3) is a multi-level concept and (4) can change over time. The most critical consequence to assessing a patient's rehabilitation potential is the impact on the patient's opportunity to access post-acute rehabilitation services.Conclusion: Rehabilitation potential is a concept rooted in clinical reasoning. We propose an operational definition and a conceptual model to provide a solid foundation for future research to advance policy and clinical decision-making regarding equitable access to post-acute rehabilitation.IMPLICATIONS FOR REHABILITATIONRehabilitation potential is a concept rooted in clinical reasoning and emerges from clinicians' prediction of how a patient might improve with rehabilitation interventions.Rehabilitation potential is not a dichotomous concept but a multi-level concept with each level falling along a continuum.It may be inaccurate/inappropriate to definitively state that a patient has or does not have rehabilitation potential, as patients may demonstrate varying levels of rehabilitation potential.Rehabilitation potential can change with time requiring re-assessment to readjust recommendations accordingly with regards to appropriate rehabilitation interventions at any given time.
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Affiliation(s)
- Priscilla Lam Wai Shun
- School of rehabilitation, Faculty of Medicine, Université de Montréal, Montréal, Canada.,Centre for Interdisciplinary Research in Rehabilitation of Greater Montreal (CRIR), Montréal, Canada
| | - Bonnie Swaine
- School of rehabilitation, Faculty of Medicine, Université de Montréal, Montréal, Canada.,Centre for Interdisciplinary Research in Rehabilitation of Greater Montreal (CRIR), Montréal, Canada
| | - Carolina Bottari
- School of rehabilitation, Faculty of Medicine, Université de Montréal, Montréal, Canada.,Centre for Interdisciplinary Research in Rehabilitation of Greater Montreal (CRIR), Montréal, Canada
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Callisaya ML, Purvis T, Lawler K, Brodtmann A, Cadilhac DA, Kilkenny MF. Dementia is Associated With Poorer Quality of Care and Outcomes After Stroke: An Observational Study. J Gerontol A Biol Sci Med Sci 2020; 76:851-858. [DOI: 10.1093/gerona/glaa139] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
To determine whether preexisting dementia is associated with poorer quality of care and outcomes after stroke in the acute hospital phase.
Method
This was a retrospective analysis of pooled data from the Australian Stroke Foundation national audit conducted in 2015 and 2017. Dementia status was obtained from the medical records. Processes of care to assess quality included: stroke unit care, time-dependent therapy, nursing/allied health assessments, and preparation for discharge. Outcomes included in-hospital complications, independence on discharge, and destination. Logistic regression was used to examine associations between dementia status and processes of care. Multilevel random effects logistic regression, with level defined as hospital, was used to examine associations between dementia status and outcomes.
Results
There were 683/7,070 (9.7%) audited patients with dementia included. Patients with dementia were less likely to be treated in stroke units (58.3% vs 70.6%), receive thrombolysis if an ischemic stroke (5.8% vs 11.1%), have access within 48 hours to physiotherapy (56.4% vs 69.7%) or occupational therapy (46.8% vs 55.6%), see a dietitian if problems with nutrition (64.4% vs 75.9%), or have mood assessed (2.6% vs 12.3%). Patients with dementia were more likely to receive no rehabilitation (adjusted odds ratio 1.88, 95% confidence interval 1.25, 2.83) and be discharged to residential care (adjusted odds ratio 2.36, 95% confidence interval 1.50, 3.72).
Conclusion
People with dementia received poorer quality of care and had worse outcomes after stroke. Our findings raise questions regarding equity and the need for better understanding of why the quality of care differs after stroke for people with dementia.
