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Aran OT, Köse B, Erikson G, Guidetti S. Impact of stroke on people that receive rehabilitation and are living in Ankara, Turkey. J Public Health Res 2023; 12:22799036231204321. [PMID: 37822997 PMCID: PMC10563490 DOI: 10.1177/22799036231204321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 08/29/2023] [Indexed: 10/13/2023] Open
Abstract
Background Clinical guidelines for stroke rehabilitation and practices vary between high and low/middle-income countries (LMICs). Knowledge of the perceived impact of stroke in Turkey is limited. Understanding these perceptions can serve as a basis for developing rehabilitation. Design and methods The aim was to investigate and compare the perceived impact of stroke in two groups of people living in Ankara. A cross-sectional study with 150 participants divided by stroke onset (Group I: stroke onset <12 months; Group II: >12 months) was conducted. The Barthel Index was used to describe the level of independence in daily living activities and stroke severity. The Stroke Impact Scale (SIS 3.0) was used to investigate the perceived impact of stroke. Results The proportion of mild strokes was 78 and 82%, respectively, and 46% of participants in the total sample were moderately dependent. The impact of stroke was high; mean domain scores were below 50 in six of the eight SIS domains. Conclusions Turkish stroke survivors perceived a higher impact of stroke regardless of the time passed since stroke onset, compared to survivors from other countries, including other LMICs. The high impact among survivors with mostly mild stroke indicates that Turkish survivors might not receive adequate rehabilitation. The content of rehabilitation services needs to be developed, and an evaluation of individually tailored interventions, preferably with a multidisciplinary approach, is warranted to find ways to decrease the perceived impact of stroke among Turkish stroke survivors.
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Affiliation(s)
- Orkun Tahir Aran
- Department of Occupational Therapy, Faculty of Health Sciences, Hacettepe University, Ankara, Turkey
| | - Barkın Köse
- Occupational Therapy Department, Gülhane Faculty of Health Sciences, University of Health Sciences, Ankara, Turkey
| | - Gunilla Erikson
- Division of Occupational Therapy, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Huddinge, Sweden
| | - Susanne Guidetti
- Division of Occupational Therapy, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Huddinge, Sweden
- Theme Women’s Health and Allied Health Professionals, Medical Unit Occupational Therapy and Physiotherapy, Karolinska University Hospital, Huddinge, Sweden
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2
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Elf M, Rasoal D, Zingmark M, Kylén M. The importance of context-a qualitative study exploring healthcare practitioners' experiences of working with patients at home after a stroke. BMC Health Serv Res 2023; 23:733. [PMID: 37415156 DOI: 10.1186/s12913-023-09735-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 06/22/2023] [Indexed: 07/08/2023] Open
Abstract
BACKGROUND Stroke significantly impacts individuals, leading to the need for long-lasting rehabilitation and adaptation to environmental demands. Rehabilitation after stroke is increasingly performed in patients' homes, and it is argued that rehabilitation in this context is more person-centred and positively impacts client outcomes. However, the role of environmental factors in this process is largely unknown. The aim of this study was to explore how multidisciplinary healthcare practitioners working with rehabilitation in the home after stroke consider possibilities and challenges in the environment and how environmental factors are documented in patients' records. METHODS Eight multidisciplinary healthcare practitioners working with home-based rehabilitation after stroke participated in two semistructured focus group sessions. Thematic analysis was used to analyse the transcripts of recorded focus group discussions. Data were also collected from patient history records (N = 14) to identify interventions to increase patients' opportunities to participate in activities inside and outside the home. These records were analysed using life-space mobility as a conceptual framework. RESULTS The analysis generated four overarching themes concerning possibilities and challenges in the environment: (1) the image of rehabilitation conflicts with place, (2) the person in the home reveals individual needs and capabilities, (3) environmental characteristics influence the rehabilitation practice, and (4) the person is integrated within a social context. The patient record analysis showed that most patients were discharged from hospital to home within four days. Assessments at the hospital mainly focused on basic activities of daily living, such as the patient's self-care and walking ability. Also at home, the assessments and actions primarily focused on basic activities with little focus on participation in meaningful activities performed in different life situations outside the home. CONCLUSIONS Our research suggests that one way to improve practice is to include the environment in the rehabilitation and consider the person´s life space. Interventions should focus on supporting out-of-home mobility and activities as part of person-centred stroke rehabilitation. This must be supported by clear documentation in the patient records to strengthen clinical practice as well as the communication between stakeholders.
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Affiliation(s)
- Marie Elf
- School of Health and Welfare, Dalarna University, Falun, Sweden
| | - Dara Rasoal
- School of Health and Welfare, Dalarna University, Falun, Sweden
| | - Magnus Zingmark
- Department of Health Sciences, Lund University, Lund, Sweden
- Health and Social Care Administration, Östersund, Sweden
- Department of Epidemiology and Global Health, Faculty of Medicine, Umeå University, Umåe, Sweden
| | - Maya Kylén
- School of Health and Welfare, Dalarna University, Falun, Sweden.
- Department of Health Sciences, Lund University, Lund, Sweden.
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3
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Sørensen AL, Marschner IC. Linear mixed models for investigating effect modification in subgroup meta-analysis. Stat Methods Med Res 2023:9622802231163330. [PMID: 36924263 DOI: 10.1177/09622802231163330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2023]
Abstract
Subgroup meta-analysis can be used for comparing treatment effects between subgroups using information from multiple trials. If the effect of treatment is differential depending on subgroup, the results could enable personalization of the treatment. We propose using linear mixed models for estimating treatment effect modification in aggregate data meta-analysis. The linear mixed models capture existing subgroup meta-analysis methods while allowing for additional features such as flexibility in modeling heterogeneity, handling studies with missing subgroups and more. Reviews and simulation studies of the best suited models for estimating possible differential effect of treatment depending on subgroups have been studied mostly within individual participant data meta-analysis. While individual participant data meta-analysis in general is recommended over aggregate data meta-analysis, conducting an aggregate data subgroup meta-analysis could be valuable for exploring treatment effect modifiers before committing to an individual participant data subgroup meta-analysis. Additionally, using solely individual participant data for subgroup meta-analysis requires collecting sufficient individual participant data which may not always be possible. In this article, we compared existing methods with linear mixed models for aggregate data subgroup meta-analysis under a broad selection of scenarios using simulation and two case studies. Both the case studies and simulation studies presented here demonstrate the advantages of the linear mixed model approach in aggregate data subgroup meta-analysis.
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Affiliation(s)
- Anne Lyngholm Sørensen
- School of Mathematical and Physical Sciences, 7788Macquarie University, Sydney, Australia.,Section of Biostatistics, Department of Public Health, 4321University of Copenhagen, Denmark
| | - Ian C Marschner
- NHMRC Clinical Trials Centre, University of Sydney, Sydney, Australia
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4
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Sarzyńska-Długosz I. An optimal model of long-term post-stroke care. Front Neurol 2023; 14:1129516. [PMID: 37034084 PMCID: PMC10076665 DOI: 10.3389/fneur.2023.1129516] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 03/01/2023] [Indexed: 04/11/2023] Open
Abstract
Stroke is a major healthcare challenge that is increasing worldwide. The burden of stroke is significant for the affected individuals as well as for the general population; high-quality care is needed to reduce its negative impacts. This article synthesized information from systematic reviews, guidelines, and primary literature on stroke care and post-stroke rehabilitation and proposes an optimal strategy for long-term post-stroke care. It also highlights the unmet needs of patients who experienced a stroke in terms of early diagnosis of complications and adequate, comprehensive therapy.
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5
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Yan C, McClure N, Dukelow SP, Mann B, Round J. Optimal Planning of Health Services through Genetic Algorithm and Discrete Event Simulation: A Proposed Model and Its Application to Stroke Rehabilitation Care. MDM Policy Pract 2022; 7:23814683221134098. [PMID: 36310567 PMCID: PMC9597031 DOI: 10.1177/23814683221134098] [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: 05/02/2022] [Accepted: 09/21/2022] [Indexed: 12/03/2022] Open
Abstract
UNLABELLED Background. Increasing demand for provision of care to stroke survivors creates challenges for health care planners. A key concern is the optimal alignment of health care resources between provision of acute care, rehabilitation, and among different segments of rehabilitation, including inpatient rehabilitation, early supported discharge (ESD), and outpatient rehabilitation (OPR). We propose a novel application of discrete event simulation (DES) combined with a genetic algorithm (GA) to identify the optimal configuration of rehabilitation that maximizes patient benefits subject to finite health care resources. Design. Our stroke rehabilitation optimal model (sROM) combines DES and GA to identify an optimal solution that minimizes wait time for each segment of rehabilitation by changing care capacity across different segments. sROM is initiated by generating parameters for DES. GA is used to evaluate wait time from DES. If wait time meets specified stopping criteria, the search process stops at a point at which optimal capacity is reached. If not, capacity estimates are updated, and an additional iteration of the DES is run. To parameterize the model, we standardized real-world data from medical records by fitting them into probability distributions. A meta-analysis was conducted to determine the likelihood of stroke survivors flowing across rehabilitation segments. Results. We predict that rehabilitation planners in Alberta, Canada, have the potential to improve services by increasing capacity from 75 to 113 patients per day for ESD and from 101 to 143 patients per day for OPR. Compared with the status quo, optimal capacity would provide ESD to 138 (s = 29.5) more survivors and OPR to 262 (s = 45.5) more annually while having an estimated net annual cost savings of $25.45 (s = 15.02) million. Conclusions. The combination of DES and GA can be used to estimate optimal service capacity. HIGHLIGHTS We created a hybrid model combining a genetic algorithm and discrete event simulation to search for the optimal configuration of health care service capacity that maximizes patient outcomes subject to finite health system resources.We applied a probability distribution fitting process to standardize real-world data to probability distributions. The process consists of choosing the distribution type and estimating the parameters of that distribution that best reflects the data. Standardizing real-word data to a best-fitted distribution can increase model generalizability.In an illustrative study of stroke rehabilitation care, resource allocation to stroke rehabilitation services under an optimal configuration allows provision of care to more stroke survivors who need services while reducing wait time.Resources needed to expand rehabilitation services could be reallocated from the savings due to reduced wait time in acute care units. In general, the predicted optimal configuration of stroke rehabilitation services is associated with a net cost savings to the health care system.
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Affiliation(s)
- Charles Yan
- Charles Yan, Institute of Health Economics,
1200-10405 Jasper Ave, Edmonton, AB T5J 3N4, Canada;
()
| | - Nathan McClure
- Institute of Health Economics; School of
Publish Health, University of Alberta, Edmonton, AB, Canada
| | - Sean P. Dukelow
- Division of Physical Medicine and
Rehabilitation, Department of Clinical Neuroscience, University of Calgary
and Stroke Rehabilitation, Calgary, AB, Canada
| | - Balraj Mann
- Cardiovascular Health and Stroke Strategic
Clinical Network, Alberta Health Services, Edmonton, AB, Canada
| | - Jeff Round
- Institute of Health Economics, Edmonton, AB,
Canada,Department of Pediatrics, Faculty of Medicine
and Dentistry, University of Alberta, Edmonton, AB, Canada
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6
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García-Pérez P, Lara JP, Rodríguez-Martínez MDC, de la Cruz-Cosme C. Interventions within the Scope of Occupational Therapy in the Hospital Discharge Process Post-Stroke: A Systematic Review. Healthcare (Basel) 2022; 10:healthcare10091645. [PMID: 36141257 PMCID: PMC9498873 DOI: 10.3390/healthcare10091645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2022] [Revised: 08/19/2022] [Accepted: 08/22/2022] [Indexed: 11/16/2022] Open
Abstract
Stroke is one of the main causes of disability in adulthood. Its rehabilitation is a complex process that requires a multidisciplinary team of specialised professionals. The main goal of this review was to determine the impact of occupational therapy intervention post-stroke on the home discharge process. A systematic search was carried out of the following databases: Pubmed, Web of Science, PsycINFO, Scopus, Otseeker, and Dialnet. A screening was performed taking into account the type of article, including exclusively RCT, and type of intervention, only including interventions within the scope of occupational therapy that take place during the process of hospital discharge post-stroke. A total of 2285 citations were identified in the search from which 13 articles met the inclusion criteria. Comparisons of the groups indicated that early occupational therapy intervention during the process of hospital discharge can be effective in terms of functional recovery and can lead to the caregiver seeing improvements in self-efficacy and fatigue. In addition, the inclusion of a caregiver in the intervention influences the patient’s adherence to treatment, leading to a reduction in the cost of treatment and rehabilitation.
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Affiliation(s)
- Patricia García-Pérez
- Faculty of Medicine, University of Málaga, Blvr. Louis Pasteur, 32, 29010 Málaga, Spain
- Occupational Therapy Department, Virgen de la Victoria University Hospital, Servicio Andaluz de Salud (SAS), 29010 Málaga, Spain
| | - José Pablo Lara
- Faculty of Medicine, University of Málaga, Blvr. Louis Pasteur, 32, 29010 Málaga, Spain
- Brain Health Unit, CIMES, 29010 Málaga, Spain
- Malaga Biomedical Research Institute (IBIMA), 29010 Málaga, Spain
- Correspondence: (J.P.L.); (M.C.R.-M.)
| | - María del Carmen Rodríguez-Martínez
- Department of Physiotherapy, Faculty of Health Sciences, University of Málaga, C/Arquitecto Francisco Peñalosa 3, 29071 Málaga, Spain
- Correspondence: (J.P.L.); (M.C.R.-M.)
| | - Carlos de la Cruz-Cosme
- Malaga Biomedical Research Institute (IBIMA), 29010 Málaga, Spain
- Neurology Department, Virgen de la Victoria University Hospital, 29010 Málaga, Spain
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7
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Cameron TM, Koller K, Byrne A, Chouliara N, Robinson T, Langhorne P, Walker M, Fisher RJ. A qualitative study exploring how stroke survivors' expectations and understanding of stroke Early Supported Discharge shaped their experience and engagement with the service. Disabil Rehabil 2022:1-8. [PMID: 35895746 DOI: 10.1080/09638288.2022.2102251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
PURPOSE To explore how stroke survivors' expectations and understanding of Early Supported Discharge (ESD) helped them make sense of their experiences, and shaped their engagement with the service. METHODS Data were collected as part of a study of large-scale implementation of stroke ESD: the WISE realist mixed-methods study. Semi-structured interviews were conducted with five purposefully selected stroke survivors from six sites in England implementing stroke ESD (n = 30). Participants were aged 32-88 years (20 males). Interviews were audio recorded, transcribed verbatim and transcripts were analysed using reflexive thematic analysis. RESULTS Three overarching themes were identified: (1) ESD as a post-stroke recovery tool, (2) desire to recover quickly, (3) psychosocial impact and support. Stroke survivors were uncertain about what to expect when they first entered the service, however, their experience of ESD exceeded their expectations and increased their engagement with the service. Stroke survivors especially valued the goal-oriented approach the team adopted. Rehabilitation at home was perceived as positive and practical, encouraging independence within real-life contexts. Psycho-social support played an important role in the stroke survivors' rehabilitation. CONCLUSIONS Ensuring stroke survivors are fully informed about ESD and what to expect, optimises engagement with the services, improves experience and could enhance outcomes.IMPLICATIONS FOR REHABILITATIONInforming stroke survivors about what to expect from ESD services could optimise engagement and improve their experience.The provision of personalised and target focussed therapy at home improves stroke survivors' experience and could potentially accelerate recovery.Preparing stroke survivors early for discharge from ESD can reduce anxiety and enhance engagement with the service.
