125 STROKE SURVIVOR AND CARER EXPERIENCES OF NAVIGATION OF STROKE SERVICES AND INFORMATION IN IRELAND: AN EXPLORATORY QUALITATIVE INTERVIEW STUDY

Background

Patient navigation of stroke services is challenging, as survivors have diverse and complex needs, and clear care pathways are often lacking, particularly in the post-acute phase. Exploring the views of stroke survivors and main carers is critical to understanding these navigational challenges.

Methods

In-depth semi-structured interviews were conducted online or by phone with stroke survivors (n=16) and main carers (n=13) recruited through voluntary organisations and social media. Participants with communication or cognitive difficulties were included, and provided with accessible information materials. Interviews were audio-recorded and transcribed. Framework analysis was used, involving data familiarisation, coding, development of an analytic framework, charting and interpretation. Ryvicker’s (2018) behavioral-ecological conceptual framework for patient navigation was used to inform the analytic framework.

Results

Barriers to successful patient navigation at the healthcare system level included complex and unclear eligibility criteria for services and entitlements, including arbitrary age limits; geographical variation; and waiting times for services, particularly rehabilitation. Having a skilled or knowledgeable advocate, such as a family member with experience of the healthcare system, was a key enabling factor. Survivors and carers had to be pro-active and “push” or “battle” for needed services and information. Navigation often involved a substantial administrative burden, which survivors and caregivers had to manage in addition to the demands of the stroke itself, the recovery process, and in many cases other co-morbidities. Healthcare provider factors that supported navigation included clear communication with survivors/carers about services and the stroke itself. Staff who specifically supported care co-ordination were helpful, but this tended to be ad-hoc and limited in availability.

Conclusion

Dedicated staff to support patient navigation across the care continuum could make a significant difference to stroke survivor access to services and consequently outcomes. Clearer, standardised and more person-centred referrals pathways, that are widely publicised and understood, would also improve access.

119 ENHANCING THE QUALITY OF STROKE CARE IN IRELAND - DEVELOPMENT OF AN IRISH NATIONAL STROKE AUDIT

Background

Population ageing, stroke treatment advances, changing models of care, and between-hospital heterogeneity in stroke outcomes demonstrate the necessity of continual audit of stroke care to support quality improvement at local and national levels, and to enhance patient recovery and wellbeing. This project aims to identify the core minimum datasets for acute and non-acute stroke care, and Patient-Reported Outcome Measures (PROMs), for integration in to the newly-developed Irish National Audit of Stroke (INAS), in addition to identifying resourcing needs and implementation procedures.

Methods

In Phase 1, a minimum dataset for acute stroke care was identified based on a scoping review of international practice and available guidelines. Phase 2 (ongoing) involves identifying datasets for non-acute rehabilitative and follow-up care based on a scoping review of international practice, iterative cycles of qualitative stakeholder engagement, and systematic review of PROMs. In Phase 3, a review of resourcing and data collection procedures used in stroke audits internationally will be used to produce an implementation strategy for data collection, contextualised to the Irish healthcare system.

Results

Twenty-one eligible international stroke registries were identified from the scoping review. Within Phase 1, core clinical and thrombectomy items in the Irish registry were benchmarked against internationally-collected items to identify common items and to generate an inventory of items that other registries collect that Ireland does not. Based on consensus agreement on the most frequently-occurring international items, as reviewed by key stakeholders, a core minimum dataset for audit of acute stroke care was delivered.

Conclusion

These minimum datasets shall act as the “gold standard” for evaluating stroke care in Ireland, by not only incorporating structure, process, and care quality outcome indicators, but also PROMs. The resultant datasets may inform policy and quality improvement initiatives, and shape health service delivery across the trajectory of stroke care, from hyper-acute care, to rehabilitation, and return to the community.

CASP-19 special section: how does chronic disease status affect CASP quality of life at older ages? Examining the WHO ICF disability domains as mediators of this relationship

OBJECTIVES

The effect of chronic disease status on quality of life (QoL) has been well established. However, less is known about how chronic diseases affect QoL. This article examines impairment in three domains of the WHO International Classification of Functioning, Health and Disability (ICF) - body function, activity and participation, as well as affective well-being, - as potential mediators of the relationship between chronic disease and QoL.

