Redesigning Rural Acute Stroke Care: A Person-Centered Approach

Stroke service delivery in rural areas in Australia lacks evidence-based, best practice care protocols as a result of limited resources and opportunity. Healthcare redesign is an approach to improving health services by understanding barriers and enablers to service provision and work with users to develop solutions for improvement. This research aimed to qualitatively evaluate stroke care in rural Tasmania using a person-centered approach, as part of a larger healthcare redesign initiative to improve acute stroke care. Semi-structured interviews, aimed at gaining insight into experiences of healthcare staff and users, were conducted. Thematic analysis revealed three global themes (communication, holistic care, and resourcing) that demonstrated some consistency between healthcare staff and user experience, highlighting that some needs and expectations were not being met. Results of this experiential study provide important perspectives for delivering needs-based improvements in service provision for acute stroke care. Overall, this study showed that systems of stroke care in rural areas could be improved by utilizing a redesign approach including healthcare staff and users in the development of solutions for health service improvement.

Information provision for stroke survivors and their carers

BACKGROUND

A stroke is a sudden loss of brain function caused by lack of blood supply. Stroke can lead to death or physical and cognitive impairment and can have long lasting psychological and social implications. Research shows that stroke survivors and their families are dissatisfied with the information provided and have a poor understanding of stroke and associated issues.

OBJECTIVES

The primary objective is to assess the effects of active or passive information provision for stroke survivors (people with a clinical diagnosis of stroke or transient ischaemic attack (TIA)) or their identified carers. The primary outcomes are knowledge about stroke and stroke services, and anxiety.

SEARCH METHODS

We updated our searches of the Cochrane Stroke Group Specialised Register on 28 September 2020 and for the following databases to May/June 2019: the Cochrane Central Register of Controlled Trials (CENTRAL; 2019, Issue 5) and the Cochrane Database of Systematic Reviews (CDSR; 2019, Issue 5) in the Cochrane Library (searched 31 May 2019), MEDLINE Ovid (searched 2005 to May week 4, 2019), Embase Ovid (searched 2005 to 29 May 2019), CINAHL EBSCO (searched 2005 to 6 June 2019), and five others. We searched seven study registers and checked reference lists of reviews.

SELECTION CRITERIA

Randomised trials involving stroke survivors, their identified carers or both, where an information intervention was compared with standard care, or where information and another therapy were compared with the other therapy alone, or where the comparison was between active and passive information provision without other differences in treatment.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial eligibility and risk of bias, and extracted data. We categorised interventions as either active information provision or passive information provision: active information provision included active participation with subsequent opportunities for clarification and reinforcement; passive information provision provided no systematic follow-up or reinforcement procedure. We stratified analyses by this categorisation. We used GRADE methods to assess the overall certainty of the evidence.

MAIN RESULTS

We have added 12 new studies in this update. This review now includes 33 studies involving 5255 stroke-survivor and 3134 carer participants. Twenty-two trials evaluated active information provision interventions and 11 trials evaluated passive information provision interventions. Most trials were at high risk of bias due to lack of blinding of participants, personnel, and outcome assessors where outcomes were self-reported. Fewer than half of studies were at low risk of bias regarding random sequence generation, concealment of allocation, incomplete outcome data or selective reporting. The following estimates have low certainty, based on the quality of evidence, unless stated otherwise. Accounting for certainty and size of effect, analyses suggested that for stroke survivors, active information provision may improve stroke-related knowledge (standardised mean difference (SMD) 0.41, 95% confidence interval (CI) 0.17 to 0.65; 3 studies, 275 participants), may reduce cases of anxiety and depression slightly (anxiety risk ratio (RR) 0.85, 95% CI 0.68 to 1.06; 5 studies, 1132 participants; depression RR 0.83, 95% CI 0.68 to 1.01; 6 studies, 1315 participants), may reduce Hospital Anxiety and Depression Scale (HADS) anxiety score slightly, (mean difference (MD) -0.73, 95% CI -1.10 to -0.36; 6 studies, 1171 participants), probably reduces HADS depression score slightly (MD (rescaled from SMD) -0.8, 95% CI -1.27 to -0.34; 8 studies, 1405 participants; moderate-certainty evidence), and may improve each domain of the World Health Organization Quality of Life assessment short-form (WHOQOL-BREF) (physical, MD 11.5, 95% CI 7.81 to 15.27; psychological, MD 11.8, 95% CI 7.29 to 16.29; social, MD 5.8, 95% CI 0.84 to 10.84; environment, MD 7.0, 95% CI 3.00 to 10.94; 1 study, 60 participants). No studies evaluated positive mental well-being. For carers, active information provision may reduce HADS anxiety and depression scores slightly (MD for anxiety -0.40, 95% CI -1.51 to 0.70; 3 studies, 921 participants; MD for depression -0.30, 95% CI -1.53 to 0.92; 3 studies, 924 participants), may result in little to no difference in positive mental well-being assessed with Bradley's well-being questionnaire (MD -0.18, 95% CI -1.34 to 0.98; 1 study, 91 participants) and may result in little to no difference in quality of life assessed with a 0 to 100 visual analogue scale (MD 1.22, 95% CI -7.65 to 10.09; 1 study, 91 participants). The evidence is very uncertain (very low certainty) for the effects of active information provision on carers' stroke-related knowledge, and cases of anxiety and depression. For stroke survivors, passive information provision may slightly increase HADS anxiety and depression scores (MD for anxiety 0.67, 95% CI -0.37 to 1.71; MD for depression 0.39, 95% CI -0.61 to 1.38; 3 studies, 227 participants) and the evidence is very uncertain for the effects on stroke-related knowledge, quality of life, and cases of anxiety and depression. For carers, the evidence is very uncertain for the effects of passive information provision on stroke-related knowledge, and HADS anxiety and depression scores. No studies of passive information provision measured carer quality of life, or stroke-survivor or carer positive mental well-being.

AUTHORS' CONCLUSIONS

Active information provision may improve stroke-survivor knowledge and quality of life, and may reduce anxiety and depression. However, the reductions in anxiety and depression scores were small and may not be important. In contrast, providing information passively may slightly worsen stroke-survivor anxiety and depression scores, although again the importance of this is unclear. Evidence relating to carers and to other outcomes of passive information provision is generally very uncertain. Although the best way to provide information is still unclear, the evidence is better for strategies that actively involve stroke survivors and carers and include planned follow-up for clarification and reinforcement.

Satisfaction with Stroke Care Among Patients with Alzheimer's and Other Dementias: A Swedish Register-Based Study

Background:

Patient dissatisfaction with stroke care is associated with poor self-rated health and unmet care needs. Dementia patients’ satisfaction with stroke care is understudied.

Objective:

To compare satisfaction with stroke care in patients with and without dementia.

Methods:

This longitudinal cohort study included 5,932 dementia patients (2007–2017) who suffered a first stroke after dementia diagnosis and 39,457 non-dementia stroke patients (2007–2017). Data were retrieved by linking the Swedish Stroke Register, the Swedish Dementia Register, the Swedish National Patient Register, and the Swedish Prescribed Drug Register. The association between dementia and satisfaction was analyzed with ordinal logistic regression.

Results:

When dementia patients answered themselves, they reported significantly lower odds of satisfaction with acute stroke care (OR: 0.71; 95% CI: 0.60–0.85), healthcare staff’s attitude (OR: 0.79; 95% CI: 0.66–0.96), communication with doctors (OR: 0.78; 95% CI: 0.66–0.92), stroke information (OR: 0.62; 95% CI: 0.52–0.74); but not regarding inpatient rehabilitation (OR: 0.93; 95% CI: 0.75–1.16), or outpatient rehabilitation (OR: 0.93; 95% CI: 0.73–1.18). When patients answered with caregivers’ help, the association between dementia status and satisfaction remained significant in all items. Subgroup analyses showed that patients with Alzheimer’s disease and mixed dementia reported lower odds of satisfaction with acute care and healthcare staff’s attitude when they answered themselves.

Conclusion:

Patients with dementia reported lower satisfaction with stroke care, revealing unfulfilled care needs among dementia patients, which are possibly due to different (or less) care, or because dementia patients require adaptations to standard care.

