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Moura L, Karakis I, Howard D. Emergency department utilization among adults with epilepsy: A multi-state cross-sectional analysis, 2010-2019. Epilepsy Res 2024; 205:107427. [PMID: 39116513 DOI: 10.1016/j.eplepsyres.2024.107427] [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: 05/02/2024] [Revised: 07/08/2024] [Accepted: 08/05/2024] [Indexed: 08/10/2024]
Abstract
OBJECTIVE We described patterns and trends in ED use among adults with epilepsy in the United States. METHODS Utilizing inpatient and ED discharge data from seven states, we conducted a cross-sectional analysis to identify adult ED visits diagnosed with epilepsy or seizures from 2010 to 2019. Using ED visit counts and estimates of state-level epilepsy prevalence, we calculated ED visit rates overall and by payer, condition, and year. RESULTS Our data captured 304,935 ED visits with epilepsy as a primary or secondary diagnosis in 2019. Across the seven states, visit rates ranged between 366 and 726 per 1000 and were higher than rates for adults without epilepsy in all states but one. ED visit rates were highest among Medicare and Medicaid beneficiaries (vs commercial or self-pay). Adults with epilepsy were more likely to be admitted as inpatients. Visits for nervous system disorders were 6.3-8.2 times higher among people with epilepsy, and visits for mental health conditions were 1.2-2.6 times higher. Increases in ED visit rates from 2010 to 2019 among people with epilepsy exceeded increases among adults without by 6.0-27.3 percentage points. CONCLUSION Adults with epilepsy visit the ED frequently and visit rates have been increasing over time. These results underscore the importance of identifying factors contributing to ED use and designing tailored interventions to improve ambulatory care quality.
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Affiliation(s)
- Lidia Moura
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA; Department of Neurology, Harvard Medical School, Boston, MA, USA.
| | - Ioannis Karakis
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia; University of Crete School of Medicine, Heraklion, Greece
| | - David Howard
- Department of Health Policy, Emory University School of Medicine, Atlanta, Georgia
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Ospel JM, Diprose WK, Ganesh A, Martins S, Nguyen T, Psychogios M, Mansour O, Al-Ajlan F, Yang P, Pandian J, Gopinathan A, Sandset EC, Kennedy J, Volders D, Fahed R, Tjoumakaris S, Bhogal P, Kurz M, Yavagal D, Inoa V, Hill MD, Goyal M. Challenges to Widespread Implementation of Stroke Thrombectomy. Stroke 2024; 55:2173-2183. [PMID: 38979609 DOI: 10.1161/strokeaha.124.045889] [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] [Indexed: 07/10/2024]
Abstract
Endovascular treatment (EVT) for acute ischemic stroke is one of the most efficacious and effective treatments in medicine, yet globally, its implementation remains limited. Patterns of EVT underutilization exist in virtually any health care system and range from a complete lack of access to selective undertreatment of certain patient subgroups. In this review, we outline different patterns of EVT underutilization and possible causes. We discuss common challenges and bottlenecks that are encountered by physicians, patients, and other stakeholders when trying to establish and expand EVT services in different scenarios and possible pathways to overcome these challenges. Lastly, we discuss the importance of implementation research studies, strategic partnerships, and advocacy efforts to mitigate EVT underutilization.
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Affiliation(s)
- Johanna Maria Ospel
- Department of Diagnostic Imaging (J.M.O., M.D.H., M.G.), Cumming School of Medicine, University of Calgary, Alberta, Canada
- Department of Clinical Neurosciences (J.M.O., W.K.D., A. Ganesh, M.D.H., M.G.), Cumming School of Medicine, University of Calgary, Alberta, Canada
| | - William K Diprose
- Department of Clinical Neurosciences (J.M.O., W.K.D., A. Ganesh, M.D.H., M.G.), Cumming School of Medicine, University of Calgary, Alberta, Canada
| | - Aravind Ganesh
- Department of Clinical Neurosciences (J.M.O., W.K.D., A. Ganesh, M.D.H., M.G.), Cumming School of Medicine, University of Calgary, Alberta, Canada
| | - Sheila Martins
- Neurology Department, Hospital Moinhos de Vento, Porto Alegre, Brazil (S.M.)
| | - Thanh Nguyen
- Departments of Radiology and Neurology, Boston Medical Center, MA (T.N.)
| | - Marios Psychogios
- Department of Neuroradiology, University Hospital Basel, Switzerland (M.P.)
| | - Ossama Mansour
- Alexandria Faculty of Medicine, Department of Neurology, Alexandria University, Egypt (O.M.)
| | - Fahad Al-Ajlan
- Neuroscience Center, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia (F.A.-A.)
| | - Pengfei Yang
- Department of Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China (P.Y.)
| | - Jeyaraj Pandian
- Department of Neurology, Christian Medical College and Hospital, Vellore, India (J.P.)
| | - Anil Gopinathan
- Division of Interventional Radiology, Department of Diagnostic Imaging, National University Health System, Singapore (A. Gopinathan)
| | | | - James Kennedy
- Oxford University Hospital NHS Foundation Trust, Oxford, United Kingdom (J.K.)
| | - David Volders
- Department of Radiology, Dalhousie University, Halifax, Canada (D.V.)
| | - Robert Fahed
- Division Neurology, Department of Medicine, The Ottawa Hospital, Ottawa Hospital Research Institute, University of Ottawa, Ontario, Canada (R.F.)
| | - Stavropoula Tjoumakaris
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA (S.T.)
| | - Pervinder Bhogal
- Department of Neuroradiology, The Royal London Hospital, Barts NHS Trust, United Kingdom (P.B.)
| | - Martin Kurz
- Department of Neurology, Stavanger University Hospital, Norway (M.K.)
| | - Dileep Yavagal
- Department of Neurology, University of Miami Miller School of Medicine, FL (D.Y.)
| | - Violiza Inoa
- Department of Neurology, University of Tennessee Health Science Center, Memphis (V.I.)