METHOD

A cross-sectional sample (n = 4961) of the general Irish community-dwelling population aged 50+ years was obtained from the Irish Longitudinal Study of Ageing (TILDA). The CASP measure of QoL was examined as two dimensions - control/autonomy and self-realisation/pleasure. Structural equation modelling was used to test the direct and indirect effects of chronic disease on QoL, via variables capturing body function, activity, participation and positive affect.

RESULTS

A factor analysis showed that indicators of body function and activity loaded onto a single overall physical impairment factor. This physical impairment factor fully mediated the effect of chronic disease on positive affect and QoL. The total effect of chronic disease on control/autonomy (-0.160) was primarily composed of an indirect effect via physical impairment (-0.86), and via physical impairment and positive affect (-0.45). The decomposition of effects on self-realisation/pleasure was similar, although the direct effect of physical impairment was weaker. The model fitted the data well (RMSEA = 0.02, TLI = 0.96, CFI = 0.96).

CONCLUSION

Chronic disease affects QoL through increased deficits in physical body function and activity. This overall physical impairment affects QoL both directly and indirectly via reduced positive affect.

Usefulness of clinical factors in predicting outcomes of passive tilt tests in patients with syncope

Pretest patient selection affects the outcome of many diagnostic tests; this may be true for tilt-table tests. We assessed the impact of patient age, sex, and symptom burden on the outcome of passive tilt tests. Two hundred one patients with idiopathic syncope (87 men, aged 45 +/- 20 years, median 5 fainting spells each) underwent passive, drug-free tilt tests for 45 minutes. Positive tests were defined as those ending in clinically reminiscent presyncope or syncope. Seventy-eight patients (39%) had a positive tilt test. Patients had a wide range of symptom burden, having a median 5 syncopal spells (interquartile range [IQR] 2.5 to 17.5) over a median 52.5 months (IQR 12 to 180) with a median frequency of 0.17 spells/month (IQR 0.042 to 0.67). None of these measures of symptom burden predicted tilt-test outcome (p = 0.33 to 0.46). In contrast, the age of the patient strongly predicted tilt-test outcome. The likelihood of a positive test was 75% in 36 patients < 25 years old and 31% in 165 patients > or = 25 years of age (p < 0.0001, chi-square for 2 x 5 table). Younger patients also fainted more quickly: patients < 25 years old fainted within 22 minutes of tilt and reached a clearly asymptotic value, whereas the likelihood of a positive tilt in patients > or = 25 years old increased linearly with time, and did not reach an asymptote. Measures of symptom burden do not predict test outcome, and younger patients are more likely to faint during passive tilt testing.

Gender differences in manifestation of cardiac arrhythmias

It is now appreciated that a patient's sex has a significant impact on presentation of cardiac diseases. This has been well described in patients with coronary artery disease but is less well appreciated in the setting of arrhythmia management. In Cardiology in Review in 1998, Tracy outlined some of the major differences between the sexes with regard to the electrocardiogram and the presentation of arrhythmias. Arrhythmia management also can be considerably different, and in this review, we address some additional aspects of differences between the sexes in this area.

The nutritional response to home enteral nutrition in childhood

The nutritional response to home enteral nutrition (HEN) was evaluated in a prospective study of 44 consecutive children (median age 48 months) who received HEN for more than 1 month (median duration 6 months). Three groups were studied: 17 children were stunted, 14 were wasted and 13 were adequately nourished but unlikely to maintain oral intake during anticipated nutritional stress. In the stunted group (median duration of HEN 15 months) there was a significant correlation between improvements in height-for-age z scores and duration of feeds (r = 0.63; p = 0.006). In the wasted group (median duration of HEN 4 months) all anthropometric indices improved significantly (p < 0.05). HEN was also successful in maintaining nutritional status in the third group. Thus, supplementary HEN is an effective method of nutritional support for a variety of indications, provided concurrent advice from a nutritional care team is available.