The adaptation and validation of the satisfaction with stroke care questionnaire (Homesat) (SASC10-My™) for use in public primary healthcare facilities caring for long- term stroke survivors residing at home in the community

Background

Satisfaction with post stroke services would assist stakeholders in addressing gaps in service delivery. Tools used to evaluate satisfaction with stroke care services need to be validated to match healthcare services provided in each country. Studies on satisfaction with post discharge stroke care delivery in low- and middle-income countries (LMIC) are scarce, despite knowledge that post stroke care delivery is fragmented and poorly coordinated. This study aims to modify and validate the HomeSat subscale of the Dutch Satisfaction with Stroke Care-19 (SASC-19) questionnaire for use in Malaysia and in countries with similar public healthcare services in the region.

Methods

The HomeSat subscale of the Dutch SASC-19 questionnaire (11 items) underwent back-to-back translation to produce a Malay language version. Content validation was done by Family Medicine Specialists involved in community post-stroke care. Community social support services in the original questionnaire were substituted with equivalent local services to ensure contextual relevance. Internal consistency reliability was determined using Cronbach alpha. Exploratory factor analysis was done to validate the factor structure of the Malay version of the questionnaire (SASC10-My™). The SASC10-My™ was then tested on 175 post-stroke patients who were recruited at ten public primary care healthcentres across Peninsular Malaysia, in a trial-within a trial study.

Results

One item from the original Dutch SASC19 (HomeSat) was dropped. Internal consistency for remaining 10 items was high (Cronbach alpha 0.830). Exploratory factor analysis showed the SASC10-My™ had 2 factors: discharge transition and social support services after discharge. The mean total score for SASC10-My™ was 10.74 (SD 7.33). Overall, only 18.2% were satisfied with outpatient stroke care services (SASC10-My™ score ≥ 20). Detailed analysis revealed only 10.9% of respondents were satisfied with discharge transition services, while only 40.9% were satisfied with support services after discharge.

Conclusions

The SASC10-My™ questionnaire is a reliable and valid tool to measure caregiver or patient satisfaction with outpatient stroke care services in the Malaysian healthcare setting. Studies linking discharge protocol patterns and satisfaction with outpatient stroke care services should be conducted to improve care delivery and longer-term outcomes.

Trial registration

No.: ACTRN12616001322426 (Registration Date: 21st September 2016.

Factors influencing the amount of therapy received during inpatient stroke care: an analysis of data from the UK Sentinel Stroke National Audit Programme

OBJECTIVES

To understand why most stroke patients receive little therapy. We investigated the factors associated with the amount of stroke therapy delivered.

METHODS

Data regarding adults admitted to hospital with stroke for at least 72 hours (July 2013-July 2015) were extracted from the UK's Sentinel Stroke National Audit Programme. Descriptive statistics and multilevel mixed effects regression models explored the factors that influenced the amount of therapy received while adjusting for confounding.

RESULTS

Of the 94,905 patients in the study cohort (mean age: 76 (SD: 13.2) years, 78% had a mild or moderate severity stroke. In all, 92% required physiotherapy, 87% required occupational therapy, 57% required speech therapy but only 5% were considered to need psychology. The average amount of therapy ranged from 2 minutes (psychology) to 14 minutes (physiotherapy) per day of inpatient stay. Unmodifiable characteristics (such as stroke severity) dominated the variation in the amount of therapy. However important, modifiable organizational factors were the day and time of admission, type of stroke team, timely therapy assessments, therapy and nursing staffing levels (qualified and support staff), and presence of weekend or early supported discharge services.

CONCLUSION

The amount of stroke therapy is associated with unmodifiable patient-related characteristics and modifiable organizational factors in that more therapy was associated with higher therapy and nurse staffing levels, specialist stroke rehabilitation services, timely therapy assessments, and the presence of weekend and early discharge services.

Delivery, dose, outcomes and resource use of stroke therapy: the SSNAPIEST observational study

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.

Systematic review of patient-reported measures of treatment burden in stroke

OBJECTIVES

Treatment burden is the workload of healthcare for people with long-term conditions (LTC) and its impact on well-being. A method of measurement is required to identify those experiencing high burden and to measure intervention efficacy. Our aim was to identify, examine and appraise validated patient-reported measures (PRMs) of treatment burden in stroke. Here, stroke serves as an exemplar LTC of older adults.

DESIGN

A systematic review of published studies that describe the development and validation of PRMs measuring treatment burden in stroke survivors.

DATA SOURCES

We searched MEDLINE, Embase, CINAHL and PsycINFO electronic databases.

ELIGIBILITY CRITERIA

Studies published between January 2000 and 12 April 2019 inclusive, in English language. No restrictions were set based on clinical setting or geographical location.

DATA EXTRACTION AND SYNTHESIS

Screening, data extraction and quality appraisal were conducted by two independent reviewers. Content of the PRMs was compared with a published taxonomy of treatment burden. Quality appraisal was conducted using International Society for Quality of Life Research standards.

RESULTS

From 3993 articles, 6 relevant PRMs were identified: 3 were stroke specific: The Satisfaction with Stroke Care questionnaire; The Stroke Patient-Reported Outcome Measure and The Barriers to Physical Activity after Stroke scale. Three were generic but validated in stroke: The WHO Quality of Life-100; The Patient's Questionnaire on Participation in Discharge Planning and The Chao Perception of Continuity scale. None comprehensively measured treatment burden. Examples of omitted burdens included developing coping strategies, managing finances and returning to driving. The most notable issue regarding quality appraisal was that three PRMs lacked any underpinning qualitative research relevant to the sample.

CONCLUSION

There is a need to develop a comprehensive PRM of treatment burden for use in stroke, with potential for use in other older populations.

Prevention of mood disorder after stroke: a randomised controlled trial of problem solving therapy versus volunteer support

BACKGROUND

Mood disorder after stroke is common but drug and psychosocial treatments have been assessed with disappointing results. Preventing mood disorder from developing in the first place could be a better approach and might reduce the need for pharmacotherapy in this predominantly older patient group. We used a brief problem-solving therapy and evaluated its effect in reducing mood disorder in the 12 months after stroke.

METHODS

A 3-group, parallel, randomised controlled trial. Four hundred fifty patients with stroke were randomised within 1 month of hospital admission to problem-solving therapy from a psychiatric nurse, non-specific support given by volunteers or treatment-as-usual. Follow up took place at 6 and 12 months after stroke. Standardised measures of mood (Present State Examination, GHQ-28), cognitive state (mini-mental state examination) and function (Barthel ADL index, Frenchay Activities Index) were taken at baseline, 6 and 12 months after randomisation. Satisfaction with care was recorded at follow up.

RESULTS

At 6 months, all psychological and activity measures favoured problem-solving therapy. At 12 months, patients in the problem-solving therapy group had significantly lower GHQ-28 scores and lower median Present State Examination symptom scores. There were no statistically significant differences in activity. The problem-solving therapy group were more satisfied with some aspects of care.

CONCLUSIONS

The results are encouraging and suggest it is possible to prevent mood disorder in stroke patients using a psychological intervention. The differences between the groups at 12 months may indicate a sustained impact of psychological therapies, by comparison with non-specific support.

TRIAL REGISTRATION

ISRCTN: ISRCTN33773710 Registered: 23/01/2004 (Retrospectively).

Surviving a stroke in South Africa: outcomes of home-based care in a low-resource rural setting

Background: Little is known of stroke outcomes in low- and middle-income countries with limited formal stroke rehabilitation services and of homebased-stroke services delivered within the primary health care (PHC) context by community health workers (CHWs). Objectives: To describe and analyze the outcomes of patients with stroke from a rural PHC setting in the Western Cape, South Africa. Methods: In a longitudinal survey, 93 stroke patients, referred to home and community-based care services (HCBC) between June 2015 and December 2017, were assessed at baseline, one month and three months. Changes in function (Barthel Index (BI)), caregiver strain (Caregiver Strain Index (CSI)), impact of environmental factors and satisfaction with stroke care were measured. Results: HCBC was delayed, fragmented and brief (median session duration 20 minutes (IQR 15.0-30.0)). Although function improved significantly, dependence remained high: median BI score changed from 40.0 (IQR 15.0-70.0) to 62.5 (IQR 30.0-81.25) (p = .019). A third (33.0% (30/91)) of caregivers initially experienced strain and the median CSI score remained 3.0 (IQR 0.0-7.0) (p = .672). Overall, patient and caregiver satisfaction with HCBC was low with only 46.9% (31/66) of caregivers and 17.4% (12/69) of patients satisfied with all aspects of care. Only 47.6% of assistive product needs were met. Environmental factors negatively impacted on patient function and caregiving. Conclusions: Clinical practice pathways and referral guidelines should be developed for the HCBC platform. Specific training of CHWs, focusing on how to educate, support and train family caregivers, provide assistive devices and refer to health services is needed.