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Affiliation(s)
- Michele L Callisaya
- Peninsula Clinical School, Central Clinical School, Monash University, Melbourne, Victoria, Australia
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia
| | - Tara Purvis
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia
| | - Katherine Lawler
- Wicking Dementia Research and Education Centre, College of Health and Medicine, University of Tasmania, Hobart, Australia
| | - Amy Brodtmann
- Florey Institute of Neuroscience and Mental Health, Heidelberg, University of Melbourne, Victoria, Australia
| | - Dominique A Cadilhac
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia
- Florey Institute of Neuroscience and Mental Health, Heidelberg, University of Melbourne, Victoria, Australia
| | - Monique F Kilkenny
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia
- Florey Institute of Neuroscience and Mental Health, Heidelberg, University of Melbourne, Victoria, Australia
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Gittins M, Lugo-Palacios DG, Paley L, Bray B, Bowen A, Vail A, Gannon B, Tyson S. How do patients pass through stroke services? Identifying stroke care pathways using national audit data. Clin Rehabil 2020; 34:698-709. [PMID: 32141324 PMCID: PMC7443957 DOI: 10.1177/0269215520907654] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective: To map and describe how patients pass through stroke services. Methods: Data from 94,905 stroke patients (July 2013–July 2015) who were still inpatients 72 hours after hospital admission were extracted from a national stroke register and were used to identify the routes patients took through hospital and community stroke services. We sought to categorize these routes through iterative consultations with clinical experts and to describe patient characteristics, therapy provision, outcomes and costs within each category. Results: We identified 874 routes defined by the type of admitting stroke team and subsequent transfer history. We consolidated these into nine distinct routes and further summarized these into three overlapping ‘pathways’ that accounted for 99% of the patients. These were direct discharge (44%), community rehabilitation (47%) and inpatient transfer (19%) with 12% of the patients receiving both inpatient transfer and community rehabilitation. Patients with the mildest and most severe strokes were more likely to follow the direct discharge pathway. Those perceived to need most therapy were more likely to follow the inpatient transfer pathway. Costs were lowest and mortality was highest for patients on the direct discharge pathway. Outcomes were best for patients on the community rehabilitation pathway and costs were highest where patients underwent inpatient transfers. Conclusion: Three overarching stroke care pathways were identified which differ according to patient characteristics, therapy needs and outcomes. This pathway mapping provides a benchmark to develop and plan clinical services, and for future research.
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Affiliation(s)
- Matthew Gittins
- Centre for Biostatistics, The University of Manchester, Manchester, UK.,Manchester Academy for Health Sciences, Manchester, UK
| | - David G Lugo-Palacios
- Manchester Academy for Health Sciences, Manchester, UK.,Manchester Centre for Health Economics, The University of Manchester, Manchester, UK
| | - Lizz Paley
- Sentinel Stroke National Audit Programme, King's College London, London, UK
| | - Benjamin Bray
- Sentinel Stroke National Audit Programme, King's College London, London, UK
| | - Audrey Bowen
- Manchester Academy for Health Sciences, Manchester, UK.,Division of Neuroscience & Experimental Psychology, The University of Manchester, Manchester, UK
| | - Andy Vail
- Centre for Biostatistics, The University of Manchester, Manchester, UK.,Manchester Academy for Health Sciences, Manchester, UK
| | - Brenda Gannon
- School of Economics, The University of Queensland, Brisbane, QLD, Australia
| | - Sarah Tyson
- Manchester Academy for Health Sciences, Manchester, UK.,Division of Nursing, Midwifery & Social Work, The University of Manchester, Manchester, UK
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Gittins M, Lugo-Palacios D, Vail A, Bowen A, Paley L, Bray B, Gannon B, Tyson SF. Delivery, dose, outcomes and resource use of stroke therapy: the SSNAPIEST observational study. HEALTH SERVICES AND DELIVERY RESEARCH 2020. [DOI: 10.3310/hsdr08170] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background
Therapy is key to effective stroke care, but many patients receive little.
Objectives
To understand how stroke therapy is delivered in England, Wales and Northern Ireland, and which factors are associated with dose, outcome and resource use.
Design
Secondary analysis of the Sentinel Stroke National Audit Programme, using standard descriptive statistics and multilevel mixed-effects regression models, while adjusting for all known and measured confounders.
Setting
Stroke services in England, Wales and Northern Ireland.
Participants
A total of 94,905 adults admitted with stroke, who remained an inpatient for > 72 hours.
Results
Routes through stroke services were highly varied (> 800), but four common stroke pathways emerged. Seven distinct impairment-based patient subgroups were characterised. The average amount of therapy was very low. Modifiable factors associated with the average amount of inpatient therapy were type of stroke team, timely therapy assessments, staffing levels and model of therapy provision. More (of any type of) therapy was associated with shorter length of stay, less resource use and lower mortality. More occupational therapy, speech therapy and psychology were also associated with less disability and institutionalisation. Large amounts of physiotherapy were associated with greater disability and institutionalisation.