| | - Michael D Hill
- Department of Diagnostic Imaging (J.M.O., M.D.H., M.G.), Cumming School of Medicine, University of Calgary, Alberta, Canada
- Department of Clinical Neurosciences (J.M.O., W.K.D., A. Ganesh, M.D.H., M.G.), Cumming School of Medicine, University of Calgary, Alberta, Canada
| | - Mayank Goyal
- Department of Diagnostic Imaging (J.M.O., M.D.H., M.G.), Cumming School of Medicine, University of Calgary, Alberta, Canada
- Department of Clinical Neurosciences (J.M.O., W.K.D., A. Ganesh, M.D.H., M.G.), Cumming School of Medicine, University of Calgary, Alberta, Canada
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Bando K, Ohashi K, Fujiwara K, Osanai T, Morii Y, Tanikawa T, Fujimura M, Ogasawara K. The Capacitated Maximal Covering Location Problem Improves Access to Stroke Treatment: A Cross-Sectional Simulation Study. Health Serv Insights 2024; 17:11786329241263699. [PMID: 39092183 PMCID: PMC11292677 DOI: 10.1177/11786329241263699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Accepted: 06/06/2024] [Indexed: 08/04/2024] Open
Abstract
Disparities in accessing advanced stroke treatment have been recognized as a policy challenge in multiple countries, including Japan, necessitating priority solutions. Nevertheless, more practical healthcare policies must be implemented due to the limited availability of healthcare staff and financial resources in most nations. This study aimed to evaluate the supply and demand balance of mechanical thrombectomy (MT) and identify areas with high priority for enhancing stroke centers. The target area of this study was Hokkaido, Japan. We adopted the capacitated maximal covering location problem (CMCLP) to propose an optimal allocation without increasing the number of medical facilities. Four realistic scenarios with varying levels of total MT supply capacity for Primary stroke centers and assuming a range of 90 minutes by car from the center were created and simulated. From scenarios 1 to 4, the coverage increased by approximately 53% to 85%, scenarios 2 and 3 had 5% oversupply, and scenario 4 had an oversupply of approximately 20%. When the supply capacity cap was eliminated and 8 PSCs received 31 or more patients, they became priority enhancement targets. The CMCLP estimates demand coverage considering the supply and demand balance and indicates areas and facilities where MT supply capacity enhancement is a priority.
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Affiliation(s)
- Kyohei Bando
- Graduate School of Health Sciences, Hokkaido University, Sapporo, Japan
| | - Kazuki Ohashi
- Faculty of Health Sciences, Hokkaido University, Sapporo, Japan
| | - Kensuke Fujiwara
- Faculty of Health Sciences, Hokkaido University, Sapporo, Japan
- Graduate School of Commerce, Otaru University of Commerce, Otaru, Japan
| | - Toshiya Osanai
- Department of Neurosurgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Yasuhiro Morii
- Faculty of Health Sciences, Hokkaido University, Sapporo, Japan
- Center for Outcomes Research and Economic Evaluation for Health, National Institute of Public Health, Wako, Japan
| | - Takumi Tanikawa
- Faculty of Health Sciences, Hokkaido University, Sapporo, Japan
- Faculty of Health Sciences, Hokkaido University of Science, Sapporo, Japan
| | - Miki Fujimura
- Department of Neurosurgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Katsuhiko Ogasawara
- Faculty of Health Sciences, Hokkaido University, Sapporo, Japan
- Faculty of Engineering, Muroran Institute of Technology, Muroran, Japan
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Becerril-Gaitan A, Mokua C, Liu C, Nguyen T, Shaker F, Nguyen J, Gusdon AM, Brown RJ, Cochran J, Blackburn S, Chen PR, Dannenbaum M, Choi HA, Chen CJ. Racial and Ethnic Differences in Mortality and Functional Outcomes Following Aneurysmal Subarachnoid Hemorrhage. Stroke 2024; 55:1572-1581. [PMID: 38716675 DOI: 10.1161/strokeaha.123.045489] [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: 10/09/2023] [Accepted: 04/11/2024] [Indexed: 05/26/2024]
Abstract
BACKGROUND Ischemic and hemorrhagic stroke incidence tends to be higher among minority racial and ethnic groups. The effect of race and ethnicity following an aneurysmal subarachnoid hemorrhage (aSAH) remains poorly understood. Thus, we aimed to explore the association between race and ethnicity and aSAH outcomes. METHODS Single-center retrospective review of patients with aSAH from January 2009 to March 2023. Primary outcome was in-hospital mortality. Secondary outcomes included delayed cerebral ischemia, cerebral infarction, radiographic and symptomatic vasospasm, pulmonary complications, epileptic seizures, external ventricular drain placement, and modified Rankin Scale score at discharge and 3-month follow-up. Associations between race and ethnicity and outcomes were assessed using binary and ordinal regression models, with multivariable models adjusted for significant covariates. RESULTS A total of 1325 patients with subarachnoid hemorrhage presented to our center. Among them, 443 cases were excluded, and data from 882 patients with radiographically confirmed aSAH were analyzed. Distribution by race and ethnicity was 40.8% (n=360) White, 31.4% (n=277) Hispanic, 22.1% (n=195) Black, and 5.7% (n=50) Asian. Based on Hunt-Hess and modified Fisher grade, aSAH severity was similar among groups (P=0.269 and P=0.469, respectively). In-hospital mortality rates were highest for Asian (14.0%) and Hispanic (11.2%) patients; however, after adjusting for patient sex, age, health insurance, smoking history, alcohol and substance abuse, and aneurysm treatment, the overall likelihood was comparable to White patients. Hispanic patients had higher risks of developing cerebral infarction (adjusted odds ratio, 2.17 [1.20-3.91]) and symptomatic vasospasm (adjusted odds ratio, 1.64 [1.05-2.56]) than White patients and significantly worse discharge modified Rankin Scale scores (adjusted odds ratio, 1.44 [1.05-1.99]). Non-White patients also demonstrated a lower likelihood of 0 to 2 discharge modified Rankin Scale scores (adjusted odds ratio, 0.71 [0.50-0.98]). No significant interactions between race and ethnicity and age or sex were found for in-hospital mortality and functional outcomes. CONCLUSIONS Our study identified significant differences in cerebral infarction and symptomatic vasospasm risk between Hispanic and White patients following aSAH. A higher likelihood of worse functional outcomes at discharge was found among non-White patients. These findings emphasize the need to better understand predisposing risk factors that may influence aSAH outcomes. Efforts toward risk stratification and patient-centered management should be pursued.