Intensive Rehabilitation Therapy Following Brain Tumor Surgery: A Pilot Study of Effectiveness and Long-Term Satisfaction

OBJECTIVE

To evaluate the effectiveness of intensive rehabilitation to support recovery of neurological function after brain tumor surgery and assess long-term satisfaction.

METHODS

This retrospective study included patients with neurological impairment after brain tumor surgery who underwent intensive rehabilitation therapy between December 2013 and May 2017. To assess effectiveness of rehabilitation, functional outcomes (motor, cognition, and activities of daily living [ADL]) were compared between brain tumor group and a control group enrolling stroke patients who received equivalent rehabilitation during the study period. Long-term satisfaction with rehabilitation was evaluated by surveying family caregivers.

RESULTS

This study included 21 patients with benign brain tumor, 14 with malignant brain tumor, and 108 with stroke. Significant and similar improvement in motor, cognition, and ADL function were noted in both the brain tumor group and the stroke group. Malignancy status did not influence the extent of functional improvement. According to medical records and surveys, 9 (69.2%) patients with malignant tumor and 2 (11.8%) with benign tumor had expired by the time of the survey. Most family caregivers confirmed that rehabilitation was effective for functional improvement (>60%), expressing overall satisfaction and stating they would recommend such therapy to patients with similar conditions (approximately 70%).

CONCLUSION

Intensive rehabilitation may help promote functional improvement following brain tumor surgery regardless of malignancy compared with stroke patients. Family caregivers expressed overall satisfaction with rehabilitation at long-term follow-up. These findings support the provision of intensive rehabilitation therapy for neurologic function recovery following brain tumor surgery.

Stroke survivor attitudes toward, and motivations for, considering experimental stem cell treatments

Purpose: Interest in stem cell treatments is increasing among some patient groups, but it is unclear whether this holds true for stroke survivors. This study examined stroke survivor attitudes toward stem cell treatments and identified a number of variables that may increase the likelihood that patients will consider these treatments.Methods: Adult stroke survivors (N = 183) were recruited (stroke advocacy/support groups, outpatient register) for a cross-sectional study. Attitudes to stem cell treatments were surveyed, guided by the Theory of Planned Behavior. Demographic information was collected, and a number of self-report medical, cognitive and psychological measures completed.Results: Twenty-five percent (n = 46) of respondents indicated they were considering undergoing stem cell treatments, although most were unsure about the safety/effectiveness and accessibility/affordability. Stroke survivors with positive attitudes toward stem cell treatments, longer post-stroke intervals, poorer physical functioning, younger age, and greater perceived caregiver burden were more likely to be considered experimental treatments (odds ratios = 1.22, 1.08, 0.95, 0.96, 1.07; respectively).Conclusions: Stroke survivors may consider undergoing experimental stem cell treatments despite uncertainty regarding the risks/benefits. Clinicians should be mindful of the factors that may increase the likelihood of patients considering these treatments and intervene, where appropriate, to clarify any misconceptions regarding the medical/financial risks.IMPLICATION FOR REHABILITATIONStem cell treatments offer a new focus for reducing stroke-related disability, although their safety and effectiveness have yet to be established.Despite uncertainty regarding the medical risks and benefits associated with stem cell injections, stroke survivors may still consider undergoing treatment in private, unregulated clinics.A number of factors, including younger age, longer post-stroke interval, poorer physical functioning, and perceived caregiver burden may place stroke survivors at an increased risk of considering these treatments.Clinicians should endeavor to educate stroke survivors regarding the risks and benefits of these experimental treatments and clarify any misconceptions, in order to reduce the likelihood that they will consider these as-yet unproven treatments.

Quality and readability of English-language internet information for aphasia

PURPOSE

Little is known about the quality and readability of treatment information in specific neurogenic disorders, such as aphasia. The purpose of this study was to assess quality and readability of English-language Internet information available for aphasia treatment.

METHOD

Forty-three aphasia treatment websites were aggregated using five different country-specific search engines. Websites were then analysed using quality and readability assessments. Statistical calculations were employed to examine website ratings, differences between website origin and quality and readability scores, and correlations between readability instruments.

RESULT

Websites exhibited low quality with few websites obtaining Health On the Net (HON) certification or clear, thorough information as measured by the DISCERN. Regardless of website origin, readability scores were also poor. Approximate educational levels required to comprehend information on aphasia treatment websites ranged from 13 to 16 years of education. Significant differences were found between website origin and readability measures with higher levels of education required to understand information on websites of non-profit organisations.

CONCLUSION

Current aphasia treatment websites were found to exhibit low levels of quality and readability, creating potential accessibility problems for people with aphasia and significant others. Websites including treatment information for aphasia must be improved in order to increase greater information accessibility.

Evaluation of reconfigurations of acute stroke services in different regions of England and lessons for implementation: a mixed-methods study

Background

Centralising acute stroke services is an example of major system change (MSC). ‘Hub and spoke’ systems, consisting of a reduced number of services providing acute stroke care over the first 72 hours following a stroke (hubs), with a larger number of services providing care beyond this phase (spokes), have been proposed to improve care and outcomes.

Objective

To use formative evaluation methods to analyse reconfigurations of acute stroke services in different regions of England and to identify lessons that will help to guide future reconfigurations, by studying the following contrasting cases: (1) London (implemented 2010) – all patients eligible for Hyperacute Stroke Units (HASUs); patients admitted 24 hours a day, 7 days a week; (2) Greater Manchester A (GMA) (2010) – only patients presenting within 4 hours are eligible for HASU treatment; one HASU operated 24/7, two operated from 07.00 to 19.00, Monday to Friday; (3) Greater Manchester B (GMB) (2015) – all patients eligible for HASU treatment (as in London); one HASU operated 24/7, two operated with admission extended to the hours of 07.00–23.00, Monday to Sunday; and (4) Midlands and East of England – planned 2012/13, but not implemented.

Design

Impact was studied through a controlled before-and-after design, analysing clinical outcomes, clinical interventions and cost-effectiveness. The development, implementation and sustainability of changes were studied through qualitative case studies, documentation analysis (n = 1091), stakeholder interviews (n = 325) and non-participant observations (n = 92; ≈210 hours). Theory-based framework was used to link qualitative findings on process of change with quantitative outcomes.

Results

Impact – the London centralisation performed significantly better than the rest of England (RoE) in terms of mortality [–1.1%, 95% confidence interval (CI) –2.1% to –0.1%], resulting in an estimated additional 96 lives saved per year beyond reductions observed in the RoE, length of stay (LOS) (–1.4 days, 95% –2.3 to –0.5 days) and delivering effective clinical interventions [e.g. arrival at a Stroke Unit (SU) within 4 hours of ‘clock start’ (when clock start refers to arrival at hospital for strokes occurring outside hospital or the appearance of symptoms for patients who are already in-patients at the time of stroke): London = 66.3% (95% CI 65.6% to 67.1%); comparator = 54.4% (95% CI 53.6% to 55.1%)]. Performance was sustained over 6 years. GMA performed significantly better than the RoE on LOS (–2.0 days, 95% CI –2.8 to –1.2 days) only. GMB (where 86% of patients were treated in HASU) performed significantly better than the RoE on LOS (–1.5 days, 95% CI –2.5 to –0.4 days) and clinical interventions [e.g. SU within 4 hours: GMB = 79.1% (95% CI 77.9% to 80.4%); comparator = 53.4% (95% CI 53.0% to 53.7%)] but not on mortality (–1.3%, 95% CI –2.7% to 0.01%; p = 0.05, accounting for reductions observed in RoE); however, there was a significant effect when examining GMB HASUs only (–1.8%, 95% CI –3.4% to –0.2%), resulting in an estimated additional 68 lives saved per year. All centralisations except GMB were cost-effective at 10 years, with a higher net monetary benefit than the RoE at a willingness to pay for a quality-adjusted life-year (QALY) of £20,000–30,000. Per 1000 patients at 10 years, London resulted in an additional 58 QALYs, GMA resulted in an additional 18 QALYs and GMB resulted in an additional 6 QALYs at costs of £1,014,363, –£470,848 and £719,948, respectively. GMB was cost-effective at 90 days. Despite concerns about the potential impact of increased travel times, patients and carers reported good experiences of centralised services; this relied on clear information at every stage. Planning change – combining top-down authority and bottom-up clinical leadership was important in co-ordinating multiple stakeholders to agree service models and overcome resistance. Implementation – minimising phases of change, use of data, service standards linked to financial incentives and active facilitation of changes by stroke networks was important. The 2013 reforms of the English NHS removed sources of top-down authority and facilitative capacity, preventing centralisation (Midlands and East of England) and delaying implementation (GMB). Greater Manchester’s Operational Delivery Network, developed to provide alternative network facilitation, and London’s continued use of standards suggested important facilitators of centralisation in a post-reform context.