Limitations
Use of observational data does not infer causation. All efforts were made to adjust for all known and measured confounding factors but some may remain. We categorised participants using the National Institutes of Health Stroke Scale, which measures a limited number of impairments relatively crudely, so mild or rare impairments may have been missed.
Conclusions
Stroke patients receive very little therapy. Modifiable organisational factors associated with greater amounts of therapy were identified, and positive associations between amount of therapy and outcome were confirmed. The reason for the unexpected associations between large amounts of physiotherapy, disability and institutionalisation is unknown. Prospective work is urgently needed to investigate further. Future work needs to investigate (1) prospectively, the association between physiotherapy and outcome; (2) the optimal amount of therapy to provide for different patient groups; (3) the most effective way of organising stroke therapy/rehabilitation services, including service configuration, staffing levels and working hours; and (4) how to reduce unexplained variation in resource use.
Funding
This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 17. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Matthew Gittins
- Centre for Biostatistics, School of Health Sciences, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - David Lugo-Palacios
- Centre for Health Economics, School of Health Sciences, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Andy Vail
- Centre for Biostatistics, School of Health Sciences, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Audrey Bowen
- Division of Neuroscience and Experimental Psychology, School of Biological Sciences, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Lizz Paley
- Sentinel Stroke National Audit Programme, Department of Population Health Sciences, King’s College London, London, UK
| | - Benjamin Bray
- Sentinel Stroke National Audit Programme, Department of Population Health Sciences, King’s College London, London, UK
| | - Brenda Gannon
- School of Economics, The University of Queensland, Brisbane, QLD, Australia
| | - Sarah F Tyson
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
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Labberton AS, Barra M, Rønning OM, Thommessen B, Churilov L, Cadilhac DA, Lynch EA. Patient and service factors associated with referral and admission to inpatient rehabilitation after the acute phase of stroke in Australia and Norway. BMC Health Serv Res 2019; 19:871. [PMID: 31752874 PMCID: PMC6873491 DOI: 10.1186/s12913-019-4713-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Accepted: 11/05/2019] [Indexed: 11/25/2022] Open
Abstract
Background Unequal access to inpatient rehabilitation after stroke has been reported. We sought to identify and compare patient and service factors associated with referral and admission to an inpatient rehabilitation facility (IRF) after acute hospital care for stroke in two countries with publicly-funded healthcare. Methods We compared two cohorts of stroke patients admitted consecutively to eight acute public hospitals in Australia in 2013–2014 (n = 553), and to one large university hospital in Norway in 2012–2013 (n = 723). Outcomes were: referral to an IRF; admission to an IRF if referred. Logistic regression models were used to identify and compare factors associated with each outcome. Results Participants were similar in both cohorts: mean age 73 years, 40–44% female, 12–13% intracerebral haemorrhage, ~ 77% mild stroke (National Institutes of Health Stroke Scale < 8). Services received during the acute admission differed (Australia vs. Norway): stroke unit treatment 82% vs. 97%, physiotherapy 93% vs. 79%, occupational therapy 83% vs. 77%, speech therapy 78% vs. 13%. Proportions referred to an IRF were: 48% (Australia) and 37% (Norway); proportions admitted: 35% (Australia) and 28% (Norway). Factors associated with referral in both countries were: moderately severe stroke, receiving stroke unit treatment or allied health assessments during the acute admission, living in the community, and independent pre-stroke mobility. Directions of associations were mostly congruent; however younger patients were more likely to be referred and admitted in Norway only. Models for admission among patients referred identified few associated factors suggesting that additional factors were important for this stage of the process. Conclusions Similar factors were associated with referral to inpatient rehabilitation after acute stroke in both countries, despite differing service provision and access rates. Assuming it is not feasible to provide inpatient rehabilitation to all patients following stroke, the criteria for the selection of candidates need to be understood to address unwanted biases.