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Affiliation(s)
| | | | - Collin Liu
- Neurosurgery Department, UTHealth Houston, TX
| | - Tien Nguyen
- Neurosurgery Department, UTHealth Houston, TX
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Fridman MR, Thompson SG, Tyson A, Barber PA, Davis A, Wu T, Fink J, Heppell D, Punter MNM, Ranta A. Sex differences in stroke reperfusion therapy in Aotearoa (New Zealand). Intern Med J 2024; 54:1010-1016. [PMID: 38327096 DOI: 10.1111/imj.16318] [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: 05/03/2023] [Accepted: 12/09/2023] [Indexed: 02/09/2024]
Abstract
BACKGROUND AND AIMS Stroke is a leading cause of death in Aotearoa (New Zealand), and stroke reperfusion therapy is a key intervention. Sex differences in stroke care have previously been asserted internationally. This study assessed potential differences in stroke reperfusion rates and quality metrics by sex in Aotearoa (New Zealand). METHODS This study used data from three overlapping sources. The National Stroke Reperfusion Register provided 4-year reperfusion data from 2018 to 2021 on all patients treated with reperfusion therapy (intravenous thrombolysis and thrombectomy), including time delays, treatment rates, mortality and complications. Linkage to Ministry of Health administrative and REGIONS Care study data provided an opportunity to control for confounders and explore potential mechanisms. T-test and Wilcoxon rank-sum analyses were used for continuous variables, while the chi-squared test and logistic regression were used for comparing dichotomous variables. RESULTS Fewer women presented with ischaemic stroke (12 186 vs 13 120) and were 4.2 years older than men (median (interquartile range (IQR)) 79 (68-86) vs 73 (63-82) years). Women were overall less likely to receive reperfusion therapy (13.9% (1704) vs 15.8% (2084), P < 0.001) with an adjusted odds ratio of 0.83 (0.77-0.90), P < 0.001. The adjusted odds ratio for thrombolysis was lower for women (0.82 (0.76-0.89), P < 0.001), but lower rates of thrombectomy fell just short of statistical significance ((0.89 (0.79-1.00), P = 0.05). There were no significant differences in complications, delays or documented reasons for non-thrombolysis. CONCLUSIONS Women were less likely to receive thrombolysis, even after adjusting for age and stroke severity. We found no definitive explanation for this disparity.
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Affiliation(s)
- Michal R Fridman
- Department of Medicine, University of Otago-Wellington, Wellington, New Zealand
| | - Stephanie G Thompson
- Older Adults, Rehabilitation and Allied Health Service, Capital, Coast, and Hutt Valley District, Te Whatu Ora - Health NZ, Wellington, New Zealand
| | - Alicia Tyson
- Department of Neurology, Capital, Coast, and Hutt Valley District, Te Whatu Ora - Health NZ, Wellington, New Zealand
| | - P A Barber
- Department of Medicine, University of Auckland, Auckland, New Zealand
| | - Alan Davis
- Medical and Elder Services, Te Tai Tokerau District, Te Whatu Ora - Health NZ, Whangārei, New Zealand
| | - Teddy Wu
- Department of Neurology, Canterbury District, Te Whatu Ora - Health NZ, Christchurch, New Zealand
| | - John Fink
- Department of Neurology, Canterbury District, Te Whatu Ora - Health NZ, Christchurch, New Zealand
| | - Darren Heppell
- Information, Communication, and Technology, Capital, Coast, Hutt Valley District, and Wairarapa Districts, Te Whatu Ora - Health NZ, Wellington, New Zealand
| | - Martin N M Punter
- Department of Medicine, University of Otago-Wellington, Wellington, New Zealand
- Department of Neurology, Capital, Coast, and Hutt Valley District, Te Whatu Ora - Health NZ, Wellington, New Zealand
| | - Anna Ranta
- Department of Medicine, University of Otago-Wellington, Wellington, New Zealand
- Department of Neurology, Capital, Coast, and Hutt Valley District, Te Whatu Ora - Health NZ, Wellington, New Zealand
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6
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Baker WL, Sharma M, Cohen A, Ouwens M, Christoph MJ, Koch B, Moore TE, Frady G, Coleman CI. Using 30-day modified rankin scale score to predict 90-day score in patients with intracranial hemorrhage: Derivation and validation of prediction model. PLoS One 2024; 19:e0303757. [PMID: 38771834 PMCID: PMC11108121 DOI: 10.1371/journal.pone.0303757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 04/30/2024] [Indexed: 05/23/2024] Open
Abstract
Whether 30-day modified Rankin Scale (mRS) scores can predict 90-day scores is unclear. This study derived and validated a model to predict ordinal 90-day mRS score in an intracerebral hemorrhage (ICH) population using 30-day mRS values and routinely available baseline variables. Adults enrolled in the Antihypertensive Treatment of Acute Cerebral Hemorrhage-2 (ATACH-2) trial between May 2011 and September 2015 with acute ICH, who were alive at 30 days and had mRS scores reported at both 30 and 90 days were included in this post-hoc analysis. A proportional odds regression model for predicting ordinal 90-day mRS scores was developed and internally validated using bootstrapping. Variables in the model included: mRS score at 30 days, age (years), hematoma volume (cm3), hematoma location (deep [basal ganglia, thalamus], lobar, or infratentorial), presence of intraventricular hemorrhage (IVH), baseline Glasgow Coma Scale (GCS) score, and National Institutes of Health Stroke Scale (NIHSS) score at randomization. We assessed model fit, calibration, discrimination, and agreement (ordinal, dichotomized functional independence), and EuroQol-5D ([EQ-5D] utility weighted) between predicted and observed 90-day mRS. A total of 898/1000 participants were included. Following bootstrap internal validation, our model (calibration slope = 0.967) had an optimism-corrected c-index of 0.884 (95% CI = 0.873-0.896) and R2 = 0.712 for 90-day mRS score. The weighted ĸ for agreement between observed and predicted ordinal 90-day mRS score was 0.811 (95% CI = 0.787-0.834). Agreement between observed and predicted functional independence (mRS score of 0-2) at 90 days was 74.3% (95% CI = 69.9-78.7%). The mean ± SD absolute difference between predicted and observed EQ-5D-weighted mRS score was negligible (0.005 ± 0.145). This tool allows practitioners and researchers to utilize clinically available information along with the mRS score 30 days after ICH to reliably predict the mRS score at 90 days.