Limitations

The main limitation of our quantitative analysis was that we were unable to control for stroke severity. In addition, findings may not apply to non-urban settings. Data on patients’ quality of life were unavailable nationally, clinical interventions measured changed over time and national participation in audits varied. Some qualitative analyses were retrospective, potentially influencing participant views.

Conclusions

Centralising acute stroke services can improve clinical outcomes and care provision. Factors related to the service model implemented, how change is implemented and the context in which it is implemented are influential in improvement. We recommend further analysis of how different types of leadership contribute to MSC, patient and carer experience during the implementation of change, the impact of change on further clinical outcomes (disability and QoL) and influence of severity of stroke on clinical outcomes. Finally, our findings should be assessed in relation to MSC implemented in other health-care specialties.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Modified Approach to Stroke Rehabilitation (MAStR): feasibility study of a method to apply procedural memory concepts to transfer training

OBJECTIVE

Training and implementation for a multidisciplinary stroke rehabilitation method emphasizing procedural memory.

BACKGROUND

Current practice in stroke rehabilitation relies on explicit memory, often compromised by stroke, failing to capitalize on better-preserved procedural memory skills. Recruitment of procedural memory requires consistency and practice, characteristics difficulty to promote on inpatient rehabilitation units. We designed a method Modified Approach to Stroke Rehabilitation (MAStR) to maximize consistency and practice for transfer training with stroke patients.

DESIGN

Phase I, single-group study. MAStR has two innovations: (1) simplification of instructions to only three words, other direction provided non-verbally; (2) having all rehabilitation staff apply the same approach for transfers. Staff training in MAStR included review of written material describing the rationale for MAStR and demonstration of a transfer using MAStR. Enrolled patients completed each transfer with MAStR in addition to standard rehabilitation therapy.

RESULTS

The MAStR method was taught to a large, multidisciplinary rehabilitation staff (n = 31). Training and certification required 15 min per staff member. Five stroke patients were enrolled. No transfers with MAStR resulted in injury, no negative feedback was received from staff or patients. Staff reported satisfaction with the brief MAStR training and reported transfers were easier to complete with the MAStR method.

CONCLUSIONS

Feasibility was demonstrated for an innovative application of procedural memory concepts to stroke rehabilitation. All rehabilitation disciplines were successfully trained. MAStR was well-tolerated and liked by rehabilitation staff and patients. These results support pursuit of a Phase II pilot study.

Patient experience of centralized acute stroke care pathways

Background

In 2010, Greater Manchester (GM) and London centralized acute stroke care services into a reduced number of hyperacute stroke units, with local stroke units providing on‐going care nearer patients’ homes.

Objective

To explore the impact of centralized acute stroke care pathways on the experiences of patients.

Design

Qualitative interview study. Thematic analysis was undertaken, using deductive and inductive approaches. Final data analysis explored themes related to five chronological phases of the centralized stroke care pathway.

Setting and participants

Recruitment from 3 hospitals in GM (15 stroke patients/8 family members) and 4 in London (21 stroke patients/9 family members).

Results

Participants were impressed with emergency services and initial reception at hospital: disquiet about travelling further than a local hospital was allayed by clear explanations. Participants knew who was treating them and were involved in decisions. Difficulties for families visiting hospitals a distance from home were raised. Repatriation to local hospitals was not always timely, but no detrimental effects were reported. Discharge to the community was viewed less positively.

Discussion and conclusions

Patients on the centralized acute stroke care pathways reported many positive aspects of care: the centralization of care pathways can offer patients a good experience. Disadvantages of travelling further were perceived to be outweighed by the opportunity to receive the best quality care. This study highlights the necessity for all staff on a centralized care pathway to provide clear and accessible information to patients, in order to maximize their experience of care.

Early discharge hospital at home

BACKGROUND

Early discharge hospital at home is a service that provides active treatment by healthcare professionals in the patient's home for a condition that otherwise would require acute hospital inpatient care. This is an update of a Cochrane review.

OBJECTIVES

To determine the effectiveness and cost of managing patients with early discharge hospital at home compared with inpatient hospital care.

SEARCH METHODS

We searched the following databases to 9 January 2017: the Cochrane Effective Practice and Organisation of Care Group (EPOC) register, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, CINAHL, and EconLit. We searched clinical trials registries.

SELECTION CRITERIA

Randomised trials comparing early discharge hospital at home with acute hospital inpatient care for adults. We excluded obstetric, paediatric and mental health hospital at home schemes.   DATA COLLECTION AND ANALYSIS: We followed the standard methodological procedures expected by Cochrane and EPOC. We used the GRADE approach to assess the certainty of the body of evidence for the most important outcomes.

MAIN RESULTS

We included 32 trials (N = 4746), six of them new for this update, mainly conducted in high-income countries. We judged most of the studies to have a low or unclear risk of bias. The intervention was delivered by hospital outreach services (17 trials), community-based services (11 trials), and was co-ordinated by a hospital-based stroke team or physician in conjunction with community-based services in four trials.Studies recruiting people recovering from strokeEarly discharge hospital at home probably makes little or no difference to mortality at three to six months (risk ratio (RR) 0.92, 95% confidence interval (CI) 0.57 to 1.48, N = 1114, 11 trials, moderate-certainty evidence) and may make little or no difference to the risk of hospital readmission (RR 1.09, 95% CI 0.71 to 1.66, N = 345, 5 trials, low-certainty evidence). Hospital at home may lower the risk of living in institutional setting at six months (RR 0.63, 96% CI 0.40 to 0.98; N = 574, 4 trials, low-certainty evidence) and might slightly improve patient satisfaction (N = 795, low-certainty evidence). Hospital at home probably reduces hospital length of stay, as moderate-certainty evidence found that people assigned to hospital at home are discharged from the intervention about seven days earlier than people receiving inpatient care (95% CI 10.19 to 3.17 days earlier, N = 528, 4 trials). It is uncertain whether hospital at home has an effect on cost (very low-certainty evidence).Studies recruiting people with a mix of medical conditionsEarly discharge hospital at home probably makes little or no difference to mortality (RR 1.07, 95% CI 0.76 to 1.49; N = 1247, 8 trials, moderate-certainty evidence). In people with chronic obstructive pulmonary disease (COPD) there was insufficient information to determine the effect of these two approaches on mortality (RR 0.53, 95% CI 0.25 to 1.12, N = 496, 5 trials, low-certainty evidence). The intervention probably increases the risk of hospital readmission in a mix of medical conditions, although the results are also compatible with no difference and a relatively large increase in the risk of readmission (RR 1.25, 95% CI 0.98 to 1.58, N = 1276, 9 trials, moderate-certainty evidence). Early discharge hospital at home may decrease the risk of readmission for people with COPD (RR 0.86, 95% CI 0.66 to 1.13, N = 496, 5 trials low-certainty evidence). Hospital at home may lower the risk of living in an institutional setting (RR 0.69, 0.48 to 0.99; N = 484, 3 trials, low-certainty evidence). The intervention might slightly improve patient satisfaction (N = 900, low-certainty evidence). The effect of early discharge hospital at home on hospital length of stay for older patients with a mix of conditions ranged from a reduction of 20 days to a reduction of less than half a day (moderate-certainty evidence, N = 767). It is uncertain whether hospital at home has an effect on cost (very low-certainty evidence).Studies recruiting people undergoing elective surgeryThree studies did not report higher rates of mortality with hospital at home compared with inpatient care (data not pooled, N = 856, low-certainty evidence; mainly orthopaedic surgery). Hospital at home may lead to little or no difference in readmission to hospital for people who were mainly recovering from orthopaedic surgery (N = 1229, low-certainty evidence). We could not establish the effects of hospital at home on the risk of living in institutional care, due to a lack of data. The intervention might slightly improve patient satisfaction (N = 1229, low-certainty evidence). People recovering from orthopaedic surgery allocated to early discharge hospital at home were discharged from the intervention on average four days earlier than people allocated to usual inpatient care (4.44 days earlier, 95% CI 6.37 to 2.51 days earlier, , N = 411, 4 trials, moderate-certainty evidence). It is uncertain whether hospital at home has an effect on cost (very low-certainty evidence).