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8
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Feldman PH, McDonald MV, Onorato N, Stein J, Williams O. Feasibility of deploying peer coaches to mentor frontline home health aides and promote mobility among individuals recovering from a stroke: pilot test of a randomized controlled trial. Pilot Feasibility Stud 2022; 8:22. [PMID: 35101133 PMCID: PMC8801561 DOI: 10.1186/s40814-022-00979-4] [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: 01/25/2021] [Accepted: 01/11/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Each year, approximately 100,000 individuals receive home health services after a stroke. Evidence has shown the benefits of home-based stroke rehabilitation, but little is known about resource-efficient ways to enhance its effectiveness, nor has anyone explored the value of leveraging low-cost home health aides (HHAs) to reinforce repetitive task training, a key component of home-based rehabilitation. We developed and piloted a Stroke Homehealth Aide Recovery Program (SHARP) that deployed specially trained HHAs as "peer coaches" to mentor frontline aides and help individuals recovering from stroke increase their mobility through greater adherence to repetitive exercise regimens. We assessed the feasibility of SHARP and its readiness for a full-scale randomized controlled trial (RCT). Specifically, we examined (1) the practicability of recruitment and randomization procedures, (2) program acceptability, (3) intervention fidelity, and (4) the performance of outcome measures. METHODS This was a feasibility study including a pilot RCT. Target enrollment was 60 individuals receiving post-stroke home health services, who were randomized to SHARP + usual home care or usual care only. The protocol specified a 30-day intervention with four planned in-home coach visits, including one joint coach/physical therapist visit. The primary participant outcome was 60-day change in mobility, using the performance-based Timed Up and Go and 4-Meter Walk Gait Speed tests. Interviews with participants, coaches, physical therapists, and frontline aides provided acceptability data. Enrollment figures, visit tracking reports, and audio recordings provided intervention fidelity data. Mixed methods included thematic analysis of qualitative data and quantitative analysis of structured data to examine the intervention feasibility and performance of outcome measures. RESULTS Achieving the 60-participant enrollment target required modifying participant eligibility criteria to accommodate a decline in the receipt of HHA services among individuals receiving home care after a stroke. This modification entailed intervention redesign. Acceptability was high among coaches and participants but lower among therapists and frontline aides. Intervention fidelity was mixed: 87% of intervention participants received all four planned coach visits; however, no joint coach/therapist visits occurred. Sixty-day follow-up retention was 78%. However, baseline and follow-up performance-based primary outcome mobility assessments could be completed for only 55% of participants. CONCLUSIONS The trial was not feasible in its current form. Before progressing to a definitive trial, significant program redesign would be required to address issues affecting enrollment, coach/HHA/therapist coordination, and implementation of performance-based outcome measures. TRIAL REGISTRATION ClinicalTrials.gov, NCT04840407 . Retrospectively registered on 9 April 2021.
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Affiliation(s)
- Penny H Feldman
- Center for Home Care Policy & Research, Visiting Nurse Service of New York, 220 East 42nd Street, New York, NY, 10017, USA
| | - Margaret V McDonald
- Center for Home Care Policy & Research, Visiting Nurse Service of New York, 220 East 42nd Street, New York, NY, 10017, USA.
| | - Nicole Onorato
- Center for Home Care Policy & Research, Visiting Nurse Service of New York, 220 East 42nd Street, New York, NY, 10017, USA
| | - Joel Stein
- Department of Rehabilitation and Regenerative Medicine, Columbia University Vagelos College of Physicians and Surgeons, Department of Rehabilitation Medicine, Weill Cornell Medicine, New York-Presbyterian Hospital, 180 Ft. Washington Ave., Harkness Pavilion Room 1-165, New York, NY, 10032, USA
| | - Olajide Williams
- Department of Neurology, Columbia University, 710 West 168th Street, New York, NY, 10032, USA
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9
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García-Pérez P, Rodríguez-Martínez MDC, Lara JP, de la Cruz-Cosme C. Early Occupational Therapy Intervention in the Hospital Discharge after Stroke. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph182412877. [PMID: 34948486 PMCID: PMC8700854 DOI: 10.3390/ijerph182412877] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 11/23/2021] [Accepted: 12/03/2021] [Indexed: 11/25/2022]
Abstract
Stroke is the leading cause of acquired disability in adults which is a cerebrovascular disease of great impact in health and social terms, not only due to its prevalence and incidence but also because of its significant consequences in terms of patient dependence and its consequent impact on the patient and family lives. The general objective of this study is to determine whether an early occupational therapy intervention at hospital discharge after suffering a stroke has a positive effect on the functional independence of the patient three months after discharge—the patient’s level of independence being the main focus of this research. Data will be collected on readmissions to hospitals, mortality, returns to work and returns to driving, as well as an economic health analysis. This is a prospective, randomized, controlled clinical trial. The sample size will be made up of 60 patients who suffered a stroke and were discharged from the neurology unit of a second-level hospital in west Malaga (Spain), who were then referred to the rehabilitation service by the joint decision of the neurology and rehabilitation department. The patients and caregivers assigned to the experimental group were included in an early occupational therapy intervention program and compared with a control group that receives usual care.
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Affiliation(s)
- Patricia García-Pérez
- Faculty of Medicine, University of Málaga, 29010 Málaga, Spain;
- Occupational Therapy Department, Hospital Marítimo, Servicio Andaluz de Salud (SAS), 29620 Málaga, Spain
| | | | - José Pablo Lara
- Faculty of Medicine, University of Málaga, 29010 Málaga, Spain;
- Brain Health Unit, CIMES, 29010 Málaga, Spain
- Malaga Biomedical Research Institute (IBIMA), 29010 Málaga, Spain;
- Correspondence: (M.C.R.-M.); (J.P.L.)
| | - Carlos de la Cruz-Cosme
- Malaga Biomedical Research Institute (IBIMA), 29010 Málaga, Spain;
- Neurology Department, Virgen de la Victoria University Hospital, 29010 Málaga, Spain
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10
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Hasan TF, Hasan H, Kelley RE. Overview of Acute Ischemic Stroke Evaluation and Management. Biomedicines 2021; 9:1486. [PMID: 34680603 PMCID: PMC8533104 DOI: 10.3390/biomedicines9101486] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Revised: 10/05/2021] [Accepted: 10/13/2021] [Indexed: 01/19/2023] Open
Abstract
Stroke is a major contributor to death and disability worldwide. Prior to modern therapy, post-stroke mortality was approximately 10% in the acute period, with nearly one-half of the patients developing moderate-to-severe disability. The most fundamental aspect of acute stroke management is "time is brain". In acute ischemic stroke, the primary therapeutic goal of reperfusion therapy, including intravenous recombinant tissue plasminogen activator (IV TPA) and/or endovascular thrombectomy, is the rapid restoration of cerebral blood flow to the salvageable ischemic brain tissue at risk for cerebral infarction. Several landmark endovascular thrombectomy trials were found to be of benefit in select patients with acute stroke caused by occlusion of the proximal anterior circulation, which has led to a paradigm shift in the management of acute ischemic strokes. In this modern era of acute stroke care, more patients will survive with varying degrees of disability post-stroke. A comprehensive stroke rehabilitation program is critical to optimize post-stroke outcomes. Understanding the natural history of stroke recovery, and adapting a multidisciplinary approach, will lead to improved chances for successful rehabilitation. In this article, we provide an overview on the evaluation and the current advances in the management of acute ischemic stroke, starting in the prehospital setting and in the emergency department, followed by post-acute stroke hospital management and rehabilitation.
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Affiliation(s)
- Tasneem F. Hasan
- Department of Neurology, Ochsner Louisiana State University Health Sciences Center, Shreveport, LA 71103, USA;
| | - Hunaid Hasan
- Hasan & Hasan Neurology Group, Lapeer, MI 48446, USA;
| | - Roger E. Kelley
- Department of Neurology, Ochsner Louisiana State University Health Sciences Center, Shreveport, LA 71103, USA;
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11
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Hoang MT, Kåreholt I, von Euler M, Jönsson L, von Koch L, Eriksdotter M, Garcia-Ptacek S. Costs of Inpatient Rehabilitation for Ischemic Stroke in Patients with Dementia: A Cohort Swedish Register-Based Study. J Alzheimers Dis 2021; 73:967-979. [PMID: 31884465 PMCID: PMC7081100 DOI: 10.3233/jad-190749] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Stroke and dementia are frequent comorbidities. Dementia possibly increases total costs of stroke care, especially cost of institutionalization and informal medical care. However, stroke rehabilitation costs in dementia patients are understudied. OBJECTIVE To estimate inpatient stroke rehabilitation costs for Swedish dementia patients in comparison with non-dementia patients. METHODS A longitudinal cohort study with linked data from the Swedish Dementia Register and the Swedish Stroke Register was conducted. Patients diagnosed with dementia who suffered a first ischemic stroke between 2010 and 2014 (n = 138) were compared with non-dementia patients (n = 935). Cost analyses were conducted from a Swedish health care perspective. The difference of rehabilitation costs between the two groups was examined via simple linear regression (before and after matching by propensity scores of dementia) and multiple linear regression. RESULTS Mean inpatient rehabilitation costs for dementia and non-dementia patients were SEK 103,693/$11,932 and SEK 130,057/$14,966, respectively (median SEK 92,183/$10,607 and SEK 106,365/$12,239) (p = 0.001). Dementia patients suffered from more comorbidities and experienced lower functioning, compared to non-dementia patients. The inpatient rehabilitation cost for patients with known dementia was 0.84 times the cost in non-dementia individuals. CONCLUSION Dementia diagnosis was significantly associated with lower inpatient stroke rehabilitation costs. This might be explained by physicians' beliefs on the limited effectiveness of rehabilitation in dementia patients. Further research on cost-effectiveness of stroke rehabilitation and patients' satisfaction with stroke rehabilitation is necessary.
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Affiliation(s)
- Minh Tuan Hoang
- Center for Alzheimer Research, Division of Clinical Geriatrics, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Huddinge, Sweden
| | - Ingemar Kåreholt
- Aging Research Center (ARC), Karolinska Institutet and Stockholm University, Stockholm, Sweden.,Institute of Gerontology, School of Health and Welfare, Aging Research Network - Jönköping (ARN-J), Jönköping University, Jönköping, Sweden
| | - Mia von Euler
- Karolinska Institutet, Departments of Clinical Science and Education, Södersjukhuset, and Medicine, Solna, Stockholm, Sweden.,Department of Clinical Pharmacology, Karolinska University Laboratory, Karolinska University Hospital, Stockholm, Sweden
| | - Linus Jönsson
- Division of Neurogeriatrics, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
| | - Lena von Koch
- Division of Family Medicine and Primary Care, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Huddinge, Sweden.,Neuro Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Maria Eriksdotter
- Center for Alzheimer Research, Division of Clinical Geriatrics, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Huddinge, Sweden.,Aging Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Sara Garcia-Ptacek
- Center for Alzheimer Research, Division of Clinical Geriatrics, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Huddinge, Sweden.,Section for Neurology, Department of Internal Medicine, Södersjukhuset, Stockholm, Sweden
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12
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Comparison of Cost-Effectiveness between Inpatient and Home-Based Post-Acute Care Models for Stroke Rehabilitation in Taiwan. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18084129. [PMID: 33919719 PMCID: PMC8070720 DOI: 10.3390/ijerph18084129] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 04/07/2021] [Accepted: 04/09/2021] [Indexed: 12/30/2022]
Abstract
Stroke rehabilitation focuses on alleviating post-stroke disability. Post-acute care (PAC) offers an intensive rehabilitative program as transitional care following acute stroke. A novel home-based PAC program has been initiated in Taiwan since 2019. Our study aimed to compare the current inpatient PAC model with a novel home-based PAC model in cost-effectiveness and functional recovery for stroke patients in Taiwan. One hundred ninety-seven stroke patients eligible for the PAC program were divided into two different health interventional groups. One received rehabilitation during hospitalization, and the other received rehabilitation by therapists at home. To evaluate the health economics, we assessed the total medical expenditure on rehabilitation using the health system of Taiwan national health insurance and performed cost-effectiveness analyses using improvements of daily activity in stroke patients based on the Barthel index (BI). Total rehabilitative duration and functional recovery were also documented. The total rehabilitative cost was cheaper in the home-based PAC group (p < 0.001), and the cost-effectiveness is USD 152.474 ± USD 164.661 in the inpatient group, and USD 48.184 ± USD 35.018 in the home group (p < 0.001). Lesser rehabilitative hours per 1-point increase of BI score was noted in the home-PAC group with similar improvements in daily activities, life quality and nutrition in both groups. Home-based PAC is more cost-effective than inpatient PAC for stroke rehabilitation.
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King R, Seeger T, Wang M, Li Pi Shan R, McGovern C, Knox J, Patel L, Fung T, Sajobi T, Debert C. Early Supported Discharge for Neurorehabilitation Following Acquired Brain Injury. Front Neurol 2021; 11:596526. [PMID: 33424748 PMCID: PMC7793829 DOI: 10.3389/fneur.2020.596526] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 11/09/2020] [Indexed: 11/24/2022] Open
Abstract
Introduction: Early Supported Discharge (ESD) is a clinical flow management service offering interdisciplinary rehabilitation, wherein patients are provided supported in-home rehabilitation treatment; in comparison to conventional hospital-based rehabilitation model of service delivery. There has been little research into the functional outcomes for other types of acquired brain injury (ABI). Methods: In this prospective cohort study, ABI patients presenting at a level I trauma center in Calgary, Canada were placed in either an ESD program or conventional inpatient rehabilitation (IPR) program based on their medical history and presentation. A small number of patients completed both programs (ESD+IPR group). ESD therapies were designed to emulate IPR. Participants completed professionally-rated Mayo-Portland Adaptability Index-4 (MPAI), Quality of Life after Brain Injury (QOLIBRI), Generalized Anxiety Questionnaire-7 (GAD7), Montreal Cognitive Assessment (MoCA), and Patient Health Questionnaire-9 (PHQ9) surveys at 1, 3, and 6 months following initial assessment pre-rehabilitation. Caregivers completed the Zarit Burden Interview (ZBI) at the same time points. The Supervision Rating Scale (SRS) and Disability Rating Scale (DRS) were completed at admission to rehabilitation and all follow-ups. Generalized estimate equations models were used to describe the three groups over time, including age as a covariate. Results: Significant effects of time were reported in the MPAI participant sub-score in the ESD and IPR groups (χ(2)2 = 42.429, p < 0.000; χ(2)2 = 9.773, p = 0.008), showing significantly higher scores between 1 and 3 month timepoints for both groups. ZBI scores were significantly lower in the ESD group at 1 month compared to 3 and 6 months (χ(2)2 = 31.252, p < 0.001). The proportion of patients with medical complications during rehabilitation was 25.3% in ESD compared to 74.7% patients in IPR. Conclusions: Improvements in functional outcomes were evident in patients participating in ESD and IPR, with more medical complications reported in the IPR group. Caregiver burden lessened over time in the ESD group but not in the IPR group. Both ESD and ESD+IPR groups can be considered viable alternatives to traditional inpatient rehabilitation. A randomized control trial would be required to properly compare rehabilitation streams. Further investigation into affective and lifestyle elements of ABI recovery would also improve our understanding of targeted neurorehabilitation in this population.