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Affiliation(s)
- William L. Baker
- University of Connecticut School of Pharmacy, Storrs, CT, United States of America
- Evidence-Based Practice Center, Hartford Hospital, Hartford, CT, United States of America
| | - Mukul Sharma
- Division of Neurology, Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Alexander Cohen
- Guy’s and St. Thomas’ Hospitals, King’s College London, London, United Kingdom
| | - Mario Ouwens
- Medical and Payer Evidence, BioPharmaceuticals Medical, AstraZeneca, Cambridge, United Kingdom
| | - Mary J. Christoph
- AstraZeneca Pharmaceuticals, Wilmington, DE, United States of America
| | - Bruce Koch
- AstraZeneca Pharmaceuticals, Wilmington, DE, United States of America
| | - Timothy E. Moore
- Statistical Consulting Services, Center for Open Research Resources & Equipment, University of Connecticut, Storrs, CT, United States of America
| | - Garrett Frady
- Department of Statistics, University of Connecticut, Storrs, CT, United States of America
| | - Craig I. Coleman
- University of Connecticut School of Pharmacy, Storrs, CT, United States of America
- Evidence-Based Practice Center, Hartford Hospital, Hartford, CT, United States of America
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McKee KE, Knighton AJ, Veale K, Martinez J, McCann C, Anderson JW, Wolfe D, Blackburn R, McKasson M, Bardsley T, Ofori-Atta B, Greene TH, Hoesch R, Püttgen HA, Srivastava R. Impact of Local Tailoring on Acute Stroke Care in 21 Disparate Emergency Departments: A Prospective Stepped Wedge Type III Hybrid Effectiveness-Implementation Study. Circ Cardiovasc Qual Outcomes 2024; 17:e010477. [PMID: 38567507 PMCID: PMC11108744 DOI: 10.1161/circoutcomes.123.010477] [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: 08/24/2023] [Accepted: 03/04/2024] [Indexed: 04/04/2024]
Abstract
BACKGROUND Faster delivery of tPA (tissue-type plasminogen activator) results in better health outcomes for eligible patients with stroke. Standardization of stroke protocols in emergency departments (EDs) has been difficult, especially in nonstroke centers. We measured the effectiveness of a centrally led implementation strategy with local site tailoring to sustain adherence to an acute stroke protocol to improve door-to-needle (DTN) times across disparate EDs in a multihospital health system. METHODS Prospective, type III hybrid effectiveness-implementation cohort study measuring performance at 21 EDs in Utah and Idaho (stroke centers [4]/nonstroke centers [17]) from January 2018 to February 2020 using a nonrandomized stepped-wedge design, monthly repeated site measures and multilevel hierarchical modeling. Each site received the implementation strategies in 1 of 6 steps providing control and intervention data. Co-primary outcomes were percentage of DTN times ≤60 minutes and median DTN time. Secondary outcomes included percentage of door-to-activation of neurological consult times ≤10 minutes and clinical effectiveness outcomes. Results were stratified between stroke and nonstroke centers. RESULTS A total of 855 474 ED patient encounters occurred with 5325 code stroke activations (median age, 69 [IQR, 56-79] years; 51.8% female patients]. Percentage of door-to-activation times ≤10 minutes increased from 47.5% to 59.9% (adjusted odds ratio, 1.93 [95% CI, 1.40-2.67]). A total of 615 patients received tPA of ≤3 hours from symptom onset (median age, 71 [IQR, 58-80] years; 49.6% female patients). The percentage of DTN times ≤60 minutes increased from 72.5% to 86.1% (adjusted odds ratio, 3.38, [95% CI, 1.47-7.78]; stroke centers (77.4%-90.0%); nonstroke centers [59.3%-72.1%]). Median DTN time declined from 46 to 38 minutes (adjusted median difference, -9.68 [95% CI, -17.17 to -2.20]; stroke centers [41-35 minutes]; nonstroke centers [55-52 minutes]). No differences were observed in clinical effectiveness outcomes. CONCLUSIONS A centrally led implementation strategy with local site tailoring led to faster delivery of tPA across disparate EDs in a multihospital system with no change in clinical effectiveness outcomes including rates of complication. Disparities in performance persisted between stroke and nonstroke centers.
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Affiliation(s)
- Kathleen E McKee
- Neurosciences Clinical Program, Intermountain Health, Salt Lake City, UT
| | - Andrew J Knighton
- Healthcare Delivery Institute, Intermountain Health, Salt Lake City, UT
| | - Kristy Veale
- Neurosciences Clinical Program, Intermountain Health, Salt Lake City, UT
| | - Julie Martinez
- Neurosciences Clinical Program, Intermountain Health, Salt Lake City, UT
| | - Cory McCann
- Neurosciences Clinical Program, Intermountain Health, Salt Lake City, UT
| | | | - Doug Wolfe
- Healthcare Delivery Institute, Intermountain Health, Salt Lake City, UT
| | - Rob Blackburn
- Continuous Improvement, Intermountain Health, Salt Lake City, UT
| | - Marilyn McKasson
- Neurosciences Clinical Program, Intermountain Health, Salt Lake City, UT
| | - Tyler Bardsley
- Division of Biostatistics, School of Medicine, University of Utah, Salt Lake City, UT
| | - Blessing Ofori-Atta
- Division of Biostatistics, School of Medicine, University of Utah, Salt Lake City, UT
| | - Tom H Greene
- Division of Biostatistics, School of Medicine, University of Utah, Salt Lake City, UT
| | - Robert Hoesch
- Neurosciences Clinical Program, Intermountain Health, Salt Lake City, UT
| | - H Adrian Püttgen
- Neurosciences Clinical Program, Intermountain Health, Salt Lake City, UT
| | - Rajendu Srivastava
- Healthcare Delivery Institute, Intermountain Health, Salt Lake City, UT
- Division of Pediatric Hospital Medicine, Department of Pediatrics, Primary Children’s Hospital, University of Utah, Salt Lake City, UT
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8
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Jordan HT, Stinear CM. Accuracy and Reliability of Remote Categorization of Upper Limb Outcome After Stroke. Neurorehabil Neural Repair 2024; 38:167-175. [PMID: 38357877 PMCID: PMC10943605 DOI: 10.1177/15459683241231272] [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] [Indexed: 02/16/2024]
Abstract
BACKGROUND There is an increasing need for motor assessments after stroke that can be performed quickly and remotely. The Fast Outcome Categorization of the Upper Limb after Stroke-4 (FOCUS-4) assessment remotely classifies upper limb outcome into 1 of 4 categories after stroke and was developed via retrospective analysis of Action Research Arm Test (ARAT) scores. OBJECTIVE The aim of this study was to prospectively evaluate the accuracy and reliability of FOCUS-4 assessments for categorizing upper limb outcome after stroke when administered remotely during a videocall compared to an in-person ARAT. METHODS Data were collected from 26 participants at 3 months post-stroke (3M), 27 participants at 6 months post-stroke (6M), and 56 participants at the chronic stage of stroke (>6M). Participants performed an in-person ARAT and a remote FOCUS-4 assessment administered during a videocall, and accuracy was evaluated by comparing the upper limb outcome categories. Participants at the chronic stage of stroke also performed a second remote FOCUS-4 assessment to assess between-day reliability. RESULTS Overall accuracy of the remote FOCUS-4 assessment was 88% at 3M and 96% at 6M. Overall accuracy of the first and second remote FOCUS-4 assessments at the chronic stage was 75% and 79%, respectively. Reliability of the FOCUS-4 assessment at the chronic stage was 82%. The remote FOCUS-4 assessment was most accurate and reliable for participants with mild or severe upper limb functional impairment. CONCLUSIONS The remote FOCUS-4 assessment has potential to classify upper limb functional capacity or to screen possible participants for stroke trials, but external validation is required.