AUTHORS' CONCLUSIONS

Despite increasing interest in the potential of early discharge hospital at home services as a less expensive alternative to inpatient care, this review provides insufficient evidence of economic benefit (through a reduction in hospital length of stay) or improved health outcomes.

[Evaluation of patient satisfaction after stroke rehabilitation program. Validation study for the Spanish version of the Satisfaction Pound Scale]

BACKGROUND AND OBJECTIVE

The Satisfaction Pound Scale is a specific questionnaire to evaluate satisfaction with the rehabilitation program after a stroke. The aim of this study was to adapt this scale to Spanish and to evaluate its metric characteristics.

METHOD

The adaptation included translation and back-translation methods. Metric characteristics were evaluated in 74 patients, all of whom were administered the Satisfaction Pound Scale and the Short Form 36 (SF-36). The statistical model was tested by confirmatory factor analysis (CFA). Reliability was determined through Cronbach alpha coefficient and a test-retest procedure. Construct validity was assessed by means of correlations between the satisfaction scale and the SF-36.

RESULTS

Adjustment indicators in the CFA were very good. Reproducibility test showed correlations higher than 0.85, and all correlations between SF-36 dimensions and the satisfaction scale were lower than 0.2, in accordance with the hypotheses raised.

CONCLUSIONS

The Spanish version of the Satisfaction Pounds Scale is reliable and valid, therefore it is a useful tool to assess satisfaction with the post-stroke rehabilitation program in our area.

Advantages and Disadvantages of the Home Setting for Therapy: Views of Patients and Therapists

A qualitative study was undertaken to explore patients' views and perceptions of a home-delivered therapy service. Fifteen subjects with hemiplegia were recruited from one health district, 10 women and 5 men. All subjects had experienced at least three consecutive sessions of both home-delivered therapy and hospital-based therapy in the preceding 18 months. A semi-structured interview was undertaken with each subject. Transcribed data were analysed using the grounded theory approach (Glaser and Strauss 1967). Five main themes were identified: ‘Convenience’, ‘Therapeutic environment’, ‘Social contact’, ‘Control’ and ‘Grateful recipient?’ Two discussion groups were held with six therapists after the data collection phase to explore their perceptions of the themes emerging from the interviews.

The subjects identified convenience and being comfortable within the home as two significant advantages of home therapy. The therapists highlighted the greater relevancy of the home environment for intervention and goal setting. The disadvantages identified by the subjects included the lack of equipment and floor space and the demotivating effect of the home setting. The therapists identified the difficulty of determining control within a therapy session.

The study demonstrated that the assumptions about the advantages and disadvantages of community-based rehabilitation services made by service providers are not necessarily experienced by the users of such services.

Home-Based Occupational Therapy: Stroke Patients' Satisfaction with Occupational Performance and Service Provision

This study evaluated a short post-discharge home-based occupational therapy service for stroke patients, including an assessment of the patients' satisfaction with occupational performance and service provision.

A single-site, blind randomised controlled trial was conducted. One hundred and thirty-eight patients were randomly allocated to either a conventional outpatient follow-up or conventional services plus 6 weeks of home-based occupational therapy. The data were collected before discharge and at 7 weeks and 6 months after discharge using the Canadian Occupational Performance Measure (COPM), the Dartmouth COOP Charts, the London Handicap Scale and a patient satisfaction questionnaire.

At 7 weeks the intervention group reported significantly greater changes in performance and satisfaction on the COPM, better emotional scores (Dartmouth COOP Charts) and improved work and leisure activity scores (London Handicap Scale). No other differences in subjective health status were described. By 6 months, the intervention group was more satisfied with several aspects of service provision but no other differences in subjective health experience were reported.

A 6-week post-discharge home-based occupational therapy service can improve patients' perceptions of their occupational performance and satisfaction with services but may not have a long-term effect on subjective health outcomes.

Consulting Service Users: The Stroke Association Home Therapy Project

In 1999, the Stroke Association set up a project to promote home-based occupational therapy for patients who had had a stroke and been discharged home from hospital. As part of the service evaluation, focus groups for service users and carers were set up in two of the sites to consult users about the changes in their quality of life during the period of the home therapy. A total of 11 service users and 9 carers attended the groups, representing 30% of the service users and 27% of the carers involved in the project. The group discussion was taped and transcribed and then analysed using a framework approach.

The group members described their personal experiences of recovery from and limitations after the stroke and reported improvements in life issues during the period of their home therapy. The content and organisation of the service and the relationships with project staff were felt to influence the effectiveness of the occupational therapy. Other issues that affected the perceived outcome for the service users included individual choice, age, stroke consequences, other rehabilitation and community services and social limitations. This consultation process allowed the service users to describe the strengths and weaknesses of the service and provided valuable feedback that could be used to design the content and application of future home therapy services.

Coordinating and Planning Services for Stroke Patients in Hospital and the Community

Much published research into the rehabilitation of patients following stroke has documented the lack of coordination between the various services for stroke patients and the Ineffectiveness of the targeting of services for patients. In an attempt to improve this situation, a stroke liaison officer has been recruited from the occupational therapy profession in South Staffordshire. Her role is to coordinate and plan services for stroke patients in hospital and the community and to act as a focal point for communication for patients, relatives and carers. The article explains the background to the project and identifies those areas where the stroke liaison officer may have an impact.

Can augmented physiotherapy input enhance recovery of mobility after stroke? A randomized controlled trial

Objective: To discover if the provision of additional inpatient physiotherapy after stroke speeds the recovery of mobility.

Design: A multisite single-blind randomized controlled trial (RCT) comparing the effects of augmented physiotherapy input with normal input on the recovery of mobility after stroke.

Setting: Three rehabilitation hospitals in North Glasgow, Scotland.

Subjects: Patients admitted to hospital with a clinical diagnosis of stroke, who were able to tolerate and benefit from mobility rehabilitation.

Intervention: We aimed to provide double the amount of physiotherapy to the augmented group.

Main measures: Primary outcomes were mobility milestones (ability to stand, step and walk), Rivermead Mobility Index (RMI) and walking speed.

Results: Seventy patients were recruited. The augmented therapy group received more direct contact with a physiotherapist (62 versus 35 minutes per weekday) and were more active (8.0% versus 4.8% time standing or walking) than normal therapy controls. The augmented group tended to achieve independent walking earlier (hazard ratio 1.48, 95% confidence interval 0.90–2.43; p=0.12) and had higher Rivermead Mobility Index scores at three months (mean difference 1.6; 0.1 to 3.3; p=0.068) but these differences did not reach statistical significance. There was no significant difference in any other outcome.

Conclusions: A modest augmented physiotherapy programme resulted in patients having more direct physiotherapy time and being more active. The inability to show statistically significant changes in outcome measures could indicate either that this intervention is ineffective or that our study could not detect modest changes.

Occupational therapy for stroke patients after hospital discharge — a randomized controlled trial

A randomized controlled trial was conducted with the aim of evaluating the influence of continued rehabilitative intervention by an occupational therapist on stroke patients after their discharge from a stroke unit. One hundred and ten patients were recruited and randomly allocated to either an intervention group, who were reviewed regularly by an occupational therapist in addition to receiving normal follow-up services, or a control group who received no special intervention. The two groups were compared at one year poststroke. Although there were few significant differences between the two groups at one year in terms of activities of daily living, extended activities of daily living, mood, and perceived quality of life, the number of aids (toilet aids and stair-rails) received by the intervention group was significantly greater (p = 0.05) and the number of readmissions to hospital was significantly smaller (p = 0.03). The provision of a follow-up service by an occupational therapist benefits stroke patients by addressing any problems they have postdischarge, ensuring they receive all necessary aids and helping to maintain them at home.

Reliability and validity of a postal version of the Reintegration to Normal Living Index, modified for use with stroke patients

Objective: To adapt the Reintegration to Normal Living Index (RNLI) for postal use with stroke patients.