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Affiliation(s)
- Regan King
- Calgary Brain Injury Program, Alberta Health Services, Calgary, AB, Canada.,Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Trevor Seeger
- Calgary Brain Injury Program, Alberta Health Services, Calgary, AB, Canada.,Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Meng Wang
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Rodney Li Pi Shan
- Calgary Brain Injury Program, Alberta Health Services, Calgary, AB, Canada.,Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Christine McGovern
- Calgary Brain Injury Program, Alberta Health Services, Calgary, AB, Canada.,Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Jason Knox
- Calgary Brain Injury Program, Alberta Health Services, Calgary, AB, Canada.,Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Lisa Patel
- Calgary Brain Injury Program, Alberta Health Services, Calgary, AB, Canada.,Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Tak Fung
- Department of Nursing, University of Calgary, Calgary, AB, Canada
| | - Tolulope Sajobi
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Chantel Debert
- Calgary Brain Injury Program, Alberta Health Services, Calgary, AB, Canada.,Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
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14
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Archambault PM, Rivard J, Smith PY, Sinha S, Morin M, LeBlanc A, Couturier Y, Pelletier I, Ghandour EK, Légaré F, Denis JL, Melady D, Paré D, Chouinard J, Kroon C, Huot-Lavoie M, Bert L, Witteman HO, Brousseau AA, Dallaire C, Sirois MJ, Émond M, Fleet R, Chandavong S. Learning Integrated Health System to Mobilize Context-Adapted Knowledge With a Wiki Platform to Improve the Transitions of Frail Seniors From Hospitals and Emergency Departments to the Community (LEARNING WISDOM): Protocol for a Mixed-Methods Implementation Study. JMIR Res Protoc 2020; 9:e17363. [PMID: 32755891 PMCID: PMC7439141 DOI: 10.2196/17363] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Accepted: 03/17/2020] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Elderly patients discharged from hospital experience fragmented care, repeated and lengthy emergency department (ED) visits, relapse into their earlier condition, and rapid cognitive and functional decline. The Acute Care for Elders (ACE) program at Mount Sinai Hospital in Toronto, Canada uses innovative strategies, such as transition coaches, to improve the care transition experiences of frail elderly patients. The ACE program reduced the lengths of hospital stay and readmission for elderly patients, increased patient satisfaction, and saved the health care system over Can $4.2 million (US $2.6 million) in 2014. In 2016, a context-adapted ACE program was implemented at one hospital in the Centre intégré de santé et de services sociaux de Chaudière-Appalaches (CISSS-CA) with a focus on improving transitions between hospitals and the community. The quality improvement project used an intervention strategy based on iterative user-centered design prototyping and a "Wiki-suite" (free web-based database containing evidence-based knowledge tools) to engage multiple stakeholders. OBJECTIVE The objectives of this study are to (1) implement a context-adapted CISSS-CA ACE program in four hospitals in the CISSS-CA and measure its impact on patient-, caregiver-, clinical-, and hospital-level outcomes; (2) identify underlying mechanisms by which our context-adapted CISSS-CA ACE program improves care transitions for the elderly; and (3) identify underlying mechanisms by which the Wiki-suite contributes to context-adaptation and local uptake of knowledge tools. METHODS Objective 1 will involve staggered implementation of the context-adapted CISSS-CA ACE program across the four CISSS-CA sites and interrupted time series to measure the impact on hospital-, patient-, and caregiver-level outcomes. Objectives 2 and 3 will involve a parallel mixed-methods process evaluation study to understand the mechanisms by which our context-adapted CISSS-CA ACE program improves care transitions for the elderly and by which our Wiki-suite contributes to adaptation, implementation, and scaling up of geriatric knowledge tools. RESULTS Data collection started in January 2019. As of January 2020, we enrolled 1635 patients and 529 caregivers from the four participating hospitals. Data collection is projected to be completed in January 2022. Data analysis has not yet begun. Results are expected to be published in 2022. Expected results will be presented to different key internal stakeholders to better support the effort and resources deployed in the transition of seniors. Through key interventions focused on seniors, we are expecting to increase patient satisfaction and quality of care and reduce readmission and ED revisit. CONCLUSIONS This study will provide evidence on effective knowledge translation strategies to adapt best practices to the local context in the transition of care for elderly people. The knowledge generated through this project will support future scale-up of the ACE program and our wiki methodology in other settings in Canada. TRIAL REGISTRATION ClinicalTrials.gov NCT04093245; https://clinicaltrials.gov/ct2/show/NCT04093245. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/17363.
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Affiliation(s)
- Patrick Michel Archambault
- Department of Family and Emergency Medicine, Université Laval, Québec, QC, Canada
- Centre intégré de santé et de services sociaux de Chaudière-Appalaches, Ste-Marie, QC, Canada
- VITAM - Centre de recherche en santé durable, Québec, QC, Canada
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, Québec, QC, Canada
- Centre de recherche intégrée pour un système apprenant en santé et services sociaux, Centre intégré de santé et de services sociaux de Chaudière-Appalaches, Lévis, QC, Canada
| | - Josée Rivard
- Centre intégré de santé et de services sociaux de Chaudière-Appalaches, Ste-Marie, QC, Canada
| | - Pascal Y Smith
- Centre de recherche intégrée pour un système apprenant en santé et services sociaux, Centre intégré de santé et de services sociaux de Chaudière-Appalaches, Lévis, QC, Canada
| | - Samir Sinha
- Department of Medicine, Sinai Health System, Toronto, ON, Canada
- Department of Medicine, University Health Network, Toronto, QC, Canada
- Department of Medicine, University of Toronto, Toronto, QC, Canada
| | - Michèle Morin
- Centre intégré de santé et de services sociaux de Chaudière-Appalaches, Ste-Marie, QC, Canada
- Centre de recherche intégrée pour un système apprenant en santé et services sociaux, Centre intégré de santé et de services sociaux de Chaudière-Appalaches, Lévis, QC, Canada
- Department of Medicine, Faculty of Medicine, Université Laval, Québec, QC, Canada
| | - Annie LeBlanc
- Department of Family and Emergency Medicine, Université Laval, Québec, QC, Canada
- VITAM - Centre de recherche en santé durable, Québec, QC, Canada
| | - Yves Couturier
- Department of Social Work, University of Sherbrooke, Sherbrooke, QC, Canada
| | - Isabelle Pelletier
- Centre intégré de santé et de services sociaux de Chaudière-Appalaches, Ste-Marie, QC, Canada
- Centre de recherche intégrée pour un système apprenant en santé et services sociaux, Centre intégré de santé et de services sociaux de Chaudière-Appalaches, Lévis, QC, Canada
| | - El Kebir Ghandour
- VITAM - Centre de recherche en santé durable, Québec, QC, Canada
- Centre de recherche intégrée pour un système apprenant en santé et services sociaux, Centre intégré de santé et de services sociaux de Chaudière-Appalaches, Lévis, QC, Canada
- Institut national d'excellence en sante et en services sociaux, Québec, QC, Canada
| | - France Légaré
- Department of Family and Emergency Medicine, Université Laval, Québec, QC, Canada
- VITAM - Centre de recherche en santé durable, Québec, QC, Canada
- Centre intégré universitaire de santé et de services sociaux de la Capitale-Nationale (CIUSSS-CN), Québec, QC, Canada
- Canada Research Chair in Shared Decision Making and Knowledge Translation, Université Laval, Québec, QC, Canada
| | - Jean-Louis Denis
- Département de gestion, d'évaluation et de politique de santé, École de santé publique, Université de Montréal, Montreal, QC, Canada
| | - Don Melady
- Schwartz-Reisman Emergency Medicine Institute, Mount Sinai Hospital, Toronto, ON, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Daniel Paré
- Centre intégré de santé et de services sociaux de Chaudière-Appalaches, Ste-Marie, QC, Canada
| | - Josée Chouinard
- Centre intégré de santé et de services sociaux de Chaudière-Appalaches, Ste-Marie, QC, Canada
| | - Chantal Kroon
- Centre intégré de santé et de services sociaux de Chaudière-Appalaches, Ste-Marie, QC, Canada
| | - Maxime Huot-Lavoie
- Centre de recherche intégrée pour un système apprenant en santé et services sociaux, Centre intégré de santé et de services sociaux de Chaudière-Appalaches, Lévis, QC, Canada
- Faculty of Medicine, Université Laval, Québec, QC, Canada
| | - Laetitia Bert
- Centre de recherche intégrée pour un système apprenant en santé et services sociaux, Centre intégré de santé et de services sociaux de Chaudière-Appalaches, Lévis, QC, Canada
- Faculty of Nursing, Université Laval, Québec, QC, Canada
| | - Holly O Witteman
- Department of Family and Emergency Medicine, Université Laval, Québec, QC, Canada
- VITAM - Centre de recherche en santé durable, Québec, QC, Canada
- Office of Education and Professional Development, Faculty of Medicine, Université Laval, Québec, QC, Canada
- CHU de Québec-Université Laval, Québec, QC, Canada
| | - Audrey-Anne Brousseau
- Centre intégré universitaire de santé et de services sociaux de l'Estrie - CHUS, Sherbrooke, QC, Canada
| | - Clémence Dallaire
- Centre de recherche intégrée pour un système apprenant en santé et services sociaux, Centre intégré de santé et de services sociaux de Chaudière-Appalaches, Lévis, QC, Canada
- Faculty of Nursing, Université Laval, Québec, QC, Canada
| | - Marie-Josée Sirois
- VITAM - Centre de recherche en santé durable, Québec, QC, Canada
- Centre d'excellence sur le vieillissement du Québec, Hôpital du Saint-Sacrement, Québec, QC, Canada
- Département de réadaptation, Faculté de médecine, Université Laval, Québec, QC, Canada
| | - Marcel Émond
- Department of Family and Emergency Medicine, Université Laval, Québec, QC, Canada
- VITAM - Centre de recherche en santé durable, Québec, QC, Canada
- CHU de Québec-Université Laval, Québec, QC, Canada
| | - Richard Fleet
- Department of Family and Emergency Medicine, Université Laval, Québec, QC, Canada
- VITAM - Centre de recherche en santé durable, Québec, QC, Canada
- Centre de recherche intégrée pour un système apprenant en santé et services sociaux, Centre intégré de santé et de services sociaux de Chaudière-Appalaches, Lévis, QC, Canada
| | - Sam Chandavong
- Centre de recherche intégrée pour un système apprenant en santé et services sociaux, Centre intégré de santé et de services sociaux de Chaudière-Appalaches, Lévis, QC, Canada
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15
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Murie-Fernández M, Laxe S. Neurorrehabilitación del ictus en España, comparativa con Europa. Neurologia 2020; 35:354-355. [DOI: 10.1016/j.nrl.2018.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Accepted: 02/17/2018] [Indexed: 10/17/2022] Open
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16
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Murie-Fernández M, Laxe S. Comparison of stroke neurorehabilitation in Spain and in Europe. NEUROLOGÍA (ENGLISH EDITION) 2020. [DOI: 10.1016/j.nrleng.2018.02.006] [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] Open
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17
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Gittins M, Lugo-Palacios D, Vail A, Bowen A, Paley L, Bray B, Gannon B, Tyson SF. Delivery, dose, outcomes and resource use of stroke therapy: the SSNAPIEST observational study. HEALTH SERVICES AND DELIVERY RESEARCH 2020. [DOI: 10.3310/hsdr08170] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background
Therapy is key to effective stroke care, but many patients receive little.
Objectives
To understand how stroke therapy is delivered in England, Wales and Northern Ireland, and which factors are associated with dose, outcome and resource use.
Design
Secondary analysis of the Sentinel Stroke National Audit Programme, using standard descriptive statistics and multilevel mixed-effects regression models, while adjusting for all known and measured confounders.
Setting
Stroke services in England, Wales and Northern Ireland.
Participants
A total of 94,905 adults admitted with stroke, who remained an inpatient for > 72 hours.
Results
Routes through stroke services were highly varied (> 800), but four common stroke pathways emerged. Seven distinct impairment-based patient subgroups were characterised. The average amount of therapy was very low. Modifiable factors associated with the average amount of inpatient therapy were type of stroke team, timely therapy assessments, staffing levels and model of therapy provision. More (of any type of) therapy was associated with shorter length of stay, less resource use and lower mortality. More occupational therapy, speech therapy and psychology were also associated with less disability and institutionalisation. Large amounts of physiotherapy were associated with greater disability and institutionalisation.
Limitations
Use of observational data does not infer causation. All efforts were made to adjust for all known and measured confounding factors but some may remain. We categorised participants using the National Institutes of Health Stroke Scale, which measures a limited number of impairments relatively crudely, so mild or rare impairments may have been missed.
Conclusions
Stroke patients receive very little therapy. Modifiable organisational factors associated with greater amounts of therapy were identified, and positive associations between amount of therapy and outcome were confirmed. The reason for the unexpected associations between large amounts of physiotherapy, disability and institutionalisation is unknown. Prospective work is urgently needed to investigate further. Future work needs to investigate (1) prospectively, the association between physiotherapy and outcome; (2) the optimal amount of therapy to provide for different patient groups; (3) the most effective way of organising stroke therapy/rehabilitation services, including service configuration, staffing levels and working hours; and (4) how to reduce unexplained variation in resource use.
Funding
This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 17. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Matthew Gittins
- Centre for Biostatistics, School of Health Sciences, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - David Lugo-Palacios
- Centre for Health Economics, School of Health Sciences, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Andy Vail
- Centre for Biostatistics, School of Health Sciences, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Audrey Bowen
- Division of Neuroscience and Experimental Psychology, School of Biological Sciences, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Lizz Paley
- Sentinel Stroke National Audit Programme, Department of Population Health Sciences, King’s College London, London, UK
| | - Benjamin Bray
- Sentinel Stroke National Audit Programme, Department of Population Health Sciences, King’s College London, London, UK
| | - Brenda Gannon
- School of Economics, The University of Queensland, Brisbane, QLD, Australia
| | - Sarah F Tyson
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
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18
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Gesell SB, Bushnell CD, Jones SB, Coleman SW, Levy SM, Xenakis JG, Lutz BJ, Bettger JP, Freburger J, Halladay JR, Johnson AM, Kucharska-Newton AM, Mettam LH, Pastva AM, Psioda MA, Radman MD, Rosamond WD, Sissine ME, Halls J, Duncan PW. Implementation of a billable transitional care model for stroke patients: the COMPASS study. BMC Health Serv Res 2019; 19:978. [PMID: 31856808 PMCID: PMC6923985 DOI: 10.1186/s12913-019-4771-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Accepted: 11/22/2019] [Indexed: 11/16/2022] Open
Abstract
Background The COMprehensive Post-Acute Stroke Services (COMPASS) pragmatic trial compared the effectiveness of comprehensive transitional care (COMPASS-TC) versus usual care among stroke and transient ischemic attack (TIA) patients discharged home from North Carolina hospitals. We evaluated implementation of COMPASS-TC in 20 hospitals randomized to the intervention using the RE-AIM framework. Methods We evaluated hospital-level Adoption of COMPASS-TC; patient Reach (meeting transitional care management requirements of timely telephone and face-to-face follow-up); Implementation using hospital quality measures (concurrent enrollment, two-day telephone follow-up, 14-day clinic visit scheduling); and hospital-level sustainability (Maintenance). Effectiveness compared 90-day physical function (Stroke Impact Scale-16), between patients receiving COMPASS-TC versus not. Associations between hospital and patient characteristics with Implementation and Reach measures were estimated with mixed logistic regression models. Results Adoption: Of 95 eligible hospitals, 41 (43%) participated in the trial. Of the 20 hospitals randomized to the intervention, 19 (95%) initiated COMPASS-TC. Reach: A total of 24% (656/2751) of patients enrolled received a billable TC intervention, ranging from 6 to 66% across hospitals. Implementation: Of eligible patients enrolled, 75.9% received two-day calls (or two attempts) and 77.5% were scheduled/offered clinic visits. Most completed visits (78% of 975) occurred within 14 days. Effectiveness: Physical function was better among patients who attended a 14-day visit versus those who did not (adjusted mean difference: 3.84, 95% CI 1.42–6.27, p = 0.002). Maintenance: Of the 19 adopting hospitals, 14 (74%) sustained COMPASS-TC. Conclusions COMPASS-TC implementation varied widely. The greatest challenge was reaching patients because of system difficulties maintaining consistent delivery of follow-up visits and patient preferences to pursue alternate post-acute care. Receiving COMPASS-TC was associated with better functional status. Trial registration ClinicalTrials.gov number: NCT02588664. Registered 28 October 2015.