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Affiliation(s)
- Harry T. Jordan
- Clinical Neuroscience Laboratory, Department of Medicine, The University of Auckland, Auckland, New Zealand
| | - Cathy M. Stinear
- Clinical Neuroscience Laboratory, Department of Medicine, The University of Auckland, Auckland, New Zealand
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9
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Long JC, Carrigan A, Roberts N, Clay-Williams R, Hibbert PD, Zurynski Y, Maka K, Loy G, Braithwaite J. Consumer and provider perceptions of the specialist unit model of care: A qualitative study. PLoS One 2024; 19:e0293025. [PMID: 38346042 PMCID: PMC10861032 DOI: 10.1371/journal.pone.0293025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 10/04/2023] [Indexed: 02/15/2024] Open
Abstract
BACKGROUND Specialist care units cater to targeted cohorts of patients, applying evidence-based practice to people with a specific condition (e.g., dementia) or meeting other specific criteria (e.g., children). This paper aimed to collate perceptions of local consumers and health providers around specialist care units, as a model of care that may be considered for a new local healthcare facility. METHODS This was a qualitative study using two-hour workshops and interviews to collect data. Participants were consumers and health providers in the planned facility's catchment: 49 suburbs in metropolitan Australia. Consumers and health providers were recruited through advertisements and emails. An initial survey collected demographic details. Consumers and health providers participated in separate two-hour workshops in which a scenario around the specialist unit model was presented and discussion on benefits, barriers and enablers of the model was led by researchers. Detailed notes were taken for analysis. RESULTS Five consumer workshops (n = 22 participants) and five health provider workshops (n = 42) were conducted. Participants were representative of this culturally diverse region. Factors identified by participants as relevant to the specialist unit model of care included: accessibility; a perceived narrow scope of practice; coordination with other services; resources and infrastructure; and awareness and expectations of the units. Some factors identified as risks or barriers when absent were identified as strengths and enablers when present by both groups of participants. CONCLUSIONS Positive views of the model centred on the higher perceived quality of care received in the units. Negative views centred on a perceived narrow scope of care and lack of flexibility. Consumers hinted, and providers stated explicitly, that the model needed to be complemented by an integrated model of care model to enable continuity of care and easy transfer of patients into and out of the specialist unit.
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Affiliation(s)
- Janet C. Long
- Australian Institute of Health Innovation, Macquarie University, Sydney, Australia
| | - Ann Carrigan
- Australian Institute of Health Innovation, Macquarie University, Sydney, Australia
| | - Natalie Roberts
- Australian Institute of Health Innovation, Macquarie University, Sydney, Australia
| | - Robyn Clay-Williams
- Australian Institute of Health Innovation, Macquarie University, Sydney, Australia
| | - Peter D. Hibbert
- Australian Institute of Health Innovation, Macquarie University, Sydney, Australia
- IIMPACT in Health, Allied Health and Human Performance, University of South Australia, Adelaide, South Australia, Australia
| | - Yvonne Zurynski
- Australian Institute of Health Innovation, Macquarie University, Sydney, Australia
| | - Katherine Maka
- Western Sydney Local Health District, Sydney, New South Wales, Australia
| | - Graeme Loy
- Western Sydney Local Health District, Sydney, New South Wales, Australia
| | - Jeffrey Braithwaite
- Australian Institute of Health Innovation, Macquarie University, Sydney, Australia
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10
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Wing JJ, Rajczyk JI, Burke JF. Geographic Distribution of Social Service Resources for Stroke Survivors in Ohio Varies by Rurality. Stroke 2023; 54:3128-3137. [PMID: 37942643 DOI: 10.1161/strokeaha.123.043929] [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: 05/17/2023] [Accepted: 09/21/2023] [Indexed: 11/10/2023]
Abstract
BACKGROUND Both social service resources and stroke prevalence vary by geography, and health care resources are scarcer in rural areas. We assessed whether distributions of resources relevant to stroke survivors were clustered around areas of the highest stroke prevalence in Ohio and whether this is varied by rurality using an ecological study design. METHODS Census tract (CT)-level self-reported stroke prevalence estimates (Centers for Disease Control and Prevention PLACES-2019 Behavioral Risk Factor Surveillance System) were linked with sociodemographic and rurality data (2019 American Community Survey) and geographic density of resources in Ohio (2020 findhelp data). Resources were grouped into categories: housing, in-home, financial, transportation, education, and therapy. Negative binomial regression models estimated the mean number of resources within 25 miles and 30 minutes of a CT centroid and quartiles of stroke prevalence for each resource group by rurality status (rural, urban, and suburban). Models were sequentially adjusted for total population and CT demographics. RESULTS In Ohio, stroke prevalence was 3.9% (0.4%-14.2%). The highest stroke prevalence quartile (versus lowest) was associated with fewer resources within 25 miles overall (resource ratio [RR], 0.57-0.98). The most pronounced disparities were in rural CT; rural CTs with the highest quartile stroke prevalence had fewer housing (RR, 0.49 [95% CI, 0.32-0.75]), in-home (RR, 0.31 [95% CI, 0.20-0.49]), and therapy (RR, 0.23 [95% CI, 0.13-0.43]) resources compared with those with the lowest quartile stroke prevalence (reference: mean, 1.2 housing, 5.1 in-home, and 4.9 therapy resources, respectively). Rural disparities no longer persisted after adjustment for federal poverty limit (rural: housing [RR, 0.69 (95% CI, 0.40-1.20)], in-home [RR, 0.65 (95% CI, 0.34-1.23)], and therapy [RR, 0.66 (95% CI, 0.33-1.32)]). CONCLUSIONS Stroke social service resources are inversely distributed relative to stroke prevalence in Ohio, particularly in rural areas. This inverse link in rural Ohio is likely explained by geographic differences in poverty. Stroke-specific resource-related interventions may be needed and should consider the roles of rurality and poverty.