Design: Reliability was examined using test–retest on 26 stroke patients. Construct validity was tested on 76 patients by examining correlations between the modified RNLI and related scales.

Subjects: Patients at three months to one year post stroke.

Results: All items demonstrated better than chance agreement between test and retest and seven items substantial agreement (kappa= >0.61). The modified RNLI correlated positively with related scales. Patients with stronger reintegration to normal living had better outcomes in anxiety, depression, daily activity and quality of life.

Conclusion: This postal instrument appears reliable and valid and may be a useful outcome measure in stroke studies.

A randomized trial to evaluate an education programme for patients and carers after stroke

Objectives: To evaluate the effectiveness of an education programme for patients and carers recovering from stroke.

Design: Randomized controlled trial.

Subjects and setting: One hundred and seventy patients admitted to a stroke rehabilitation unit and 97 carers of these patients.

Interventions: The intervention group received a specifically designed stroke information manual and were invited to attend education meetings every two weeks with members of their multidisciplinary team. The control group received usual practice.

Measures: Primary outcome was knowledge of stroke and stroke services. Secondary outcomes were handicap (London Handicap Scale), physical function (Barthel Index), social function (Frenchay Activities Index), mood (Hospital Anxiety and Depression Scale) and satisfaction (Pound Scale). Carer mood was measured by the General Health Questionnaire-28.

Results: There was no statistical evidence for a treatment effect on knowledge but there were trends that favoured the intervention. The education programme was associated with a significantly greater reduction in patient anxiety score at both three months (p=0.034) and six months (p=0.021) and consequently fewer ‘cases’ (Hospital Anxiety and Depression Scale anxiety subscale score ≥ 11). There were no other significant statistical differences between the patient or carer groups for other outcomes, although there were trends in favour of the education programme.

Conclusion: An education programme delivered within a stroke unit did not result in improved knowledge about stroke and stroke services but there was a significant reduction in patient anxiety at six months post stroke onset.

Validity of the extended activities of daily living scale

Scales that measure independence in the basic self-care activities of daily living (ADLs) suffer from ceiling effects when applied to an outpatient population. The instrumental activities of daily living (IADL) measures, which assess the performance of tasks required for independence at home are more appropriate. However, validity evaluation of IADL measures seldom goes beyond content validity and little is known about their sensitivity to change. The aim of this study was to evaluate the construct validity of the extended ADL scale (EADL) and to test its sensitivity to change. Three hundred and sixty-one consecutive acute stroke admissions were recruited and surveyed at one, six and 12 months after stroke, using the EADL. There were the expected correlations with the Barthel Index, Nottingham Health Profile, Geriatric Depression Score and the London Stroke Satisfaction Score. Logistic regression analysis showed that, although men were more mobile, they were less likely to carry out domestic and kitchen tasks. Also, nonwhites were more disabled, owner-occupiers had higher leisure scores and those living alone had higher kitchen scores. Analysis of effect sizes showed that the EADL is sensitive to the changes that occur after stroke and would be sensitive to the effect of an intervention that produced a change in independence of two or more ADLs. The EADL is a valid measure of the performance of instrumental ADLs and is sensitive to clinically important changes.

The Suitability of Written Education Materials for Stroke Survivors and Their Carers

This study evaluated the suitability of written materials for stroke survivors and their carers. Twenty stroke survivors and 14 carers were interviewed about the stroke information they had received and their perceptions of the content and presentation of materials of increasing reading difficulty. The mean readability level of materials (grade 9) was higher than participants' mean reading ability (grade 7-8). Satisfaction with materials decreased as the content became more difficult to read. Seventy-five percent reported that their information needs were not met in hospital. More stroke survivors with aphasia wanted support from health professionals to read and understand written information, and identified simple language, large font size, color, and diagrams to complement the text as being important features of written materials. Simple materials that meet clients' information needs and design preferences may optimally inform them about stroke.

The Language of Recovery: How Effective Communication of Information Is Crucial to Restructuring Post-Stroke Life

BACKGROUND

Providing appropriate and effective information to people with stroke and their families has been identified as a key component to successful practice. Researchers continue to focus on "lack of information" as being the lack of specific technical medical information rather than the communication of practical knowledge and how people use that knowledge to restructure life after stroke. To meet patients' expectations and achieve better outcomes in stroke, professionals need access to communication theory, research, and training.

OBJECTIVES

Improve stroke communication systematically.

METHOD

This article will examine stroke communication using a three-part framework: 1. Utilize theory to clearly conceptualize how communication influences stroke outcome. 2. Identify components and mechanisms of communication content to positively influence stroke outcome. 3. Develop goals and strategies for putting content skills into stroke communication practice.

CONCLUSION

Relatively little is known about the content and structure of informal communication transactions between stroke survivors, families, and health care professionals and how they accommodate (or resist) realignment of identity after stroke. The professional discourse attempts to ensure realistic expectations of recovery whereas stroke survivors and families complain about the negative discourses, how possibilities for life after stroke are presented, and the hopelessness that this creates. More research is required into how these different discourses affect outcomes.

Written Education Materials for Stroke Patients and Their Carers: Perspectives and Practices of Health Professionals

Inadequacies in the provision of written education materials to stroke patients and their carers have been reported. In this study, 20 stroke team health professionals were surveyed regarding their use of and perspectives on written education materials. Seventy percent of participants provided materials to 25% or fewer stroke patients and 90% believed that patients and carers are only occasionally or rarely provided with sufficient written information. Health professionals were uncertain which team members provided written information and identified the need to improve the quality of materials used. Stroke teams should implement a system that facilitates the routine provision of quality written materials to patients and carers, communication among team members, and documentation and verbal reinforcement of the information provided.

Satisfaction with care as a quality-of-life predictor for stroke patients and their caregivers

PURPOSE

We sought to identify indicators associated with the quality of life (QoL) of stroke patients and caregivers.

METHODS

The cross-sectional study was conducted at nine Dutch stroke service facilities involving 251 stroke patients and their caregivers. We used the EuroQol (EQ-5D) and Satisfaction with Stroke Care questionnaires, and included the variables (1) disability at hospital admission, (2) length of hospital stay, (3) demographic data, and (4) caregivers' relationship with stroke patients. The Actor-Partner (patient-caregiver) Interdependence Model (APIM) was used to examine dependence between patients' and caregivers' QoL scores through dyad membership.

RESULTS

Patients' age was significantly related to their QoL, and caregivers' age and educational level were significantly related to their QoL. Patients' disability on hospital admission and length of stay were associated with patients' QoL, and their disability on admission was related to caregivers' QoL. No relationship was found between length of stay and caregivers' QoL. Satisfaction with care was associated with both patients' and caregivers' QoL.

CONCLUSIONS

The APIM distinguished the different roles of patients and caregivers while acknowledging the interdependence of their QoL scores. Satisfaction with care was identified as important indicator of stroke patients' and caregivers' QoL.

Information provision for stroke patients and their caregivers

BACKGROUND

Research shows that stroke patients and their families are dissatisfied with the information provided and have a poor understanding of stroke and associated issues.

OBJECTIVES

To assess the effectiveness of information provision strategies in improving the outcome for stroke patients or their identified caregivers, or both.

SEARCH METHODS

For this update we searched the Cochrane Stroke Group Trials Register (June 2012), the Cochrane Central Register of Controlled trials (CENTRAL), the Cochrane Database of Systematic Reviews (CDSR), the Database of Abstracts of Reviews of Effects (DARE), the NHS Economic Evaluation Database (EED), and the Health Technology Assessment (HTA) Database (The Cochrane Library June, 2012), MEDLINE (1966 to June 2012), EMBASE (1980 to June 2012), CINAHL (1982 to June 2012) and PsycINFO (1974 to June 2012). We also searched ongoing trials registers, scanned bibliographies of relevant articles and books and contacted researchers.

SELECTION CRITERIA

Randomised trials involving patients or carers of patients with a clinical diagnosis of stroke or transient ischaemic attack (TIA) where an information intervention was compared with standard care, or where information and another therapy were compared with the other therapy alone.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial eligibility and methodological quality and extracted data. Primary outcomes were knowledge about stroke and stroke services, and impact on mood.