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Affiliation(s)
- Sabina B Gesell
- Department of Social Sciences and Health Policy, Department of Implementation Science, Wake Forest School of Medicine, One Medical Center Boulevard, Winston-Salem, NC, 27157, USA.
| | - Cheryl D Bushnell
- Department of Neurology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Sara B Jones
- Department of Epidemiology, University of North Carolina at Chapel Hill, Gillings School of Global Public Health, Chapel Hill, NC, USA
| | - Sylvia W Coleman
- Department of Neurology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Samantha M Levy
- Department of Biostatistics, University of North Carolina at Chapel Hill, Gillings School of Global Public Health, Chapel Hill, NC, USA
| | - James G Xenakis
- Department of Family Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Barbara J Lutz
- University of North Carolina at Wilmington, School of Nursing, Wilmington, NC, USA
| | | | - Janet Freburger
- University of Pittsburgh, School of Health and Rehabilitation Sciences, Pittsburgh, PA, USA
| | - Jacqueline R Halladay
- Department of Family Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Anna M Johnson
- Department of Epidemiology, University of North Carolina at Chapel Hill, Gillings School of Global Public Health, Chapel Hill, NC, USA
| | - Anna M Kucharska-Newton
- Department of Epidemiology, University of North Carolina at Chapel Hill, Gillings School of Global Public Health, Chapel Hill, NC, USA.,Department of Epidemiology, University of Kentucky, College of Public Health, Lexington, KY, USA
| | - Laurie H Mettam
- Department of Epidemiology, University of North Carolina at Chapel Hill, Gillings School of Global Public Health, Chapel Hill, NC, USA
| | - Amy M Pastva
- Duke University, School of Medicine, Durham, NC, USA
| | - Matthew A Psioda
- Department of Biostatistics, University of North Carolina at Chapel Hill, Gillings School of Global Public Health, Chapel Hill, NC, USA
| | - Meghan D Radman
- Department of Neurology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Wayne D Rosamond
- Department of Epidemiology, University of North Carolina at Chapel Hill, Gillings School of Global Public Health, Chapel Hill, NC, USA
| | - Mysha E Sissine
- Department of Neurology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Joanne Halls
- Department of Earth and Ocean Sciences, University of North Carolina at Wilmington, Wilmington, NC, USA
| | - Pamela W Duncan
- Department of Neurology, Wake Forest School of Medicine, Winston-Salem, NC, USA
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19
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Rafsten L, Danielsson A, Nordin A, Björkdahl A, Lundgren-Nilsson A, Larsson MEH, Sunnerhagen KS. Gothenburg Very Early Supported Discharge study (GOTVED): a randomised controlled trial investigating anxiety and overall disability in the first year after stroke. BMC Neurol 2019; 19:277. [PMID: 31706292 PMCID: PMC6878692 DOI: 10.1186/s12883-019-1503-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Accepted: 10/20/2019] [Indexed: 12/13/2022] Open
Abstract
Background and purpose Early supported discharge (ESD) has been shown to be efficient and safe as part of the stroke care pathway. The best results have been seen with a multidisciplinary team and after mild to moderate stroke. However, how very early supported discharge (VESD) works has not been studied. The aim of this study was to investigate whether VESD for stroke patients in need of ongoing individualized rehabilitation affects the level of anxiety and overall disability for the patient compared with ordinary discharge routine. Methods A randomized controlled trial was performed with intention to treat analyses comparing VESD and ordinary discharge from hospital. All patients admitted at the stroke care unit at Sahlgrenska University Hospital of Gothenburg between August 2011 and April 2016 were screened. Inclusion occurred on day 4 using a block randomization of 20 and with a blinded assessor. Assessments were made 5 days post-stroke and 3 and 12 months post-stroke. Patients in the VESD group underwent continued rehabilitation in their homes with a multidisciplinary team from the stroke care unit for a maximum of 1 month. The patients in the control group had support as usual after discharge when needed such as home care service and outpatient rehabilitation. The primary outcome was anxiety as assessed by the Hospital Anxiety and Depression Scale-Anxiety subscale (HADS-A). The secondary outcome was the patients’ degree of overall disability, measured by the modified Rankin Scale (mRS). Results No significant differences were found between the groups regarding anxiety at three or 12 months post-stroke (p = 0.811). The overall disability was significantly lower in the VESD group 3 months post-stroke (p = 0.004), compared to the control group. However, there was no significant difference between the groups 1 year post-stroke. Conclusions The VESD does not affects the level of anxiety compared to ordinary rehabilitation. The VESD leads to a faster improvement of overall disability compared to ordinary rehabilitation. We suggest considering coordinated VESD for patients with mild to moderate stroke in addition to ordinary rehabilitation as part of the service from a stroke unit. Trial registration Clinical Trials.gov: NCT01622205. Registered 19 June 2012 (retrospectively registered).
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Affiliation(s)
- Lena Rafsten
- Institute of Neuroscience and Physiology, Department of Clinical Neuroscience and Rehabilitation Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden. Per Dubbsgatan 14, fl. 3, 413 45, Gothenburg, Sweden. .,Department of Occupational Therapy and Physiotherapy, Sahlgrenska University Hospital, Gothenburg, Sweden. .,Gothenburg Centre for Person-Centred Care (GPCC), University of Gothenburg, Gothenburg, Sweden.
| | - Anna Danielsson
- Institute of Neuroscience and Physiology, Department of Clinical Neuroscience and Rehabilitation Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden. Per Dubbsgatan 14, fl. 3, 413 45, Gothenburg, Sweden.,Institute of Neuroscience and Physiology, Department of Health and Rehabilitation, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Asa Nordin
- Institute of Neuroscience and Physiology, Department of Clinical Neuroscience and Rehabilitation Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden. Per Dubbsgatan 14, fl. 3, 413 45, Gothenburg, Sweden.,Gothenburg Centre for Person-Centred Care (GPCC), University of Gothenburg, Gothenburg, Sweden
| | - Ann Björkdahl
- Institute of Neuroscience and Physiology, Department of Clinical Neuroscience and Rehabilitation Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden. Per Dubbsgatan 14, fl. 3, 413 45, Gothenburg, Sweden.,Institute of Social Science, Campus Bräcke, Ersta Sköndal Bräcke University College, Gothenburg, Sweden
| | - Asa Lundgren-Nilsson
- Institute of Neuroscience and Physiology, Department of Clinical Neuroscience and Rehabilitation Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden. Per Dubbsgatan 14, fl. 3, 413 45, Gothenburg, Sweden.,Gothenburg Centre for Person-Centred Care (GPCC), University of Gothenburg, Gothenburg, Sweden
| | - Maria E H Larsson
- Institute of Neuroscience and Physiology, Department of Health and Rehabilitation, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Närhälsan, Research and Development Primary Health Care, Gothenburg, Region Västra Götaland, Sweden
| | - Katharina S Sunnerhagen
- Institute of Neuroscience and Physiology, Department of Clinical Neuroscience and Rehabilitation Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden. Per Dubbsgatan 14, fl. 3, 413 45, Gothenburg, Sweden.,Gothenburg Centre for Person-Centred Care (GPCC), University of Gothenburg, Gothenburg, Sweden
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20
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Lehnerer S, Hotter B, Padberg I, Knispel P, Remstedt D, Liebenau A, Grittner U, Wellwood I, Meisel A. Social work support and unmet social needs in life after stroke: a cross-sectional exploratory study. BMC Neurol 2019; 19:220. [PMID: 31492151 PMCID: PMC6729017 DOI: 10.1186/s12883-019-1451-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Accepted: 08/27/2019] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Stroke patients are often affected by long-term disabilities with needs concerning social issues. There is relatively little consideration of social recovery of patients and the support required to return to work, receive social benefits, participate in daily life activities, maintain contact with family and friends and to organize financial affairs. In our study we aimed to investigate if existing tools record social needs adequately. We analyzed the current provision of social support provided in long-term care after stroke and whether unmet social needs were associated with quality of life, caregiver burden, overall function and degree of disability. METHODS Our analysis is part of the Managing Aftercare of Stroke study (MAS-I), a cross-sectional exploratory study of patient needs 2-3 years after initial stroke. Assessment tools included the Nikolaus-score (social situation), the EuroQoL (quality of life), the German Burden Scale for Family Caregivers (caregiver burden), the modified Rankin Scale (disability / dependence), Stroke Impact Scale (function and degree of disability) and the Stroke Survivor Needs Questionnaire (unmet needs). RESULTS Overall 57 patients were included in MAS-I, with ten patients classified in urgent need of socio-economic support according to the Nikolaus-score. Patients with lower than normal Nikolaus-score had a higher degree of disability. Thirty percent of all patients had never received professional social support. Social worker contact happened mostly during the stay in acute hospital or rehabilitation institution. Only four patients (11%) reported long-term support after discharge. Apart from social worker contact during acute care, 43% of patients had unmet needs in the long-term aftercare. Forty percent of all patients included in MAS-I were recommended for social work intervention after an in-depth analysis of their situation. Finally, we saw that unmet social needs were associated with lower quality of life and higher caregiver burden. CONCLUSIONS Our data suggest significant unmet needs in social care in long-term stroke patients. Screening tools for unmet social needs such as the Nikolaus-score do not holistically report patients' needs. TRIAL REGISTRATION Clinicaltrials.Gov NCT02320994 . Registered 19 December 2014 (retrospectively registered).
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Affiliation(s)
- Sophie Lehnerer
- Center for Stroke Research Berlin, Charité University Medicine Berlin, Charitéplatz 1, 10117 Berlin, Germany
- Department of Neurology, Charité University Medicine Berlin, Charitéplatz 1, 10117 Berlin, Germany
- NeuroCure Clinical Research Center, Charité University Medicine Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Benjamin Hotter
- Center for Stroke Research Berlin, Charité University Medicine Berlin, Charitéplatz 1, 10117 Berlin, Germany
- Department of Neurology, Charité University Medicine Berlin, Charitéplatz 1, 10117 Berlin, Germany
- NeuroCure Clinical Research Center, Charité University Medicine Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Inken Padberg
- Center for Stroke Research Berlin, Charité University Medicine Berlin, Charitéplatz 1, 10117 Berlin, Germany
- Clinical Epidemiology and Health Services in Stroke, Charité University Medicine Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Petra Knispel
- Center for Stroke Research Berlin, Charité University Medicine Berlin, Charitéplatz 1, 10117 Berlin, Germany
- Berlin Stroke Alliance (BSA), Charitéplatz 1, 10117 Berlin, Germany
| | - Dike Remstedt
- NeuroCure Clinical Research Center, Charité University Medicine Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Andrea Liebenau
- Center for Stroke Research Berlin, Charité University Medicine Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Ulrike Grittner
- Institute of Biometry and Clinical Epidemiology, Charité University Medicine Berlin, Charitéplatz 1, 10117 Berlin, Germany
- Berlin Institute of Health (BIH), Anna-Louisa-Karsch 2, 10178 Berlin, Germany
| | - Ian Wellwood
- Department of Public Health and Primary Care, Cambridge Institute of Public Health, University of Cambridge, Cambridge, CB2 0SR UK
| | - Andreas Meisel
- Center for Stroke Research Berlin, Charité University Medicine Berlin, Charitéplatz 1, 10117 Berlin, Germany
- Department of Neurology, Charité University Medicine Berlin, Charitéplatz 1, 10117 Berlin, Germany
- NeuroCure Clinical Research Center, Charité University Medicine Berlin, Charitéplatz 1, 10117 Berlin, Germany
- Berlin Stroke Alliance (BSA), Charitéplatz 1, 10117 Berlin, Germany
| | - on behalf of the BSA Long Term Care Study Group
- Center for Stroke Research Berlin, Charité University Medicine Berlin, Charitéplatz 1, 10117 Berlin, Germany
- Department of Neurology, Charité University Medicine Berlin, Charitéplatz 1, 10117 Berlin, Germany
- NeuroCure Clinical Research Center, Charité University Medicine Berlin, Charitéplatz 1, 10117 Berlin, Germany
- Clinical Epidemiology and Health Services in Stroke, Charité University Medicine Berlin, Charitéplatz 1, 10117 Berlin, Germany
- Berlin Stroke Alliance (BSA), Charitéplatz 1, 10117 Berlin, Germany
- Institute of Biometry and Clinical Epidemiology, Charité University Medicine Berlin, Charitéplatz 1, 10117 Berlin, Germany
- Berlin Institute of Health (BIH), Anna-Louisa-Karsch 2, 10178 Berlin, Germany
- Department of Public Health and Primary Care, Cambridge Institute of Public Health, University of Cambridge, Cambridge, CB2 0SR UK
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21
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van der Veen DJ, Döpp CME, Siemonsma PC, Nijhuis-van der Sanden MWG, de Swart BJM, Steultjens EM. Factors influencing the implementation of Home-Based Stroke Rehabilitation: Professionals' perspective. PLoS One 2019; 14:e0220226. [PMID: 31344103 PMCID: PMC6657875 DOI: 10.1371/journal.pone.0220226] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 07/11/2019] [Indexed: 01/10/2023] Open
Abstract
Background Stroke has a major impact on survivors and their social environment. Care delivery is advocated to become more client-centered and home-based because of their positive impact on client outcomes. The objective of this study was to explore professionals’ perspectives on the provision of Home-Based Stroke Rehabilitation (HBSR) in the Netherlands and on the barriers and facilitators influencing the implementation of HBSR in daily practice. Methods Semi-structured focus groups were conducted to explore the perspectives of health and social care professionals involved in stroke rehabilitation. Directed content analysis was performed to analyze the transcripts of recorded conversations. Results Fourteen professionals participated in focus groups (n = 12) or, if unable to attend, an interview (n = 2). Participants varied in professional backgrounds and roles in treating Dutch clients post stroke. Barriers and facilitators influencing the implementation of HBSR in daily practice were identified in relation to: the innovation, the user, the organization and the socio-political context. Participants reported that HBSR can be efficient and effective to most clients because it facilitates client- and caregiver-centered rehabilitation within the clients’ own environment. However, barriers in implementing HBSR were perceived in a lack of (structured) inter-professional collaboration and the transparency of expertise of primary care professionals. Also, the current financial structures for HBSR in the Netherlands are viewed as inappropriate. Discussion In line with previous studies, we found that HBSR is recognized by professionals as a promising alternative to institution-based rehabilitation for clients with sufficient capabilities (e.g. their own health and informal support). Conclusion Multiple factors influencing the implementation of HBSR were identified. Our study suggests that, in order to implement HBSR in daily practice, region specific implementation strategies need to be developed. We recommend developing strategies concerning: organized and coordinated inter-professional collaboration, transparency of the expertise of primary care professionals, and the financial structures of HBSR.