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Affiliation(s)
- Jeffrey J Wing
- Division of Epidemiology, College of Public Health (J.J.W., J.I.R.), The Ohio State University, Columbus
| | - Jenna I Rajczyk
- Division of Epidemiology, College of Public Health (J.J.W., J.I.R.), The Ohio State University, Columbus
| | - James F Burke
- Department of Neurology, Wexner Medical Center (J.F.B.), The Ohio State University, Columbus
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11
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Steiger K, Singh R, Fox WC, Koester S, Brown N, Shahrestani S, Miller DA, Patel NP, Catapano JS, Srinivasan VM, Meschia JF, Erben Y. Procedural, workforce, and reimbursement trends in neuroendovascular procedures. J Neurointerv Surg 2023; 15:909-913. [PMID: 35961665 DOI: 10.1136/jnis-2022-019297] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 08/07/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND This study aims to define the proportion of Medicare neuroendovascular procedures performed by different specialists from 2013 to 2019, map the geographic distribution of these specialists, and trend reimbursement for these procedures. METHODS The Medicare Provider Utilization Database was queried for recognized neuroendovascular procedures. Data on specialists and their geographic distribution were tabulated. Reimbursement data were gathered using the Physician Fee Schedule Look-Up Tool and adjusted for inflation using the United States Bureau of Labor Statistics' Consumer Price Index Inflation calculator. RESULTS The neuroendovascular workforce in 2013 and 2019, respectively, was as follows: radiologists (46% vs 44%), neurosurgeons (45% vs 35%), and neurologists (9% vs 21%). Neurologists increased proportionally (p=0.03). Overall procedure numbers increased across each specialty: radiology (360%; p=0.02), neurosurgery (270%; p<0.01), and neurology (1070%; p=0.03). Neuroendovascular revascularization (CPT 61645) increased in all fields: radiology (170%; p<0.01), neurosurgery (280%; p<0.01), neurology (240%; p<0.01); central nervous system (CNS) permanent occlusion/embolization (CPT61624) in neurosurgery (67%; p=0.03); endovascular temporary balloon artery occlusion (CPT61623) in neurology (29%; p=0.04). In 2019, radiologists were the most common neuroendovascular specialists everywhere except in the Northeast where neurosurgeons predominated. Inflation adjusted reimbursement decreased for endovascular temporary balloon occlusion (CPT61623, -13%; p=0.01), CNS transcatheter permanent occlusion or embolization (CPT61624, -13%; p=0.02), non-CNS transcatheter permanent occlusion or embolization (CPT61626, -12%; p<0.01), and intracranial stent placement (CPT61635, -12%; p=0.05). CONCLUSIONS The number of neuroendovascular procedures and specialists increased, with neurologists becoming more predominant. Reimbursement decreased. Coordination among neuroendovascular specialists in terms of training and practice location may maximize access to acute care.
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Affiliation(s)
- Kyle Steiger
- Division of Vascular and Endovascular Surgery, Mayo Clinic in Florida, Jacksonville, Florida, USA
| | - Rohin Singh
- Neurosurgery, Mayo Clinic Arizona, Scottsdale, Arizona, USA
| | | | - Stefan Koester
- Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Nolan Brown
- Neurosurgery, Mayo Clinic Arizona, Scottsdale, Arizona, USA
| | | | - David A Miller
- Radiology, Mayo Clinic in Florida, Jacksonville, Florida, USA
| | - Naresh P Patel
- Neurosurgery, Mayo Clinic Arizona, Scottsdale, Arizona, USA
| | | | | | - James F Meschia
- Neurology, Mayo Clinic in Florida, Jacksonville, Florida, USA
| | - Young Erben
- Division of Vascular and Endovascular Surgery, Mayo Clinic in Florida, Jacksonville, Florida, USA
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12
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Yoon SY, Kim YW, Park JM, Yang SN. Accessibility for Rehabilitation Therapy According to Socioeconomic Status in Patients With Stroke: A Population-Based Retrospective Cohort Study. BRAIN & NEUROREHABILITATION 2023; 16:e16. [PMID: 37554252 PMCID: PMC10404810 DOI: 10.12786/bn.2023.16.e16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2023] [Revised: 07/01/2023] [Accepted: 07/03/2023] [Indexed: 08/10/2023] Open
Abstract
This study aimed to investigate accessibility for rehabilitation therapy according to socioeconomic status (SES) after stroke using nationwide population-based cohort data. We selected patients with a diagnosis with stroke (International Classification of Diseases, 10th Revision code: I60-64) and SES including residential area, income level, and insurance type were also assessed. Receiving continuous rehabilitation therapy was defined as accumulation of "Rehabilitative developmental therapy for disorder of central nervous system (claim code: MM105)" more than 41 times. Logistic regression analyses were performed to investigate the association between SES and rehabilitation therapy using odds ratios (ORs) and 95% confidence intervals (CIs). A total of 18,842 patients with stroke were enrolled. Rural area (OR, 0.745; 95% CI, 0.664-0.836) and medical aid (OR, 0.605; 95% CI, 0.494-0.741) were associated with lower rate of receiving rehabilitation therapy. As for income level, when lowest income group was used as a reference group, low-middle group showed an increased rate of receiving rehabilitation therapy (OR, 1.206; 95% CI, 1.020-1.426). Although rehabilitation therapy after stroke is covered with national health insurance program in Korea, there still existed disparities of accessibility for rehabilitation therapy according to SES. Our results would suggest helpful information for health policy in patients with stroke.
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Affiliation(s)
- Seo Yeon Yoon
- Department and Research Institute of Rehabilitation Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Yong Wook Kim
- Department and Research Institute of Rehabilitation Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Jong Mi Park
- Department and Research Institute of Rehabilitation Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Seung Nam Yang
- Department of Physical Medicine & Rehabilitation, Korea University Guro Hospital, Seoul, Korea
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13
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Kim J, Cadilhac DA, Thompson S, Gommans J, Davis A, Barber PA, Fink J, Harwood M, Levack W, McNaughton H, Abernethy V, Girvan J, Feigin V, Denison H, Corbin M, Wilson A, Douwes J, Ranta A. Comparison of Stroke Care Costs in Urban and Nonurban Hospitals and Its Association With Outcomes in New Zealand: A Nationwide Economic Evaluation. Stroke 2023; 54:848-856. [PMID: 36848424 DOI: 10.1161/strokeaha.122.040869] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/01/2023]
Abstract
BACKGROUND Although geographical differences in treatment and outcomes after stroke have been described, we lack evidence on differences in the costs of treatment between urban and nonurban regions. Additionally, it is unclear whether greater costs in one setting are justified given the outcomes achieved. We aimed to compare costs and quality-adjusted life years in people with stroke admitted to urban and nonurban hospitals in New Zealand. METHODS Observational study of patients with stroke admitted to the 28 New Zealand acute stroke hospitals (10 in urban areas) recruited between May and October 2018. Data were collected up to 12 months poststroke including treatments in hospital, inpatient rehabilitation, other health service utilization, aged residential care, productivity, and health-related quality of life. Costs in New Zealand dollars were estimated from a societal perspective and assigned to the initial hospital that patients presented to. Unit prices for 2018 were obtained from government and hospital sources. Multivariable regression analyses were conducted when assessing differences between groups. RESULTS Of 1510 patients (median age 78 years, 48% female), 607 presented to nonurban and 903 to urban hospitals. Mean hospital costs were greater in urban than nonurban hospitals ($13 191 versus $11 635, P=0.002), as were total costs to 12 months ($22 381 versus $17 217, P<0.001) and quality-adjusted life years to 12 months (0.54 versus 0.46, P<0.001). Differences in costs and quality-adjusted life years remained between groups after adjustment. Depending on the covariates included, costs per additional quality-adjusted life year in the urban hospitals compared to the nonurban hospitals ranged from $65 038 (unadjusted) to $136 125 (covariates: age, sex, prestroke disability, stroke type, severity, and ethnicity). CONCLUSIONS Better outcomes following initial presentation to urban hospitals were associated with greater costs compared to nonurban hospitals. These findings may inform greater targeted expenditure in some nonurban hospitals to improve access to treatment and optimize outcomes.