MAIN RESULTS

We have added four new trials to this update. This review now includes 21 trials involving 2289 patient and 1290 carer participants. Nine trials evaluated a passive and 12 trials an active information intervention. Meta-analyses showed a significant effect in favour of the intervention on patient knowledge (standardised mean difference (SMD) 0.29, 95% confidence interval (CI) 0.12 to 0.46, P < 0.001), carer knowledge (SMD 0.74, 95% CI 0.06 to 1.43, P = 0.03), one aspect of patient satisfaction (odds ratio (OR) 2.07, 95% CI 1.33 to 3.23, P = 0.001), and patient depression scores (mean difference (MD) -0.52, 95% CI -0.93 to -0.10, P = 0.01). There was no significant effect (P > 0.05) on number of cases of anxiety or depression in patients, carer mood or satisfaction, or death. Qualitative analyses found no strong evidence of an effect on other outcomes. Post-hoc subgroup analyses showed that active information had a significantly greater effect than passive information on patient mood but not on other outcomes.

AUTHORS' CONCLUSIONS

There is evidence that information improves patient and carer knowledge of stroke, aspects of patient satisfaction, and reduces patient depression scores. However, the reduction in depression scores was small and may not be clinically significant. Although the best way to provide information is still unclear there is some evidence that strategies that actively involve patients and carers and include planned follow-up for clarification and reinforcement have a greater effect on patient mood.

Physiotherapy practice in stroke rehabilitation: a cross-sectional survey of physiotherapists in the state of Kerala, India

BACKGROUND

Physiotherapy, a major component of rehabilitation for stroke patients, has been shown to have a positive effect on outcome. However, there is debate over efficacy of different interventions related to stroke rehabilitation.

PURPOSE

The purpose of this study was to compare knowledge and attitudes of physiotherapists working with stroke patients in Kerala, India, with emphasis on demographics, approach to treatment, and beliefs about stroke rehabilitation.

METHODS

Two hundred one physiotherapists in Kerala were surveyed using questionnaires, which were sent by post. Questionnaires consisted of items related to stroke rehabilitation such as approaches to physiotherapy, use of walking aids, and discharge issues. Data analysis was done using percentage-wise comparisons.

RESULTS

Examination of results showed variation in the beliefs held by physiotherapists about treatment of stroke patients. Of the 201 respondents, 153 (76.1%) used a conventional treatment approach. There was a strong disparity among physiotherapists regarding use of walking aids by stroke patients: 119 (59.2%) agreed that tripods or quadripods should be given to patients, but 55 (27.4%) disagreed and 27 (13.4%) were unsure. In response to questions about discharge issues, 30 (14.9%) of the 118 respondents agreed that they were actively involved in discharge planning for stroke patients, and 158 (78.6%) agreed that skill of the physiotherapist influences outcomes.

CONCLUSION

A great deal of variation among physiotherapists in treatment approaches and beliefs was revealed in this study, which indicates the need for development and implementation of a standardized protocol for stroke rehabilitation in Kerala.

How has the impact of 'care pathway technologies' on service integration in stroke care been measured and what is the strength of the evidence to support their effectiveness in this respect?

EXECUTIVE SUMMARY:

BACKGROUND

Across the developed world, we are witnessing an increasing emphasis on the need for more closely coordinated forms of health and social care provision. Integrated care pathways (ICPs) have emerged as a response to this aspiration and are believed by many to address the factors which contribute to service integration. ICPs map out a patient's journey, providing coordination of services for users. They aim to have: 'the right people, doing the right things, in the right order, at the right time, in the right place, with the right outcome'. The value for ICPs in supporting the delivery of care across organisational boundaries, providing greater consistency in practice, improving service continuity and increasing collaboration has been advocated by many. However, there is little evidence to support their use, and the need for systematic evaluations in order to measure their effectiveness has been widely identified. A recent Cochrane review assessed the effects of ICPs on functional outcome, process of care, quality of life and hospitalisation costs of inpatients with acute stroke, but did not specifically focus on service integration or its derivatives. To the best of our knowledge, no such systematic review of the literature exists.

OBJECTIVES

• To systematically review all high-quality studies which have evaluated the impact of care pathway technologies on 'service integration' and its derivatives in stroke care • To examine how elements of service integration are defined in such studies • To examine the type of evidence utilised to measure service integration • To analyse the weight of evidence used to support claims about the effectiveness of ICPs on improving service integration • To produce recommendations for ICP developers, users and evaluators.

INCLUSION CRITERIA

Types of participants The review focused on the care of adult patients who had suffered a stroke. It included the full spectrum of services - acute care, rehabilitation and long-term support - in hospital and community settings. Types of intervention(s)/phenomena of interest Integrated care pathways were the intervention of interest, defined for the purpose of this review as 'a multidisciplinary tool to improve the quality and efficiency of evidence based care and is used as a communication tool between professionals to manage and standardise the outcome orientated care' Here 'multidisciplinary' is taken to refer to the involvement of two or more disciplines. Types of outcomes 'Service integration' was the outcome of interest however, this was defined and measured in the selected studies. Types of studies This review was concerned with how 'service integration' was defined in evaluations of ICPs; the type of evidence utilised in measuring the impact of the intervention and the weight of evidence to support the effectiveness of care pathway technologies on 'service integration'. Studies that made an explicit link between ICPs and service integration were included in the review. Evidence generated from randomised controlled trials, quasi-experimental, qualitative and health economics research was sought. The search was limited to publications after 1980, coinciding with the emergence of ICPs in the healthcare context. Assessment for inclusion of foreign papers was based on the English-language abstract, where available. These were included only if an English translation was available.

EXCLUSION CRITERIA

This review excluded studies that: • focused only on a single aspect of stroke care (e.g. dysphasia) • evaluated ICPs as part of a wider program of service development • did not make an explicit link between ICPs and service integration • did not meet the definition of ICP utilised for the purposes of the review • focused exclusively on the outcomes of variance analysis

SEARCH STRATEGY

In order to avoid replication, the Joanna Briggs Institute for Evidence Based Nursing and Midwifery Database and the Cochrane Library were searched to establish that no systematic reviews existed and none were in progress. A three-stage search strategy was then used to identify both published and unpublished studies (see Appendix III).

DATA COLLECTION

Our search strategy located 2123 papers, of which 39 were retrieved for further evaluation. We critically appraised seven papers, representing five studies. These were all evaluation studies and, as is typical in this field, comprised a range of study designs and data collection methods. Owing to the diversity of the study types included in the review, we developed a single-appraisal checklist and data-extraction tool which could be applied to all research designs.(32) The tool drew on the Joanna Briggs Institute (JBI) appraisal checklists for experimental studies and interpretive and critical research, and also incorporated specific information and issues which were relevant for our purposes (see Appendix VI). This extends the thinking outlined in Lyne et al.(31) in which, drawing on Campbell and Stanley's classic paper, the case is made for developing an appraisal tool which is applicable to all types of evaluation, irrespective of study design. In assessing the quality of the papers, we were sympathetic to the methodological challenges of evaluating complex interventions such as ICPs. We were also cognisant of the very real constraints in which service evaluations are frequently undertaken in healthcare contexts. In accordance with the aims of this particular review, we have included studies, which are methodologically weaker than is typical of many systematic reviews because, in our view, in the absence of stronger evidence, they yield useful information.

DATA SYNTHESIS

Given the heterogeneity of the included studies, meta-analysis and/or qualitative synthesis was not possible. A narrative summary of the study findings is presented.

RESULTS

1 ICPs can be effective in ensuring that patients receive relevant clinical interventions and/or assessments in a timely manner, although these improvements may reflect better documentation rather than actual changes in practice. 2 ICPs can be effective in improving the documentation of rehabilitation goals, documentation of communication with patients, carers (diagnosis, prognosis and follow-up arrangements) and documentation of notification of primary care physicians of discharge. However, this can create additional burdens of work for staff. 3 Early studies of ICP-managed care in the acute stroke context have demonstrated reduced length of stay without any associated adverse effects on discharge destination, morbidity or mortality. These effects do not reach statistical significance, however, and may reflect wider changes in service provision and a general trend towards reduced length of hospital stay. While later studies in the acute and rehabilitation contexts do not reveal any significant reduction in length of stay, they do report greater documented use of certain clinical interventions and assessments, suggesting that ICPs can be effective in mobilising hospital resources around the patient. 4 ICPs implemented in the context of acute stroke care can be effective in reducing the occurrence of urinary tract infections, although we do not know whether this can be attributed to improved service integration. 5 ICP management in stroke rehabilitation may not be flexible enough to meet diverse patient needs and can result in insufficient attention to higher-level functioning and carer needs influencing perceptions of quality of life. 6 ICP management may assist in clarifying role boundaries and a shared understanding of the work, but this can result in some members of the disciplinary team perceiving that their contribution is not appropriately reflected in the documentation. 7 There is some evidence that ICPs may be effective in changing professional behaviours in the desired direction where there is scope for improvement, but in situations in which multidisciplinary working is effective, their positive effects may be limited. Furthermore, it is far from clear what the active ingredients of ICPs actually are. Kwan et al. suggest that it was the process of ICP development that had most impact on behaviours rather than the use of the artefact per se.(20) 8 None of the studies assessed the balance of costs and benefits of ICP use. Therefore, we do not know whether the costs of ICP development and implementation are justified by any of the reported benefits.