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Affiliation(s)
- Dinja J. van der Veen
- Institute of Health Studies, University of Applied Sciences HAN, Nijmegen, the Netherlands
- * E-mail:
| | | | - Petra C. Siemonsma
- Healthy Living, TNO Leiden, Leiden, the Netherlands
- University of Applied Sciences THIM, Nieuwegein, the Netherlands
- Faculty of Health, University of Applied Sciences Leiden, Leiden, the Netherlands
| | | | - Bert J. M. de Swart
- Institute of Health Studies, University of Applied Sciences HAN, Nijmegen, the Netherlands
- Department of Neurorehabilitation, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Esther M. Steultjens
- Institute of Health Studies, University of Applied Sciences HAN, Nijmegen, the Netherlands
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22
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Harnett PJ, Kennelly S, Williams P. A 10 Step Framework to Implement Integrated Care for Older Persons. AGEING INTERNATIONAL 2019. [DOI: 10.1007/s12126-019-09349-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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23
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Vloothuis JDM, Mulder M, Nijland RHM, Goedhart QS, Konijnenbelt M, Mulder H, Hertogh CMPM, van Tulder M, van Wegen EEH, Kwakkel G. Caregiver-mediated exercises with e-health support for early supported discharge after stroke (CARE4STROKE): A randomized controlled trial. PLoS One 2019; 14:e0214241. [PMID: 30958833 PMCID: PMC6453481 DOI: 10.1371/journal.pone.0214241] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2018] [Accepted: 03/08/2019] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND AND PURPOSE We designed an 8-week caregiver-mediated exercise program with e-health support after stroke (CARE4STROKE) in addition to usual care with the aim to improve functional outcome and to facilitate early supported discharge by increasing the intensity of task specific training. METHODS An observer-blinded randomized controlled trial in which 66 stroke patient-caregiver couples were included during inpatient rehabilitation. Patients allocated to the CARE4STROKE program trained an additional amount of 150 minutes a week with a caregiver and were compared to a control group that received usual care alone. Primary outcomes: self-reported mobility domain of the Stroke Impact Scale 3.0 (SIS) and length of stay (LOS). Secondary outcomes: motor impairment, strength, walking ability, balance, mobility and (Extended) Activities of Daily Living of patients, caregiver strain of caregivers, and mood, self-efficacy, fatigue and quality of life of both patients and caregivers. Outcomes were assessed at baseline, 8 and 12 weeks after randomization. RESULTS No significant between-group differences were found regarding SIS-mobility after 8 (β 6.21, SD 5.16; P = 0.229) and 12 weeks (β 0.14, SD 2.87; P = 0.961), and LOS (P = 0.818). Significant effects in favor of the intervention group were found for patient's anxiety (β 2.01, SD 0.88; P = 0.023) and caregiver's depression (β 2.33, SD 0.77; P = 0.003) post intervention. Decreased anxiety in patients remained significant at the 12-week follow-up (β 1.01, SD 0.40; P = 0.009). CONCLUSIONS This proof-of concept trial did not find significant effects on both primary outcomes mobility and LOS as well as the secondary functional outcomes. Treatment contrast in terms of total exercise time may have been insufficient to achieve these effects. However, caregiver-mediated exercises showed a favorable impact on secondary outcome measures of mood for both patient and caregiver. CLINICAL TRIAL REGISTRATION NTR4300, URL- http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=4300.
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Affiliation(s)
- Judith D. M. Vloothuis
- Amsterdam Rehabilitation Research Centre, Reade, Amsterdam, The Netherlands
- Department of Rehabilitation Medicine, Amsterdam Neuroscience and Amsterdam Movement Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Marijn Mulder
- Department of Rehabilitation Medicine, Amsterdam Neuroscience and Amsterdam Movement Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | | | - Quirine S. Goedhart
- Department of Rehabilitation Medicine, Amsterdam Neuroscience and Amsterdam Movement Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Manin Konijnenbelt
- Amsterdam Rehabilitation Research Centre, Reade, Amsterdam, The Netherlands
| | | | - Cees M. P. M. Hertogh
- Department of General Practice and Elderly Care Medicine and the EMGO Institute for Health and Care Research, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Maurits van Tulder
- Department of Health Sciences & Amsterdam Movement Sciences, Faculty of Science, VU University, Amsterdam, The Netherlands
- Department of Physiotherapy & Occupational Therapy, Aarhus University Hospital, Aarhus, Denmark
| | - Erwin E. H. van Wegen
- Department of Rehabilitation Medicine, Amsterdam Neuroscience and Amsterdam Movement Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- * E-mail:
| | - Gert Kwakkel
- Amsterdam Rehabilitation Research Centre, Reade, Amsterdam, The Netherlands
- Department of Rehabilitation Medicine, Amsterdam Neuroscience and Amsterdam Movement Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Department of Physical Therapy and Human Movement Sciences, Northwestern University, Evanston, IL, United States of America
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24
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Bråndal A, Eriksson M, Glader EL, Wester P. Effect of early supported discharge after stroke on patient reported outcome based on the Swedish Riksstroke registry. BMC Neurol 2019; 19:40. [PMID: 30866844 PMCID: PMC6417172 DOI: 10.1186/s12883-019-1268-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Accepted: 03/05/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The efficacy of early supported discharge (ESD) has not been tested in current stroke care setting, which provide relatively short hospital stays, access to hyper-acute therapies and early carotid stenosis interventions. This study aimed to compare patient-reported outcome measures (PROM) among patients with stroke that received modern stroke unit care with or without ESD. METHODS Observational study of 30,232 patients with first-ever stroke registered in the Riksstroke registry in Sweden, between 1 January 2010 and 31 December 2013. Patient characteristics were collected from the Riksstroke and Statistics Sweden databases. The primary outcome was satisfaction with the rehabilitation at 3 months after discharge. Secondary outcome were information about stroke provided, tiredness/fatigue, pain, dysthymia/depression, general health status and dependence in activities of daily living (mobility, toileting and dressing) at 3 months after the stroke. We used separate multivariable logistic regression models for each PROM variable to analyze associations between PROMs and ESD/no ESD. RESULTS The ESD group comprised 1495 participants: the control group comprised 28,737 participants. Multivariable logistic regression models of PROMs showed that, compared to controls, the ESD group was more satisfied with rehabilitation after discharge (OR: 1.78, 95% CI: 1.17-2.49), experienced less dysthymia/depression (OR: 0.68, 95% 0.55-0.84) and showed more independence in mobility (OR: 1.50, 95% CI: 1.17-1.92), toileting (OR: 1.30, 95%CI: 1.05-1.61), and dressing (OR: 1.23, 95%CI: 1.02-1.48). CONCLUSION In the setting of modern stroke unit care, ESD appeared to have positive effects on stroke rehabilitation, in the subacute phase.
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Affiliation(s)
- Anna Bråndal
- Department of Public Health and Clinical Medicine, Umeå University, S-901 87, Umeå, Sweden. .,Department of Community Medicine and Rehabilitation, Physiotherapy, Umeå University, S-901 87, Umeå, Sweden.
| | - Marie Eriksson
- Department of Statistics, Umeå School of Business and Economics Umeå University, S-901 87, Umeå, Sweden
| | - Eva-Lotta Glader
- Department of Public Health and Clinical Medicine, Umeå University, S-901 87, Umeå, Sweden
| | - Per Wester
- Department of Public Health and Clinical Medicine, Umeå University, S-901 87, Umeå, Sweden.,Department of Clinical Sciences, Karolinska Institute, Danderyd hospital, S-182 88, Stockholm, Sweden
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25
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Walther F, Kuester D, Schmitt J. Impact of Complex Quality-Interventions on Patient Outcome: A Systematic Overview of Systematic Reviews. INQUIRY : A JOURNAL OF MEDICAL CARE ORGANIZATION, PROVISION AND FINANCING 2019; 56:46958019884182. [PMID: 31746255 PMCID: PMC6868575 DOI: 10.1177/0046958019884182] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Revised: 09/23/2019] [Accepted: 09/27/2019] [Indexed: 01/08/2023]
Abstract
Quality of care and the increasing strategies to its promotion, especially in inpatient settings, led to the question which quality-interventions work best and which do not. The aim was to summarize and critically appraise the evidence on the effects of structure- and/or process-related quality-interventions on patient outcome in predominantly controlled and inpatient settings. A systematic overview of systematic reviews after electronic searches in Medline, Embase, Cinahl, and PsycINFO, supplemented by hand search and expert survey, was conducted. From a total of 1559 identified records, 37 reviews fulfilled the inclusion criteria. 26 reviews assessed process-related quality-interventions, 6 structure-related quality-interventions, and 5 combined structure- and process-related quality-interventions. In all, 19 reviews reported pooled effect estimates (meta-analysis). Based on the evidence of this systematic overview, stroke units and pathways can be recommended. Although patient-relevant improvements for interprofessional approaches and discharge planning have been reported, pooled effect estimated evidence are currently missing for these and other quality-interventions.
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Affiliation(s)
- Felix Walther
- Center for Evidence-Based Healthcare, University Hospital and Faculty of Medicine Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - Denise Kuester
- Center for Evidence-Based Healthcare, University Hospital and Faculty of Medicine Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - Jochen Schmitt
- Center for Evidence-Based Healthcare, University Hospital and Faculty of Medicine Carl Gustav Carus, TU Dresden, Dresden, Germany
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Norrving B, Barrick J, Davalos A, Dichgans M, Cordonnier C, Guekht A, Kutluk K, Mikulik R, Wardlaw J, Richard E, Nabavi D, Molina C, Bath PM, Stibrant Sunnerhagen K, Rudd A, Drummond A, Planas A, Caso V. Action Plan for Stroke in Europe 2018-2030. Eur Stroke J 2018; 3:309-336. [PMID: 31236480 PMCID: PMC6571507 DOI: 10.1177/2396987318808719] [Citation(s) in RCA: 252] [Impact Index Per Article: 42.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2018] [Accepted: 10/01/2018] [Indexed: 12/21/2022] Open
Abstract
Two previous pan-European consensus meetings, the 1995 and 2006 Helsingborg
meetings, were convened to review the scientific evidence and the state of
current services to identify priorities for research and development and to set
targets for the development of stroke care for the decade to follow. Adhering to
the same format, the European Stroke Organisation (ESO) prepared a European
Stroke Action Plan (ESAP) for the years 2018 to 2030, in cooperation with the
Stroke Alliance for Europe (SAFE). The ESAP included seven domains: primary
prevention, organisation of stroke services, management of acute stroke,
secondary prevention, rehabilitation, evaluation of stroke outcome and quality
assessment and life after stroke. Research priorities for translational stroke
research were also identified. Documents were prepared by a working group and
were open to public comments. The final document was prepared after a workshop
in Munich on 21–23 March 2018. Four overarching targets for 2030 were
identified: (1) to reduce the absolute number of strokes in Europe by 10%, (2)
to treat 90% or more of all patients with stroke in Europe in a dedicated stroke
unit as the first level of care, (3) to have national plans for stroke
encompassing the entire chain of care, (4) to fully implement national
strategies for multisector public health interventions. Overall, 30 targets and
72 research priorities were identified for the seven domains. The ESAP provides
a basic road map and sets targets for the implementation of evidence-based
preventive actions and stroke services to 2030.
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Affiliation(s)
- Bo Norrving
- Department of Clinical Sciences Lund, Neurology, Skåne University Hospital, Lund University, Lund, Sweden
| | | | - Antoni Davalos
- Department of Neurosciences, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Martin Dichgans
- Institute for Stroke and Dementia Research, University Hospital, Ludwig-Maximilians University, Munich, and Munich Cluster of Systems Neurology (SyNergy), Munich, Germany
| | | | - Alla Guekht
- Clinical Center for Neuropsychiatry, Russian National Research Medical University, Moscow, Russia
| | - Kursad Kutluk
- Department of Neurology, Stroke Unit, University of Dokuz Eylul, Izmir, Turkey
| | - Robert Mikulik
- International Clinical Research Center and Neurology Department, St Anne's University Hospital Brno and Masaryk University Brno, Czech Republic
| | - Joanna Wardlaw
- Centre for Clinical Neurosciences, Edinburgh Imaging and UK Dementia Research Institute, University of Edinburgh, Edinburgh, UK
| | - Edo Richard
- Department of Neurology, Radboud University Medical Centre, Nijmegen, and Department of Neurology, Academic Medical Centre, Amsterdam, the Netherlands
| | - Darius Nabavi
- Department of Neurology with Stroke Unit, Vivantes Hospital Neukölln, Berlin, Germany
| | - Carlos Molina
- Stroke Unit, Department of Neurology, Hospital Vall d´Hebron Barcelona, Spain
| | - Philip M Bath
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | | | - Anthony Rudd
- Guy's and St Thomas' NHS Foundation Trust, Stroke NHS England and Royal College of Physicians, London, UK
| | - Avril Drummond
- School of Health Sciences, University of Nottingham, Nottingham, UK
| | - Anna Planas
- Institut d'Investigacions Biomèdiques de Barcelona (IIBB), Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Valeria Caso
- Stroke Unit, Department of Medicine and Cardiovascular Medicine, University of Perugia, Perugia, Italy
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27
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Tistad M, Flink M, Ytterberg C, Eriksson G, Guidetti S, Tham K, von Koch L. Resource use of healthcare services 1 year after stroke: a secondary analysis of a cluster-randomised controlled trial of a client-centred activities of daily living intervention. BMJ Open 2018; 8:e022222. [PMID: 30082359 PMCID: PMC6078276 DOI: 10.1136/bmjopen-2018-022222] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Revised: 04/30/2018] [Accepted: 06/12/2018] [Indexed: 12/01/2022] Open
Abstract
OBJECTIVE The objective of the study was to compare the total use of healthcare services in the course of the first year after a stroke between participants who, after the acute care, had received occupational therapy as a client-centred activities of daily living (ADL) intervention (CADL) and participants who had received usual ADL intervention (UADL). DESIGN A secondary analysis of a multicentre cluster-randomised controlled trial (RCT). SETTING Primary and secondary care in Sweden. PARTICIPANTS Participants were included if they: (1) had received CADL or UADL in the RCT, either as inpatients in geriatric rehabilitation units or in their own homes, and (2) data could be retrieved about their use of healthcare services provided by the county council from computerised registers. INTERVENTIONS CADL or UADL. OUTCOME MEASURES Inpatient and outpatient healthcare in the course of the first year after stroke. RESULTS Participants from 7 of the 16 units included in the RCT met the criteria. Participants in the CADL group (n=26) who received geriatric inpatient rehabilitation had a shorter length of hospital stay (p=0.03) than participants in the UADL group (n=46), and the CADL group with home rehabilitation (n=13) had fewer outpatient contacts (p=0.01) compared with the UADL group (n=25). Multiple regression analyses showed that in four of the models, a higher age was associated with a lower use of healthcare services. The use of healthcare services was also associated (some of the models) with dependence in ADL, stroke severity and type of rehabilitation received, CADL or UADL. CONCLUSIONS The provision of client-centred occupational therapy after stroke did not appear to increase the use of healthcare services during the first year after stroke.rrrrr TRIAL REGISTRATION NUMBER: NCT01417585.