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Affiliation(s)
- Joosup Kim
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Department of Medicine, Monash University, Clayton, Australia (J.K., D.A.C.).,Stroke Division, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Heidelberg, Australia (J.K., D.A.C.)
| | - Dominique A Cadilhac
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Department of Medicine, Monash University, Clayton, Australia (J.K., D.A.C.).,Stroke Division, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Heidelberg, Australia (J.K., D.A.C.)
| | - Stephanie Thompson
- Department of Medicine, University of Otago, Wellington, New Zealand (S.T., W.L., A.R.)
| | - John Gommans
- Department of Medicine, Hawkes's Bay Hospital, Hastings, New Zealand (J. Gommans)
| | - Alan Davis
- Department of Medicine, Whangarei Hospital, New Zealand (A.D.)
| | - P Alan Barber
- Department of Medicine, University of Auckland, New Zealand (P.A.B.)
| | - John Fink
- Department of Neurology, Christchurch Hospital, New Zealand (J.F.)
| | - Matire Harwood
- Department of General Practice and Primary Healthcare, University of Auckland, New Zealand (M.H.)
| | - William Levack
- Department of Medicine, University of Otago, Wellington, New Zealand (S.T., W.L., A.R.)
| | - Harry McNaughton
- Medical Research Institute of New Zealand, Wellington, New Zealand (H.M.)
| | | | | | - Valery Feigin
- National Institute for Stroke and Applied Neurosciences, Auckland University of Technology, New Zealand (V.F.)
| | - Hayley Denison
- Research Centre for Hauora and Health, Massey University, Wellington, New Zealand (H.D., M.C., J.D.)
| | - Marine Corbin
- Research Centre for Hauora and Health, Massey University, Wellington, New Zealand (H.D., M.C., J.D.)
| | - Andrew Wilson
- Department of Medicine, Wairau Hospital, Blenheim, New Zealand (A.W.)
| | - Jeroen Douwes
- Research Centre for Hauora and Health, Massey University, Wellington, New Zealand (H.D., M.C., J.D.)
| | - Anna Ranta
- Department of Medicine, University of Otago, Wellington, New Zealand (S.T., W.L., A.R.).,Department of Neurology, Wellington Hospital, New Zealand (A.R.)
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14
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MARTIN RA, JOHNS JK, HACKNEY JJ, BOURKE JA, YOUNG TJ, NUNNERLEY JL, SNELL DL, DERRETT S, DUNN JA. Early Opportunities to Explore Occupational Identity Change: Qualitative Study of Return-To-Work Experiences After Stroke. J Rehabil Med 2023; 55:jrm00363. [PMID: 36748979 PMCID: PMC9926496 DOI: 10.2340/jrm.v55.4825] [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: 10/03/2022] [Accepted: 11/18/2022] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Rates of return-to-work after stroke are low, yet work is known to positively impact people's wellbeing and overall health outcomes. OBJECTIVE To understand return-to-work trajectories, barriers encountered, and resources that may be used to better support participants during early recovery and rehabilitation. PARTICIPANTS The experiences of 31 participants (aged 25-76 years) who had or had not returned to work after stroke were explored. METHODS Interview data were analysed using reflexive thematic analysis methods within a broader realist research approach. RESULTS Participants identified an early need to explore a changed and changing occupational identity within a range of affirming environments, thereby ascertaining their return-to-work options early after stroke. The results articulate resources participants identified as most important for their occupational explorations. Theme 1 provides an overview of opportunities participants found helpful when exploring work options, while theme 2 explores fundamental principles for ensuring the provided opportunities were perceived as beneficial. Finally, theme 3 provides an overview of prioritized return-to-work service characteristics. CONCLUSION The range and severity of impairments experienced by people following stroke are broad, and therefore their return-to-work needs are diverse. However, all participants, irrespective of impairment, highlighted the need for early opportunities to explore their changed and changing occupational identity.