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Affiliation(s)
- Angela S Labberton
- Health Services Research Unit, Akershus University Hospital, PO Box 1000, 1478, Lørenskog, Norway. .,Institute of Clinical Medicine, University of Oslo, Oslo, Norway.
| | - Mathias Barra
- Health Services Research Unit, Akershus University Hospital, PO Box 1000, 1478, Lørenskog, Norway.,Centre for Connected Care, Oslo University Hospital, Oslo, Norway
| | - Ole Morten Rønning
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Department of Neurology, Akershus University Hospital, Lørenskog, Norway
| | - Bente Thommessen
- Department of Neurology, Akershus University Hospital, Lørenskog, Norway
| | - Leonid Churilov
- Department of Medicine (Austin Health), Melbourne Medical School, The University of Melbourne, Heidelberg, Australia.,NHMRC Centre of Research Excellence in Stroke Rehabilitation and Brain Recovery, Melbourne and Newcastle, Melbourne, Australia.,Stroke Division, The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Heidelberg, Australia
| | - Dominique A Cadilhac
- NHMRC Centre of Research Excellence in Stroke Rehabilitation and Brain Recovery, Melbourne and Newcastle, Melbourne, Australia.,Stroke Division, The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Heidelberg, Australia.,Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, Australia
| | - Elizabeth A Lynch
- NHMRC Centre of Research Excellence in Stroke Rehabilitation and Brain Recovery, Melbourne and Newcastle, Melbourne, Australia.,Stroke Division, The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Heidelberg, Australia.,Adelaide Nursing School, University of Adelaide, Adelaide, Australia
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Longley V, Peters S, Swarbrick C, Rhodes S, Bowen A. Does pre-existing cognitive impairment impact on amount of stroke rehabilitation received? An observational cohort study. Clin Rehabil 2019; 33:1492-1502. [PMID: 31020850 PMCID: PMC6716203 DOI: 10.1177/0269215519843984] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To examine whether stroke survivors in inpatient rehabilitation with pre-existing cognitive impairment receive less therapy than those without. DESIGN Prospective observational cohort. SETTING Four UK inpatient stroke rehabilitation units. PARTICIPANTS A total of 139 stroke patients receiving rehabilitation, able to give informed consent/had an individual available to act as personal consultee. In total, 33 participants were categorized with pre-existing cognitive impairment based on routine documentation by clinicians and 106 without. MEASURES Number of inpatient therapy sessions received during the first eight weeks post-stroke, referral to early supported discharge, and length of stay. RESULTS On average, participants with pre-existing cognitive impairment received 40 total physiotherapy and occupational therapy sessions compared to 56 for those without (mean difference = 16.0, 95% confidence interval (CI) = 2.9, 29.2), which was not fully explained by adjusting for potential confounders (age, sex, National Institutes of Health Stroke Scale (NIHSS), and pre-stroke modified Rankin Scale (mRS)). While those with pre-existing cognitive impairment received nine fewer single-discipline physiotherapy sessions (95% CI = 3.7, 14.8), they received similar amounts of single-discipline occupational therapy, psychology, and speech and language therapy; two more non-patient-facing occupational therapy sessions (95% CI = -4.3, -0.6); and nine fewer patient-facing occupational therapy sessions (95% CI = 3.5, 14.9). There was no evidence to suggest they were discharged earlier, but of the 85 participants discharged within eight weeks, 8 (42%) with pre-existing cognitive impairment were referred to early supported discharge compared to 47 (75%) without. CONCLUSION People in stroke rehabilitation with pre-existing cognitive impairments receive less therapy than those without, but it remains unknown whether this affects outcomes.
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Affiliation(s)
- Verity Longley
- 1 Division of Neuroscience and Experimental Psychology, MAHSC, The University of Manchester, Manchester, UK.,2 CLAHRC Greater Manchester, Manchester, UK
| | - Sarah Peters
- 3 Manchester Centre for Health Psychology, MAHSC, The University of Manchester, Manchester, UK
| | | | - Sarah Rhodes
- 2 CLAHRC Greater Manchester, Manchester, UK.,5 Centre for Biostatistics, MAHSC, The University of Manchester, Manchester, UK
| | - Audrey Bowen
- 1 Division of Neuroscience and Experimental Psychology, MAHSC, The University of Manchester, Manchester, UK.,2 CLAHRC Greater Manchester, Manchester, UK
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