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Affiliation(s)
- Malin Tistad
- Division of Occupational Therapy, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Huddinge, Sweden
- School of Education, Health and Social Studies, Dalarna University, Falun, Sweden
- Department of Rehabilitation and Social Medicine, Physiotherapy, Umeå University, Umeå, Sweden
| | - Maria Flink
- Function Area Social Work in Health, Karolinska University Hospital, Stockholm, Sweden
- Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden
| | - Charlotte Ytterberg
- Division of Physiotherapy, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Huddinge, Sweden
- Function Area Occupational Therapy & Physiotherapy, Karolinska University Hospital, Stockholm, Sweden
| | - Gunilla Eriksson
- Division of Occupational Therapy, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Huddinge, Sweden
- Department of Neuroscience, Rehabilitation Medicine, Uppsala University, Uppsala, Sweden
| | - Susanne Guidetti
- Division of Occupational Therapy, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Huddinge, Sweden
| | - Kerstin Tham
- Division of Occupational Therapy, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Huddinge, Sweden
- Faculty of Health and Society, Malmö University, Malmö, Sweden
| | - Lena von Koch
- Division of Occupational Therapy, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Huddinge, Sweden
- Theme Neuro, Karolinska University Hospital, Stockholm, Sweden
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28
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Vloothuis J, de Bruin J, Mulder M, Nijland R, Kwakkel G, van Wegen EEH. Description of the CARE4STROKE programme: A caregiver-mediated exercises intervention with e-health support for stroke patients. PHYSIOTHERAPY RESEARCH INTERNATIONAL 2018; 23:e1719. [PMID: 29797740 PMCID: PMC6055845 DOI: 10.1002/pri.1719] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Revised: 02/09/2018] [Accepted: 04/27/2018] [Indexed: 01/19/2023]
Affiliation(s)
- Judith Vloothuis
- Amsterdam Rehabilitation Research Centre
- Reade, Amsterdam, The Netherlands
| | - Julya de Bruin
- Amsterdam Rehabilitation Research Centre
- Reade, Amsterdam, The Netherlands
| | - Marijn Mulder
- Department of Rehabilitation Medicine, Amsterdam Movement Sciences, VU University Medical Center, Amsterdam, The Netherlands
| | - Rinske Nijland
- Amsterdam Rehabilitation Research Centre
- Reade, Amsterdam, The Netherlands
| | - Gert Kwakkel
- Amsterdam Rehabilitation Research Centre
- Reade, Amsterdam, The Netherlands.,Department of Rehabilitation Medicine, Amsterdam Movement Sciences, VU University Medical Center, Amsterdam, The Netherlands.,Amsterdam Neuroscience, Vrije Universiteit, Amsterdam, The Netherlands.,Department of Physical Therapy and Human Movement Sciences, Northwestern University, Evanston, IL, USA
| | - Erwin E H van Wegen
- Department of Rehabilitation Medicine, Amsterdam Movement Sciences, VU University Medical Center, Amsterdam, The Netherlands.,Amsterdam Neuroscience, Vrije Universiteit, Amsterdam, The Netherlands
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Hotter B, Padberg I, Liebenau A, Knispel P, Heel S, Steube D, Wissel J, Wellwood I, Meisel A. Identifying unmet needs in long-term stroke care using in-depth assessment and the Post-Stroke Checklist - The Managing Aftercare for Stroke (MAS-I) study. Eur Stroke J 2018; 3:237-245. [PMID: 31008354 DOI: 10.1177/2396987318771174] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Accepted: 03/23/2018] [Indexed: 11/16/2022] Open
Abstract
Introduction Detailed data on the long-term consequences and treatment of stroke are scarce. We aimed to assess the needs and disease burden of community-dwelling stroke patients and their carers and to compare their treatment to evidence-based guidelines by a stroke neurologist. Methods We invited long-term stroke patients from two previous acute clinical studies (n = 516) in Berlin, Germany to participate in an observational, cross-sectional study. Participants underwent a comprehensive interview and examination using the Post-Stroke Checklist and validated standard measures of: self-reported needs, quality of life, overall outcome, spasticity, pain, aphasia, cognition, depression, secondary prevention, social needs and caregiver burden. Results Fifty-seven participants (median initial National Institutes of Health Stroke Scale score 10 interquartile range 4-12.75) consented to assessment (median 41 months (interquartile range 36-50) after stroke. Modified Rankin Scale was 2 (median; interquartile range 1-3), EuroQoL index value was 0.81 (median; interquartile range 0.70-1.00). The frequencies for disabilities in the major domains were: spasticity 35%; cognition 61%; depression 20%; medication non-compliance 14%. Spasticity (p = 0.008) and social needs (p < 0.001) had the strongest impact on quality of life. The corresponding items in the Post-Stroke Checklist were predictive for low mood (p < 0.001), impaired cognition (p = 0.015), social needs (p = 0.005) and caregiver burden (p = 0.031). In the comprehensive interview, we identified the following needs: medical review (30%), optimization of pharmacotherapy (18%), outpatient therapy (47%) and social work input (33%). Conclusion These results suggest significant unmet needs and gaps in health and social care in long-term stroke patients. Further research to develop a comprehensive model for managing stroke aftercare is warranted.Clinical Trial Registration: clinicaltrials.gov NCT02320994.
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Affiliation(s)
- Benjamin Hotter
- Center for Stroke Research Berlin and Department of Neurology, Charité University Hospital Berlin, Berlin, Germany
| | - Inken Padberg
- Center for Stroke Research Berlin and Department of Neurology, Charité University Hospital Berlin, Berlin, Germany
| | - Andrea Liebenau
- Center for Stroke Research Berlin and Department of Neurology, Charité University Hospital Berlin, Berlin, Germany
| | - Petra Knispel
- Center for Stroke Research Berlin and Department of Neurology, Charité University Hospital Berlin, Berlin, Germany
| | - Sabine Heel
- Zentrum für ambulante Neuropsychologie und Verhaltenstherapie, Berlin, Germany
| | | | - Jörg Wissel
- Department Neurorehabilitation and Physical Therapy, Department of Neurology, Vivantes Hospital Spandau, Berlin, Germany
| | - Ian Wellwood
- Department of Public Health and Primary Care, Cambridge Institute of Public Health, University of Cambridge, Cambridge, UK
| | - Andreas Meisel
- Center for Stroke Research Berlin and Department of Neurology, Charité University Hospital Berlin, Berlin, Germany
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Ciapponi A, Lewin S, Herrera CA, Opiyo N, Pantoja T, Paulsen E, Rada G, Wiysonge CS, Bastías G, Dudley L, Flottorp S, Gagnon M, Garcia Marti S, Glenton C, Okwundu CI, Peñaloza B, Suleman F, Oxman AD. Delivery arrangements for health systems in low-income countries: an overview of systematic reviews. Cochrane Database Syst Rev 2017; 9:CD011083. [PMID: 28901005 PMCID: PMC5621087 DOI: 10.1002/14651858.cd011083.pub2] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Delivery arrangements include changes in who receives care and when, who provides care, the working conditions of those who provide care, coordination of care amongst different providers, where care is provided, the use of information and communication technology to deliver care, and quality and safety systems. How services are delivered can have impacts on the effectiveness, efficiency and equity of health systems. This broad overview of the findings of systematic reviews can help policymakers and other stakeholders identify strategies for addressing problems and improve the delivery of services. OBJECTIVES To provide an overview of the available evidence from up-to-date systematic reviews about the effects of delivery arrangements for health systems in low-income countries. Secondary objectives include identifying needs and priorities for future evaluations and systematic reviews on delivery arrangements and informing refinements of the framework for delivery arrangements outlined in the review. METHODS We searched Health Systems Evidence in November 2010 and PDQ-Evidence up to 17 December 2016 for systematic reviews. We did not apply any date, language or publication status limitations in the searches. We included well-conducted systematic reviews of studies that assessed the effects of delivery arrangements on patient outcomes (health and health behaviours), the quality or utilisation of healthcare services, resource use, healthcare provider outcomes (such as sick leave), or social outcomes (such as poverty or employment) and that were published after April 2005. We excluded reviews with limitations important enough to compromise the reliability of the findings. Two overview authors independently screened reviews, extracted data, and assessed the certainty of evidence using GRADE. We prepared SUPPORT Summaries for eligible reviews, including key messages, 'Summary of findings' tables (using GRADE to assess the certainty of the evidence), and assessments of the relevance of findings to low-income countries. MAIN RESULTS We identified 7272 systematic reviews and included 51 of them in this overview. We judged 6 of the 51 reviews to have important methodological limitations and the other 45 to have only minor limitations. We grouped delivery arrangements into eight categories. Some reviews provided more than one comparison and were in more than one category. Across these categories, the following intervention were effective; that is, they have desirable effects on at least one outcome with moderate- or high-certainty evidence and no moderate- or high-certainty evidence of undesirable effects. Who receives care and when: queuing strategies and antenatal care to groups of mothers. Who provides care: lay health workers for caring for people with hypertension, lay health workers to deliver care for mothers and children or infectious diseases, lay health workers to deliver community-based neonatal care packages, midlevel health professionals for abortion care, social support to pregnant women at risk, midwife-led care for childbearing women, non-specialist providers in mental health and neurology, and physician-nurse substitution. Coordination of care: hospital clinical pathways, case management for people living with HIV and AIDS, interactive communication between primary care doctors and specialists, hospital discharge planning, adding a service to an existing service and integrating delivery models, referral from primary to secondary care, physician-led versus nurse-led triage in emergency departments, and team midwifery. Where care is provided: high-volume institutions, home-based care (with or without multidisciplinary team) for people living with HIV and AIDS, home-based management of malaria, home care for children with acute physical conditions, community-based interventions for childhood diarrhoea and pneumonia, out-of-facility HIV and reproductive health services for youth, and decentralised HIV care. Information and communication technology: mobile phone messaging for patients with long-term illnesses, mobile phone messaging reminders for attendance at healthcare appointments, mobile phone messaging to promote adherence to antiretroviral therapy, women carrying their own case notes in pregnancy, interventions to improve childhood vaccination. Quality and safety systems: decision support with clinical information systems for people living with HIV/AIDS. Complex interventions (cutting across delivery categories and other health system arrangements): emergency obstetric referral interventions. AUTHORS' CONCLUSIONS A wide range of strategies have been evaluated for improving delivery arrangements in low-income countries, using sound systematic review methods in both Cochrane and non-Cochrane reviews. These reviews have assessed a range of outcomes. Most of the available evidence focuses on who provides care, where care is provided and coordination of care. For all the main categories of delivery arrangements, we identified gaps in primary research related to uncertainty about the applicability of the evidence to low-income countries, low- or very low-certainty evidence or a lack of studies.
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Affiliation(s)
- Agustín Ciapponi
- Institute for Clinical Effectiveness and Health Policy (IECS‐CONICET)Argentine Cochrane CentreDr. Emilio Ravignani 2024Buenos AiresCapital FederalArgentinaC1414CPV
| | - Simon Lewin
- Norwegian Institute of Public HealthPO Box 4404OsloNorway0403
- South African Medical Research CouncilHealth Systems Research UnitPO Box 19070TygerbergSouth Africa7505
| | - Cristian A Herrera
- Pontificia Universidad Católica de ChileDepartment of Public Health, School of MedicineMarcoleta 434SantiagoChile
- Pontificia Universidad Católica de ChileEvidence Based Health Care ProgramSantiagoChile
| | - Newton Opiyo
- CochraneCochrane Editorial UnitSt Albans House, 57‐59 HaymarketLondonUKSW1Y 4QX
| | - Tomas Pantoja
- Pontificia Universidad Católica de ChileEvidence Based Health Care ProgramSantiagoChile
- Pontificia Universidad Católica de ChileDepartment of Family Medicine, Faculty of MedicineCentro Medico San Joaquin, Vicuña Mackenna 4686MaculSantiagoChile
| | | | - Gabriel Rada
- Pontificia Universidad Católica de ChileEvidence Based Health Care ProgramSantiagoChile
- Pontificia Universidad Católica de ChileDepartment of Internal Medicine and Evidence‐Based Healthcare Program, Faculty of MedicineLira 44, Decanato Primer pisoSantiagoChile
| | - Charles S Wiysonge
- South African Medical Research CouncilCochrane South AfricaFrancie van Zijl Drive, Parow ValleyCape TownWestern CapeSouth Africa7505
- Stellenbosch UniversityCentre for Evidence‐based Health Care, Faculty of Medicine and Health SciencesCape TownSouth Africa
| | - Gabriel Bastías
- Pontificia Universidad Católica de ChileDepartment of Public Health, School of MedicineMarcoleta 434SantiagoChile
| | - Lilian Dudley
- Stellenbosch UniversityDivision of Community Health, Faculty of Medicine and Health SciencesFransie Van Zyl DriveTygerbergCape TownSouth Africa7505
| | - Signe Flottorp
- Norwegian Institute of Public HealthDepartment for Evidence SynthesisPO Box 4404 NydalenOsloNorway0403
| | - Marie‐Pierre Gagnon
- CHU de Québec ‐ Université Laval Research CentrePopulation Health and Optimal Health Practices Research Unit10 Rue de l'Espinay, D6‐727Québec CityQCCanadaG1L 3L5
| | - Sebastian Garcia Marti
- Institute for Clinical Effectiveness and Health PolicyBuenos AiresCapital FederalArgentinaC1056ABH
| | - Claire Glenton
- Norwegian Institute of Public HealthGlobal Health UnitPO Box 7004 St Olavs plassOsloNorwayN‐0130
| | - Charles I Okwundu
- Stellenbosch UniversityCentre for Evidence‐based Health Care, Faculty of Medicine and Health SciencesCape TownSouth Africa
| | - Blanca Peñaloza
- Pontificia Universidad Católica de ChileEvidence Based Health Care ProgramSantiagoChile
- Pontificia Universidad Católica de ChileDepartment of Family Medicine, Faculty of MedicineCentro Medico San Joaquin, Vicuña Mackenna 4686MaculSantiagoChile
| | - Fatima Suleman
- University of KwaZulu‐NatalDiscipline of Pharmaceutical Sciences, School of Health SciencesPrivate Bag X54001DurbanKZNSouth Africa4000
| | - Andrew D Oxman
- Norwegian Institute of Public HealthPO Box 4404OsloNorway0403
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Kwakkel G, van Wegen EEH. Family-delivered rehabilitation services at home: is the glass empty? Lancet 2017; 390:538-539. [PMID: 28666681 DOI: 10.1016/s0140-6736(17)31489-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Accepted: 05/03/2017] [Indexed: 11/22/2022]
Affiliation(s)
- Gert Kwakkel
- Department of Rehabilitation Medicine, VU University Medical Center, Amsterdam Movement Sciences, 1081 HV Amsterdam, Netherlands; Amsterdam Neuroscience, Amsterdam, Netherlands; Neurorehabilitation Research Center, Reade, Amsterdam, Netherlands; Department of Physical Therapy and Human Movement Sciences, Northwestern University, Chicago, IL, USA.