CONCLUSIONS

Implications for practice There is some evidence that ICPs may support certain elements of service integration in the context of stroke care. This seems to be as a result of their ability to support the timely implementation of clinical interventions and the mobilisation of resources around the patient without incurring additional increases in length of stay. ICPs appear to be most successful in improving service coordination in the acute stroke context where patient care trajectories are predictable. Their value in the context of rehabilitation settings in which recovery pathways are more variable is less clear. There is some evidence that ICPs may be effective in bringing about behavioural changes in contexts where deficiencies in service provision have been identified. Their value in contexts where inter-professional working is well established is less clear. While earlier before and after studies show a reduction in length of stay in ICP-managed care, this may reflect wider healthcare trends, and the failure of later studies to demonstrate further reductions suggests that there may be limits as to how far this can continue to be reduced. There is some evidence to suggest that ICPs bring about improvements in documentation, but we do not know how far documented practice reflects actual practice. It is unclear how ICPs have their effects and the relative importance of the process of development and the artefact in use. (ABSTRACT TRUNCATED)

Reliability and Validity of the Neurorehabilitation Experience Questionnaire for Inpatients

Background. Patient-centered measures of the inpatient neurorehabilitation experience are needed to assess services. Objective. The objective of this study was to develop a valid and reliable Neurorehabilitation Experience Questionnaire (NREQ) to assess whether neurorehabilitation inpatients experience service elements important to them. Methods. Based on the themes established in prior qualitative research, adopting questions from established inventories and using a literature review, a draft version of the NREQ was generated. Focus groups and interviews were conducted with 9 patients and 26 staff from neurological rehabilitation units to establish face validity. Then, 70 patients were recruited to complete the NREQ to ascertain reliability (internal and test-retest) and concurrent validity. Results. On the basis of the face validity testing, several modifications were made to the draft version of the NREQ. Subsequently, internal reliability (time 1 α = .76, time 2 α = .80), test retest reliability ( r = 0.70), and concurrent validity ( r = 0.32 and r = 0.56) were established for the revised version. Whereas responses were associated with positive mood ( r = 0.30), they appeared not to be influenced by negative mood, age, education, length of stay, sex, functional independence, or whether a participant had been a patient on a unit previously. Conclusions. Preliminary validation of the NREQ suggests promise for use with its target population.

Validation of the caregivers' satisfaction with Stroke Care Questionnaire: C-SASC hospital scale

To date, researchers have lacked a validated instrument to measure stroke caregivers' satisfaction with hospital care. We adjusted a validated patient version of satisfaction with hospital care for stroke caregivers and tested the 11-item caregivers' satisfaction with hospital care (C-SASC hospital scale) on caregivers of stroke patients admitted to nine stroke service facilities in the Netherlands. Stroke patients were identified through the stroke service facilities; caregivers were identified through the patients. We collected admission demographic data from the caregivers and gave them the C-SASC hospital scale. We tested the instrument by means of structural equation modeling and examined its validity and reliability. After the elimination of three items, the confirmatory factor analyses revealed good indices of fit with the resulting eight-item C-SASC hospital scale. Cronbach's α was high (0.85) and correlations with general satisfaction items with hospital care ranged from 0.594 to 0.594 (convergent validity). No significant relations were found with health and quality of life (divergent validity). Such results indicate strong construct validity. We conclude that the C-SASC hospital scale is a promising instrument for measuring stroke caregivers' satisfaction with hospital stroke care.

Structured re-assessment system at 6 months after a disabling stroke: a randomised controlled trial with resource use and cost study

BACKGROUND

national policy recommends routine re-assessment of disabled patients and their carers at 6 months after stroke onset. The clinical and resource outcomes of this policy were investigated.

DESIGN

prospective, single-blind, randomised controlled trial in two centres.

PARTICIPANTS

a total of 265 patients with a disabling stroke and their carers.

INTERVENTIONS

a structured re-assessment system for patients and their carers at 6 months post-stroke or existing care.

OUTCOME MEASURES

primary: patient independence (Frenchay activities index) and carer stress (general health questionnaire 28). Secondary: activities of daily living, mood state, satisfaction with services, carer strain index, health and social service resource use and costs.

RESULTS

independence at 12 months post-stroke was similar in both groups (Frenchay activities index, adjusted mean difference 0.64; 95% confidence interval -0.74-2.02). Emotional distress in carers was similar in both groups (general health questionnaire 28, mean difference 0.02; 95% confidence interval -0.95-1.00). Results for the secondary outcome measures and total mean costs were similar for both groups. The intervention group patients used 301 fewer hospital bed days and 1,631 fewer care home bed days.

CONCLUSIONS

the structured, systematic re-assessment for patients and their carers was not associated with any clinically significant evidence of benefit at 12 months. Health and social care resource use and mean cost per patient were broadly similar in both groups.

TRIAL REGISTRATION

International Standard Randomised Controlled Trial Register; number: ISRCTN55412871.

Efficacy of Functional Strength Training on Restoration of Lower-Limb Motor Function Early After Stroke: Phase I Randomized Controlled Trial

After stroke, physiotherapy can promote brain reorganization and motor recovery. Combining muscle strength and functional training (functional strength training, FST) may be beneficial. The aim of the authors was to compare FST with conventional physiotherapy (CPT) while controlling for the potential confounder of therapy intensity in a multicenter, randomized controlled observer-blind trial. The mean age of the participants was 68.3 (standard deviation [SD] = 12.03) years at a mean of 34 (SD = 20) days after stroke, with mean peak paretic knee extension torque (torque) of 22 (SD = 25) Nm. The estimated sample size was 102 to detect a between-group difference of 0.2 m/s in walking speed. After baseline measures, participants were allocated randomly to CPT or CPT + CPT or CPT + FST for 6 weeks. Additional experimental therapy was provided for up to 1 hour a day, 4 times each week. Outcomes were measured 6 weeks after baseline and at follow-up 12 weeks thereafter. Measures included walking speed, knee extensor torque, and functional mobility (Rivermead). At outcome, both extraintensity groups showed greater increases in walking speed than the CPT group, but this reached significance only for the CPT + CPT group ( P = .031). The CPT + CPT group also had a greater number of participants who walked at 0.8 m/s or above. No significant differences were observed for torque about the knee or for the Rivermead score. At follow-up, no significant differences were observed. These phase I results justify a subsequent trial of CPT + CPT versus CPT + FST.

Predictors of resuming therapy within four weeks after discharge from inpatient rehabilitation

PURPOSE

To identify the percentage of persons with stroke resuming therapy within 4 weeks of inpatient rehabilitation discharge, to compare the characteristics of those who did and did not resume therapy, and to determine the predictors of resuming physical (PT), occupational (OT), and speech (ST) therapy.

METHOD

Sociodemographic, stroke-related, and therapy data for persons with stroke (N = 131) were abstracted from inpatient rehabilitation charts. FIM, Stroke Impact Scale, Geriatric Depression Scale, and data on therapy received after discharge were also collected.

RESULTS

Logistic regression models demonstrated that minorities were less likely to resume PT (odds ratio [OR] = 0.30) and OT (OR = 0.25). Survivors with neglect/visual-field cut/spatial-perceptual loss were 2-3 times more likely to resume PT, OT, and ST. Survivors with higher scores on the SIS Physical domain subscale were less likely to resume PT (OR = 0.98) and OT (OR = 0.97). Men were 3.3 times more likely to have OT than women. Those with comprehensive health insurance were 11.2 times more likely to receive ST.

CONCLUSIONS

The benefits of outpatient therapy are not universally available to all persons with stroke. Further research needs to explore the factors that hinder the prompt resumption of therapy for minority and female persons with stroke and to test appropriate interventions.