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Affiliation(s)
- Rachelle A. MARTIN
- Burwood Academy Trust, Christchurch,Department of Medicine, University of Otago Wellington
| | | | | | - John A. BOURKE
- Burwood Academy Trust, Christchurch,Ngāi Tahu Māori Health Research Unit, University of Otago, Dunedin
| | | | - Joanne L. NUNNERLEY
- Burwood Academy Trust, Christchurch,Department of Orthopaedic Surgery and Musculoskeletal Medicine, University of Otago Christchurch
| | - Deborah L. SNELL
- Department of Orthopaedic Surgery and Musculoskeletal Medicine, University of Otago Christchurch
| | - Sarah DERRETT
- Department of Preventive and Social Medicine, University of Otago, Dunedin, New Zealand
| | - Jennifer A. DUNN
- Department of Orthopaedic Surgery and Musculoskeletal Medicine, University of Otago Christchurch
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15
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Fasugba O, Dale S, McInnes E, Cadilhac DA, Noetel M, Coughlan K, McElduff B, Kim J, Langley T, Cheung NW, Hill K, Pollnow V, Page K, Sanjuan Menendez E, Neal E, Griffith S, Christie LJ, Slark J, Ranta A, Levi C, Grimshaw JM, Middleton S. Evaluating remote facilitation intensity for multi-national translation of nurse-initiated stroke protocols (QASC Australasia): a protocol for a cluster randomised controlled trial. Implement Sci 2023; 18:2. [PMID: 36703172 PMCID: PMC9879239 DOI: 10.1186/s13012-023-01260-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 01/06/2023] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Facilitated implementation of nurse-initiated protocols to manage fever, hyperglycaemia (sugar) and swallowing difficulties (FeSS Protocols) in 19 Australian stroke units resulted in reduced death and dependency for stroke patients. However, a significant gap remains in translating this evidence-based care bundle protocol into standard practice in Australia and New Zealand. Facilitation is a key component for increasing implementation. However, its contribution to evidence translation initiatives requires further investigation. We aim to evaluate two levels of intensity of external remote facilitation as part of a multifaceted intervention to improve FeSS Protocol uptake and quality of care for patients with stroke in Australian and New Zealand acute care hospitals. METHODS A three-arm cluster randomised controlled trial with a process evaluation and economic evaluation. Australian and New Zealand hospitals with a stroke unit or service will be recruited and randomised in blocks of five to one of the three study arms-high- or low-intensity external remote facilitation or a no facilitation control group-in a 2:2:1 ratio. The multicomponent implementation strategy will incorporate implementation science frameworks (Theoretical Domains Framework, Capability, Opportunity, Motivation - Behaviour Model and the Consolidated Framework for Implementation Research) and include an online education package, audit and feedback reports, local clinical champions, barrier and enabler assessments, action plans, reminders and external remote facilitation. The primary outcome is implementation effectiveness using a composite measure comprising six monitoring and treatment elements of the FeSS Protocols. Secondary outcome measures are as follows: composite outcome of adherence to each of the combined monitoring and treatment elements for (i) fever (n=5); (ii) hyperglycaemia (n=6); and (iii) swallowing protocols (n=7); adherence to the individual elements that make up each of these protocols; comparison for composite outcomes between (i) metropolitan and rural/remote hospitals; and (ii) stroke units and stroke services. A process evaluation will examine contextual factors influencing intervention uptake. An economic evaluation will describe cost differences relative to each intervention and study outcomes. DISCUSSION We will generate new evidence on the most effective facilitation intensity to support implementation of nurse-initiated stroke protocols nationwide, reducing geographical barriers for those in rural and remote areas. TRIAL REGISTRATION ACTRN12622000028707. Registered 14 January, 2022.
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Affiliation(s)
- O Fasugba
- Nursing Research Institute, St Vincent's Health Network Sydney & St Vincent's Hospital Melbourne & Australian Catholic University, Level 5, deLacy Building, St. Vincent's Hospital, 390 Victoria Street, Darlinghurst, NSW, 2010, Australia
- School of Nursing, Midwifery and Paramedicine, Australian Catholic University, Sydney, Australia
| | - S Dale
- Nursing Research Institute, St Vincent's Health Network Sydney & St Vincent's Hospital Melbourne & Australian Catholic University, Level 5, deLacy Building, St. Vincent's Hospital, 390 Victoria Street, Darlinghurst, NSW, 2010, Australia
- School of Nursing, Midwifery and Paramedicine, Australian Catholic University, Sydney, Australia
| | - E McInnes
- Nursing Research Institute, St Vincent's Health Network Sydney & St Vincent's Hospital Melbourne & Australian Catholic University, Level 5, deLacy Building, St. Vincent's Hospital, 390 Victoria Street, Darlinghurst, NSW, 2010, Australia
- School of Nursing, Midwifery and Paramedicine, Australian Catholic University, Sydney, Australia
| | - D A Cadilhac
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia
| | - M Noetel
- School of Psychology, University of Queensland, Brisbane, Australia
| | - K Coughlan
- Nursing Research Institute, St Vincent's Health Network Sydney & St Vincent's Hospital Melbourne & Australian Catholic University, Level 5, deLacy Building, St. Vincent's Hospital, 390 Victoria Street, Darlinghurst, NSW, 2010, Australia
- School of Nursing, Midwifery and Paramedicine, Australian Catholic University, Sydney, Australia
| | - B McElduff
- Nursing Research Institute, St Vincent's Health Network Sydney & St Vincent's Hospital Melbourne & Australian Catholic University, Level 5, deLacy Building, St. Vincent's Hospital, 390 Victoria Street, Darlinghurst, NSW, 2010, Australia
- School of Nursing, Midwifery and Paramedicine, Australian Catholic University, Sydney, Australia
| | - J Kim
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia
| | - T Langley
- St Vincent's Health Network Sydney, Sydney, New South Wales, Australia
| | - N W Cheung
- Centre for Diabetes and Endocrinology Research, Westmead Hospital and University of Sydney, Sydney, New South Wales, Australia
| | - K Hill
- Stroke Foundation, Sydney, New South Wales, Australia
| | - V Pollnow
- St Vincent's Health Network Sydney, Sydney, New South Wales, Australia
| | - K Page
- St Vincent's Health Network Sydney, Sydney, New South Wales, Australia
| | | | - E Neal
- Prince of Wales Hospital, Randwick, New South Wales, Australia
| | - S Griffith
- School of Psychology, University of Queensland, Brisbane, Australia
| | - L J Christie
- Allied Health Research Unit, St Vincent's Health Network, Sydney, Australia
- School of Allied Health, Faculty of Health Sciences, Australian Catholic University, Sydney, Australia
| | - J Slark
- School of Nursing, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - A Ranta
- Department of Medicine, University of Otago Wellington, Wellington, New Zealand
- Department of Neurology, Wellington Hospital, Wellington, New Zealand
| | - C Levi
- John Hunter Health and Innovation Precinct, New Lambton Heights, New South Wales, Australia
- Department of Medicine, University of Newcastle, Newcastle, New South Wales, Australia
| | - J M Grimshaw
- University of Ottawa, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Canada
| | - S Middleton
- Nursing Research Institute, St Vincent's Health Network Sydney & St Vincent's Hospital Melbourne & Australian Catholic University, Level 5, deLacy Building, St. Vincent's Hospital, 390 Victoria Street, Darlinghurst, NSW, 2010, Australia.
- School of Nursing, Midwifery and Paramedicine, Australian Catholic University, Sydney, Australia.
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16
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Brewer KM, Taki TW, Heays G, Purdy SC. Tino rangatiratanga – a rural Māori community’s response to stroke: ‘I’m an invalid but I’m not invalid’. J R Soc N Z 2022. [DOI: 10.1080/03036758.2022.2132964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
| | | | - Grace Heays
- School of Psychology, The University of Auckland, Auckland, New Zealand
| | - Suzanne C. Purdy
- School of Psychology, The University of Auckland, Auckland, New Zealand
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