| | - Erwin E H van Wegen
- Department of Rehabilitation Medicine, VU University Medical Center, Amsterdam Movement Sciences, 1081 HV Amsterdam, Netherlands; Amsterdam Neuroscience, Amsterdam, Netherlands
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Duncan PW, Bushnell CD, Rosamond WD, Jones Berkeley SB, Gesell SB, D'Agostino RB, Ambrosius WT, Barton-Percival B, Bettger JP, Coleman SW, Cummings DM, Freburger JK, Halladay J, Johnson AM, Kucharska-Newton AM, Lundy-Lamm G, Lutz BJ, Mettam LH, Pastva AM, Sissine ME, Vetter B. The Comprehensive Post-Acute Stroke Services (COMPASS) study: design and methods for a cluster-randomized pragmatic trial. BMC Neurol 2017; 17:133. [PMID: 28716014 PMCID: PMC5513078 DOI: 10.1186/s12883-017-0907-1] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Accepted: 06/23/2017] [Indexed: 12/04/2022] Open
Abstract
Background Patients discharged home after stroke face significant challenges managing residual neurological deficits, secondary prevention, and pre-existing chronic conditions. Post-discharge care is often fragmented leading to increased healthcare costs, readmissions, and sub-optimal utilization of rehabilitation and community services. The COMprehensive Post-Acute Stroke Services (COMPASS) Study is an ongoing cluster-randomized pragmatic trial to assess the effectiveness of a comprehensive, evidence-based, post-acute care model on patient-centered outcomes. Methods Forty-one hospitals in North Carolina were randomized (as 40 units) to either implement the COMPASS care model or continue their usual care. The recruitment goal is 6000 patients (3000 per arm). Hospital staff ascertain and enroll patients discharged home with a clinical diagnosis of stroke or transient ischemic attack. Patients discharged from intervention hospitals receive 2-day telephone follow-up; a comprehensive clinic visit within 2 weeks that includes a neurological evaluation, assessments of social and functional determinants of health, and an individualized COMPASS Care Plan™ integrated with a community-specific resource database; and additional follow-up calls at 30 and 60 days post-stroke discharge. This model is consistent with the Centers for Medicare and Medicaid Services transitional care management services provided by physicians or advanced practice providers with support from a nurse to conduct patient assessments and coordinate follow-up services. Patients discharged from usual care hospitals represent the control group and receive the standard of care in place at that hospital. Patient-centered outcomes are collected from telephone surveys administered at 90 days. The primary endpoint is patient-reported functional status as measured by the Stroke Impact Scale 16. Secondary outcomes are: caregiver strain, all-cause readmissions, mortality, healthcare utilization, and medication adherence. The study engages patients, caregivers, and other stakeholders (including policymakers, advocacy groups, payers, and local community coalitions) to advise and support the design, implementation, and sustainability of the COMPASS care model. Discussion Given the high societal and economic burden of stroke, identifying a care model to improve recovery, independence, and quality of life is critical for stroke survivors and their caregivers. The pragmatic trial design provides a real-world assessment of the COMPASS care model effectiveness and will facilitate rapid implementation into clinical practice if successful. Trial registration Clinicaltrials.gov: NCT02588664; October 23, 2015. Electronic supplementary material The online version of this article (doi:10.1186/s12883-017-0907-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Pamela W Duncan
- Department of Neurology, Wake Forest School of Medicine, Medical Center Blvd, Winston-Salem, NC, 27157, USA
| | - Cheryl D Bushnell
- Department of Neurology, Wake Forest School of Medicine, Medical Center Blvd, Winston-Salem, NC, 27157, USA
| | - Wayne D Rosamond
- Department of Epidemiology, University of North Carolina at Chapel Hill, Gillings School of Global Public Health, 135 Dauer Drive, Chapel Hill, 27599, USA
| | - Sara B Jones Berkeley
- Department of Epidemiology, University of North Carolina at Chapel Hill, Gillings School of Global Public Health, 135 Dauer Drive, Chapel Hill, 27599, USA.
| | - Sabina B Gesell
- Department of Social Sciences & Health Policy, Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC, 27157, USA
| | - Ralph B D'Agostino
- Department of Biostatistical Sciences, Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC, 27157, USA
| | - Walter T Ambrosius
- Department of Biostatistical Sciences, Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC, 27157, USA
| | - Blair Barton-Percival
- Piedmont Triad Regional Council Area Agency on Aging, 1398 Carrollton Crossing Drive, Kernersville, NC, 27284, USA
| | - Janet Prvu Bettger
- Duke University School of Medicine, 40 Medicine Circle DUMC 2919, Durham, NC, 27710, USA
| | - Sylvia W Coleman
- Department of Neurology, Wake Forest School of Medicine, Medical Center Blvd, Winston-Salem, NC, 27157, USA
| | - Doyle M Cummings
- East Carolina University, Brody School of Medicine, Family Medicine Center, MS #654, 101 Heart Drive, Greenville, NC, 27834, USA
| | - Janet K Freburger
- Department of Physical Therapy, University of Pittsburgh, Bridgeside Point 1, 100 Technology Drive, Suite 210, Pittsburgh, PA, 15219-3130, USA
| | - Jacqueline Halladay
- Department of Family Medicine, University of North Carolina at Chapel Hill, 725 Martin Luther King Jr. Blvd., CB #7590, Chapel Hill, NC, 27599-7590, USA
| | - Anna M Johnson
- Department of Epidemiology, University of North Carolina at Chapel Hill, Gillings School of Global Public Health, 135 Dauer Drive, Chapel Hill, 27599, USA
| | - Anna M Kucharska-Newton
- Department of Epidemiology, University of North Carolina at Chapel Hill, Gillings School of Global Public Health, 135 Dauer Drive, Chapel Hill, 27599, USA
| | - Gladys Lundy-Lamm
- Minority Women Health Alliance (TriStroke), 5409 Olive Road, Raleigh, NC, 27606, USA
| | - Barbara J Lutz
- University of North Carolina Wilmington School of Nursing, 601 S. College Road, Wilmington, NC, 28403, USA
| | - Laurie H Mettam
- Department of Epidemiology, University of North Carolina at Chapel Hill, Gillings School of Global Public Health, 135 Dauer Drive, Chapel Hill, 27599, USA
| | - Amy M Pastva
- Department of Orthopaedic Surgery, Doctor of Physical Therapy Division, & Center for the Study of Aging and Human Development, Duke University, DUMC 104002, Durham, NC, 27708, USA
| | - Mysha E Sissine
- Department of Neurology, Wake Forest School of Medicine, Medical Center Blvd, Winston-Salem, NC, 27157, USA
| | - Betsy Vetter
- American Heart Association, 3131 RDU Center Drive, Suite 100, Morrisville, NC, 27560, USA
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Abstract
BACKGROUND People with stroke conventionally receive a substantial part of their rehabilitation in hospital. Services have now been developed that offer people in hospital an early discharge with rehabilitation at home (early supported discharge: ESD). OBJECTIVES To establish if, in comparison with conventional care, services that offer people in hospital with stroke a policy of early discharge with rehabilitation provided in the community (ESD) can: 1) accelerate return home, 2) provide equivalent or better patient and carer outcomes, 3) be acceptable satisfactory to patients and carers, and 4) have justifiable resource implications use. SEARCH METHODS We searched the Cochrane Stroke Group Trials Register (January 2017), Cochrane Central Register of Controlled Trials (CENTRAL 2017, Issue 1) in the Cochrane Library (searched January 2017), MEDLINE in Ovid (searched January 2017), Embase in Ovid (searched January 2017), CINAHL in EBSCO (Cumulative Index to Nursing and Allied Health Literature; 1937 to December 2016), and Web of Science (to January 2017). In an effort to identify further published, unpublished, and ongoing trials we searched six trial registries (March 2017). We also performed citation tracking of included studies, checked reference lists of relevant articles, and contacted trialists. SELECTION CRITERIA Randomised controlled trials (RCTs) recruiting stroke patients in hospital to receive either conventional care or any service intervention that has provided rehabilitation and support in a community setting with an aim of reducing the duration of hospital care. DATA COLLECTION AND ANALYSIS The primary patient outcome was the composite end-point of death or long-term dependency recorded at the end of scheduled follow-up. Two review authors scrutinised trials, categorised them on their eligibility and extracted data. Where possible we sought standardised data from the primary trialists. We analysed the results for all trials and for subgroups of patients and services, in particular whether the intervention was provided by a co-ordinated multidisciplinary team (co-ordinated ESD team) or not. We assessed risk of bias for the included trials and used GRADE to assess the quality of the body of evidence. MAIN RESULTS We included 17 trials, recruiting 2422 participants, for which outcome data are currently available. Participants tended to be a selected elderly group of stroke survivors with moderate disability. The ESD group showed reductions in the length of hospital stay equivalent to approximately six days (mean difference (MD) -5.5; 95% confidence interval (CI) -3 to -8 days; P < 0.0001; moderate-grade evidence). The primary outcome was available for 16 trials (2359 participants). Overall, the odds ratios (OR) for the outcome of death or dependency at the end of scheduled follow-up (median 6 months; range 3 to 12) was OR 0.80 (95% CI 0.67 to 0.95, P = 0.01, moderate-grade evidence) which equates to five fewer adverse outcomes per 100 patients receiving ESD. The results for death (16 trials; 2116 participants) and death or requiring institutional care (12 trials; 1664 participants) were OR 1.04 (95% CI 0.77 to 1.40, P = 0.81, moderate-grade evidence) and OR 0.75 (95% CI 0.59 to 0.96, P = 0.02, moderate-grade evidence), respectively. Small improvements were also seen in participants' extended activities of daily living scores (standardised mean difference (SMD) 0.14, 95% CI 0.03 to 0.25, P = 0.01, low-grade evidence) and satisfaction with services (OR 1.60, 95% CI 1.08 to 2.38, P = 0.02, low-grade evidence). We saw no clear differences in participants' activities of daily living scores, patients subjective health status or mood, or the subjective health status, mood or satisfaction with services of carers. We found low-quality evidence that the risk of readmission to hospital was similar in the ESD and conventional care group (OR 1.09, 95% CI 0.79 to 1.51, P = 0.59, low-grade evidence). The evidence for the apparent benefits were weaker at one- and five-year follow-up. Estimated costs from six individual trials ranged from 23% lower to 15% greater for the ESD group in comparison to usual care.In a series of pre-planned analyses, the greatest reductions in death or dependency were seen in the trials evaluating a co-ordinated ESD team with a suggestion of poorer results in those services without a co-ordinated team (subgroup interaction at P = 0.06). Stroke patients with mild to moderate disability at baseline showed greater reductions in death or dependency than those with more severe stroke (subgroup interaction at P = 0.04). AUTHORS' CONCLUSIONS Appropriately resourced ESD services with co-ordinated multidisciplinary team input provided for a selected group of stroke patients can reduce long-term dependency and admission to institutional care as well as reducing the length of hospital stay. Results are inconclusive for services without co-ordinated multidisciplinary team input. We observed no adverse impact on the mood or subjective health status of patients or carers, nor on readmission to hospital.
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Affiliation(s)
- Peter Langhorne
- ICAMS, University of GlasgowAcademic Section of Geriatric MedicineLevel 2, New Lister BuildingGlasgow Royal InfirmaryGlasgowUKG31 2ER
| | - Satu Baylan
- Queen Elizabeth University HospitalInstitute of Health and Wellbeing, College of Medical, Veterinary and Life SciencesGlasgowUKG51 4TF
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Gonçalves-Bradley DC, Iliffe S, Doll HA, Broad J, Gladman J, Langhorne P, Richards SH, Shepperd S. Early discharge hospital at home. Cochrane Database Syst Rev 2017; 2017:CD000356. [PMID: 28651296 PMCID: PMC6481686 DOI: 10.1002/14651858.cd000356.pub4] [Citation(s) in RCA: 69] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
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.
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Yoshida S, Matsushima M, Wakabayashi H, Mutai R, Murayama S, Hayashi T, Ichikawa H, Nakano Y, Watanabe T, Fujinuma Y. Validity and reliability of the Patient Centred Assessment Method for patient complexity and relationship with hospital length of stay: a prospective cohort study. BMJ Open 2017; 7:e016175. [PMID: 28490567 PMCID: PMC5623372 DOI: 10.1136/bmjopen-2017-016175] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES Several instruments for evaluating patient complexity have been developed from a biopsychosocial perspective. Although relationships between the results obtained by these instruments and the length of stay in hospital have been examined, many instruments are complicated and not easy to use. The Patient Centred Assessment Method (PCAM) is a candidate for practical use. This study aimed to test the validity and reliability of the PCAM and examine the correlations between length of hospital stay and PCAM scores in a regional secondary care hospital in Japan. DESIGN Prospective cohort study. PARTICIPANTS AND SETTING Two hundred and one patients admitted to Ouji Coop Hospital between July 2014 and September 2014. MAIN PREDICTOR PCAM total score in initial phase of hospital admission. MAIN OUTCOME Length of stay in hospital. RESULTS Among 201 patients (Female/Male=98/103) with mean (SD) age of 77.4±11.9 years, the mean PCAM score was 25±7.3 and mean (SD) length of stay in hospital (LOS) 34.1±40.9 days. Using exploratory factor analysis to examine construct validity, PCAM evidently has a two-factor structure, comprising medicine-oriented and patient-oriented complexity. The Spearman rank correlation coefficient for evaluating criterion-based validity between PCAM and INTERMED was 0.90. For reliability, Cronbach's alpha was 0.85. According to negative binomial regression analyses, PCAM scores are a statistically significant predictor (p<0.001) of LOS after adjusting for age, gender, Mini Nutritional Assessment Short-Form, Charlson Comorbidity Index, serum sodium concentration, total number of medications and whether public assistance was required. In another model, each factor in PCAM was independently correlated with length of stay in hospital after adjustment (medicine-oriented complexity: p=0.001, patient-oriented complexity: p=0.014). CONCLUSION PCAM is a reliable and valid measurement of patient complexity and PCAM scores have a significant correlation with hospital length of stay.
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Affiliation(s)
- Shuhei Yoshida
- Kitaadachi-seikyo Clinic, Japanese Health and Welfare Co-operative Federation, Tokyo, Japan
- Division of Clinical Epidemiology, Research Center for Medical Sciences, Jikei University School of Medicine, Tokyo, Japan
- Centre for Family Medicine Development, Japanese Health and Welfare Co-operative Federation, Tokyo, Japan
| | - Masato Matsushima
- Division of Clinical Epidemiology, Research Center for Medical Sciences, Jikei University School of Medicine, Tokyo, Japan
| | - Hidetaka Wakabayashi
- Department of Rehabilitation Medicine, Yokohama City University Medical Center, Yokohama, Japan
| | - Rieko Mutai
- Division of Clinical Epidemiology, Research Center for Medical Sciences, Jikei University School of Medicine, Tokyo, Japan
| | - Shinichi Murayama
- Division of Clinical Epidemiology, Research Center for Medical Sciences, Jikei University School of Medicine, Tokyo, Japan
- Shioiri-seikyo clinic, Japanese Health and Welfare Co-operative Federation, Tokyo, Japan
| | - Tetsuro Hayashi
- Division of Clinical Epidemiology, Research Center for Medical Sciences, Jikei University School of Medicine, Tokyo, Japan
- National Hospital Organization Tokyo Medical Center, Tokyo, Japan
| | - Hiroko Ichikawa
- Division of Clinical Epidemiology, Research Center for Medical Sciences, Jikei University School of Medicine, Tokyo, Japan
- Tokyo Rinkai Byoin, Edogawa-ku, Tokyo, Japan
| | - Yuko Nakano
- Division of Clinical Epidemiology, Research Center for Medical Sciences, Jikei University School of Medicine, Tokyo, Japan
- Japan Small Animal Cancer Center, Saitama, Japan
| | - Takamasa Watanabe
- Kitaadachi-seikyo Clinic, Japanese Health and Welfare Co-operative Federation, Tokyo, Japan
- Division of Clinical Epidemiology, Research Center for Medical Sciences, Jikei University School of Medicine, Tokyo, Japan
- Centre for Family Medicine Development, Japanese Health and Welfare Co-operative Federation, Tokyo, Japan
| | - Yasuki Fujinuma
- Centre for Family Medicine Development, Japanese Health and Welfare Co-operative Federation, Tokyo, Japan
- Seikyo-ukima clinic, Japanese Health and Welfare Co-operative Federation, Tokyo, Japan
- Interprofessional Education Research Center (IPERC), Graduate School of Nursing, Chiba University, Chiba, Japan
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Forman DE, Arena R, Boxer R, Dolansky MA, Eng JJ, Fleg JL, Haykowsky M, Jahangir A, Kaminsky LA, Kitzman DW, Lewis EF, Myers J, Reeves GR, Shen WK. Prioritizing Functional Capacity as a Principal End Point for Therapies Oriented to Older Adults With Cardiovascular Disease: A Scientific Statement for Healthcare Professionals From the American Heart Association. Circulation 2017; 135:e894-e918. [PMID: 28336790 PMCID: PMC7252210 DOI: 10.1161/cir.0000000000000483] [Citation(s) in RCA: 164] [Impact Index Per Article: 23.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Adults are living longer, and cardiovascular disease is endemic in the growing population of older adults who are surviving into old age. Functional capacity is a key metric in this population, both for the perspective it provides on aggregate health and as a vital goal of care. Whereas cardiorespiratory function has long been applied by cardiologists as a measure of function that depended primarily on cardiac physiology, multiple other factors also contribute, usually with increasing bearing as age advances. Comorbidity, inflammation, mitochondrial metabolism, cognition, balance, and sleep are among the constellation of factors that bear on cardiorespiratory function and that become intricately entwined with cardiovascular health in old age. This statement reviews the essential physiology underlying functional capacity on systemic, organ, and cellular levels, as well as critical clinical skills to measure multiple realms of function (eg, aerobic, strength, balance, and even cognition) that are particularly relevant for older patients. Clinical therapeutic perspectives and patient perspectives are enumerated to clarify challenges and opportunities across the caregiving spectrum, including patients who are hospitalized, those managed in routine office settings, and those in skilled nursing facilities. Overall, this scientific statement provides practical recommendations and vital conceptual insights.
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Abstract
Stroke units reduce death and disability through the provision of specialist multidisciplinary care for diagnosis, emergency treatments, normalisation of homeostasis, prevention of complications, rehabilitation and secondary prevention. All stroke patients can benefit from provision of high-quality basic medical care and some need high impact specific treatments, such as thrombolysis, that are often time dependent. A standard patient pathway should include assessment of neurological impairment, vascular risk factors, swallowing, fluid balance and nutrition, cognitive function, communication, mood disorders, continence, activities of daily living and rehabilitation goals. Good communication and shared decision making with patients and their families are key to high-quality stroke care. Patients with mild or moderate disability, who are medically stable, can continue rehabilitation at home with early supported discharge teams rather than needing a prolonged stay in hospital. National clinical guidelines and prospective audits are integral to monitoring and developing stroke services in the UK.
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Affiliation(s)
- Helen Rodgers
- Newcastle University and honorary consultant stroke physician, Northumbria Healthcare NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Chris Price
- Newcastle University and honorary consultant stroke physician, Northumbria Healthcare NHS Foundation Trust, Newcastle upon Tyne, UK
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Opara J, Błaszczyszyn M, Mehlich K, Kucio C. Where is the idea of Early Supported Discharge after stroke going? REHABILITACJA MEDYCZNA 2017. [DOI: 10.5604/01.3001.0009.7395] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
In 2009 and in 2012 we published two articles in “Medical Rehabilitation” regarding the development of idea of Early Home Supported Discharge in stroke rehabilitation. Today, omitting the word “Home”, the abbreviation ESD is more popular. The aim of this article is to present the latest developments around the idea of continuing rehabilitation after early discharge from the hospital in a home setting. We primarily focus on the most recent reports, particularly systematic reviews. Each country has its own eligibility criteria which are different for early hospital discharge and follow-up rehabilitation in the place of residence, and sometimes the rehabilitation team staff also differs. So far, studies have shown that the optimal role of the rehabilitation team is coordination and delivery of rehabilitation in a home setting. It is also clear that the ESD model brings tangible economic benefits, mainly by shortening hospital stays. Specific organizational solutions used in different countries depend on cultural traditions, capabilities and financial sources.
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Affiliation(s)
- Józef Opara
- Akademia Wychowania Fizycznego im. Jerzego Kukuczki w Katowicach / Jerzy Kukuczka Academy of Physical Education in Katowice, Poland
| | | | - Krzysztof Mehlich
- Akademia Wychowania Fizycznego im. Jerzego Kukuczki w Katowicach / Jerzy Kukuczka Academy of Physical Education in Katowice, Poland
| | - Cezary Kucio
- Akademia Wychowania Fizycznego im. Jerzego Kukuczki w Katowicach / Jerzy Kukuczka Academy of Physical Education in Katowice, Poland
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Fisher DJ, Carpenter JR, Morris TP, Freeman SC, Tierney JF. Meta-analytical methods to identify who benefits most from treatments: daft, deluded, or deft approach? BMJ 2017; 356:j573. [PMID: 28258124 PMCID: PMC5421441 DOI: 10.1136/bmj.j573] [Citation(s) in RCA: 125] [Impact Index Per Article: 17.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Identifying which individuals benefit most from particular treatments or other interventions underpins so-called personalised or stratified medicine. However, single trials are typically underpowered for exploring whether participant characteristics, such as age or disease severity, determine an individual’s response to treatment. A meta-analysis of multiple trials, particularly one where individual participant data (IPD) are available, provides greater power to investigate interactions between participant characteristics (covariates) and treatment effects. We use a published IPD meta-analysis to illustrate three broad approaches used for testing such interactions. Based on another systematic review of recently published IPD meta-analyses, we also show that all three approaches can be applied to aggregate data as well as IPD. We also summarise which methods of analysing and presenting interactions are in current use, and describe their advantages and disadvantages. We recommend that testing for interactions using within-trials information alone (the deft approach) becomes standard practice, alongside graphical presentation that directly visualises this.
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Affiliation(s)
- David J Fisher
- London Hub for Trials Methodology Research, MRC Clinical Trials Unit, University College London, London, UK
| | - James R Carpenter
- London Hub for Trials Methodology Research, MRC Clinical Trials Unit, University College London, London, UK
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
| | - Tim P Morris
- London Hub for Trials Methodology Research, MRC Clinical Trials Unit, University College London, London, UK
| | - Suzanne C Freeman
- London Hub for Trials Methodology Research, MRC Clinical Trials Unit, University College London, London, UK
| | - Jayne F Tierney
- London Hub for Trials Methodology Research, MRC Clinical Trials Unit, University College London, London, UK
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Methods guiding stakeholder engagement in planning a pragmatic study on changing stroke systems of care. J Clin Transl Sci 2017. [PMID: 28649454 PMCID: PMC5471818 DOI: 10.1017/cts.2016.26] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Background: The Comprehensive Post-Acute Stroke Services (COMPASS) Study is one of the first large pragmatic randomized-controlled clinical trials using comparative effectiveness research methods, funded by the Patient-Centered Outcomes Research Institute. In the COMPASS Study, we compare the effectiveness of a patient-centered, transitional care intervention versus usual care for stroke patients discharged home from acute care. Outcomes include stroke patient post-discharge functional status and caregiver strain 90 days after discharge, and hospital readmissions. A central tenet of Patient-Centered Outcomes Research Institute-funded research is stakeholder engagement throughout the research process. However, evidence on how to successfully implement a pragmatic trial that changes systems of care in combination with robust stakeholder engagement is limited. This combination is not without challenges. Methods: We present our approach for broad-based stakeholder engagement in the context of a pragmatic trial with the participation of patients, caregivers, community stakeholders, including the North Carolina Stroke Care Collaborative hospital network, and policy makers. To maximize stakeholder engagement throughout the COMPASS Study, we employed a conceptual model with the following components: (1) Patient and Other Stakeholder Identification and Selection; (2) Patient and Other Stakeholder Involvement Across the Spectrum of Research Activities; (3) Dedicated Resources for Patient and Other Stakeholder Involvement; (4) Support for Patient and Other Stakeholder Engagement Through Organizational Processes; (5) Communication with Patients and Other Stakeholders; (6) Transparent Involvement Processes; (7) Tracking of Engagement; and (8) Evaluation of Engagement. Conclusion: In this paper, we describe how each component of the model is being implemented and how this approach addresses existing gaps in the literature on strategies for engaging stakeholders in meaningful and useful ways when conducting pragmatic trials.
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Abstract
In the past decade, the definition of stroke has been revised and major advances have been made for its treatment and prevention. For acute ischaemic stroke, the addition of endovascular thrombectomy of proximal large artery occlusion to intravenous alteplase increases functional independence for a further fifth of patients. The benefits of aspirin in preventing early recurrent ischaemic stroke are greater than previously recognised. Other strategies to prevent recurrent stroke now include direct oral anticoagulants as an alternative to warfarin for atrial fibrillation, and carotid stenting as an alternative to endarterectomy for symptomatic carotid stenosis. For acute intracerebral haemorrhage, trials are ongoing to assess the effectiveness of acute blood pressure lowering, haemostatic therapy, minimally invasive surgery, anti-inflammation therapy, and neuroprotection methods. Pharmacological and stem-cell therapies promise to facilitate brain regeneration, rehabilitation, and functional recovery. Despite declining stroke mortality rates, the global burden of stroke is increasing. A more comprehensive approach to primary prevention of stroke is required that targets people at all levels of risk and is integrated with prevention strategies for other diseases that share common risk factors.
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Affiliation(s)
- Graeme J Hankey
- School of Medicine & Pharmacology, The University of Western Australia, Perth, WA, Australia; Department of Neurology, Sir Charles Gairdner Hospital, Perth, WA, Australia; Western Australian Neuroscience Research Institute (WANRI), Perth, WA, Australia.
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Damery S, Flanagan S, Combes G. Does integrated care reduce hospital activity for patients with chronic diseases? An umbrella review of systematic reviews. BMJ Open 2016; 6:e011952. [PMID: 27872113 PMCID: PMC5129137 DOI: 10.1136/bmjopen-2016-011952] [Citation(s) in RCA: 103] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2016] [Revised: 08/08/2016] [Accepted: 09/30/2016] [Indexed: 12/03/2022] Open
Abstract
OBJECTIVE To summarise the evidence regarding the effectiveness of integrated care interventions in reducing hospital activity. DESIGN Umbrella review of systematic reviews and meta-analyses. SETTING Interventions must have delivered care crossing the boundary between at least two health and/or social care settings. PARTICIPANTS Adult patients with one or more chronic diseases. DATA SOURCES MEDLINE, Embase, ASSIA, PsycINFO, HMIC, CINAHL, Cochrane Library (HTA database, DARE, Cochrane Database of Systematic Reviews), EPPI-Centre, TRIP, HEED, manual screening of references. OUTCOME MEASURES Any measure of hospital admission or readmission, length of stay (LoS), accident and emergency use, healthcare costs. RESULTS 50 reviews were included. Interventions focused on case management (n=8), chronic care model (CCM) (n=9), discharge management (n=15), complex interventions (n=3), multidisciplinary teams (MDT) (n=10) and self-management (n=5). 29 reviews reported statistically significant improvements in at least one outcome. 11/21 reviews reported significantly reduced emergency admissions (15-50%); 11/24 showed significant reductions in all-cause (10-30%) or condition-specific (15-50%) readmissions; 9/16 reported LoS reductions of 1-7 days and 4/9 showed significantly lower A&E use (30-40%). 10/25 reviews reported significant cost reductions but provided little robust evidence. Effective interventions included discharge management with postdischarge support, MDT care with teams that include condition-specific expertise, specialist nurses and/or pharmacists and self-management as an adjunct to broader interventions. Interventions were most effective when targeting single conditions such as heart failure, and when care was provided in patients' homes. CONCLUSIONS Although all outcomes showed some significant reductions, and a number of potentially effective interventions were found, interventions rarely demonstrated unequivocally positive effects. Despite the centrality of integrated care to current policy, questions remain about whether the magnitude of potentially achievable gains is enough to satisfy national targets for reductions in hospital activity. TRIAL REGISTRATION NUMBER CRD42015016458.
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Affiliation(s)
- Sarah Damery
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, UK
| | - Sarah Flanagan
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, UK
| | - Gill Combes
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, UK
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Kayyali R, Odeh B, Frerichs I, Davies N, Perantoni E, D’arcy S, Vaes AW, Chang J, Spruit MA, Deering B, Philip N, Siva R, Kaimakamis E, Chouvarda I, Pierscionek B, Weiler N, Wouters EFM, Raptopoulos A, Nabhani-Gebara S. COPD care delivery pathways in five European Union countries: mapping and health care professionals' perceptions. Int J Chron Obstruct Pulmon Dis 2016; 11:2831-2838. [PMID: 27881915 PMCID: PMC5115685 DOI: 10.2147/copd.s104136] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND COPD is among the leading causes of chronic morbidity and mortality in the European Union with an estimated annual economic burden of €25.1 billion. Various care pathways for COPD exist across Europe leading to different responses to similar problems. Determining these differences and the similarities may improve health and the functioning of health services. OBJECTIVE The aim of this study was to compare COPD patients' care pathway in five European Union countries including England, Ireland, the Netherlands, Greece, and Germany and to explore health care professionals' (HCPs) perceptions about the current pathways. METHODS HCPs were interviewed in two stages using a qualitative, semistructured email interview and a face-to-face semistructured interview. RESULTS Lack of communication among different health care providers managing COPD and comorbidities was a common feature of the studied care pathways. General practitioners/family doctors are responsible for liaising between different teams/services, except in Greece where this is done through pulmonologists. Ireland and the UK are the only countries with services for patients at home to shorten unnecessary hospital stay. HCPs emphasized lack of communication, limited resources, and poor patient engagement as issues in the current pathways. Furthermore, no specified role exists for pharmacists and informal carers. CONCLUSION Service and professional integration between care settings using a unified system targeting COPD and comorbidities is a priority. Better communication between health care providers, establishing a clear role for informal carers, and enhancing patients' engagement could optimize current care pathways resulting in a better integrated system.
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Affiliation(s)
- Reem Kayyali
- Faculty of Science, Engineering and Computing, Kingston University, Kingston-Upon-Thames, UK
| | - Bassel Odeh
- Faculty of Science, Engineering and Computing, Kingston University, Kingston-Upon-Thames, UK
| | - Inéz Frerichs
- Department of Anaesthesiology and Intensive Care Medicine, University Medical Centre Schleswig-Holstein, Kiel, Germany
| | - Nikki Davies
- Chest Clinic and Research and Development, Croydon University Hospital, Croydon, UK
| | - Eleni Perantoni
- Pulmonary Clinic, AHEPA University Hospital, Thessaloniki, Greece
| | - Shona D’arcy
- Department of Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Anouk W Vaes
- Research and Education, CIRO – Centre of Expertise for Chronic Organ Failure, Horn, the Netherlands
| | - John Chang
- Chest Clinic and Research and Development, Croydon University Hospital, Croydon, UK
| | - Martijn A Spruit
- Research and Education, CIRO – Centre of Expertise for Chronic Organ Failure, Horn, the Netherlands
| | | | - Nada Philip
- Faculty of Science, Engineering and Computing, Kingston University, Kingston-Upon-Thames, UK
| | - Roshan Siva
- Chest Clinic and Research and Development, Croydon University Hospital, Croydon, UK
| | | | | | - Barbara Pierscionek
- Faculty of Science, Engineering and Computing, Kingston University, Kingston-Upon-Thames, UK
| | - Norbert Weiler
- Department of Anaesthesiology and Intensive Care Medicine, University Medical Centre Schleswig-Holstein, Kiel, Germany
| | - Emiel FM Wouters
- Research and Education, CIRO – Centre of Expertise for Chronic Organ Failure, Horn, the Netherlands
| | | | - Shereen Nabhani-Gebara
- Faculty of Science, Engineering and Computing, Kingston University, Kingston-Upon-Thames, UK
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Pindus DM, Lim L, Rundell AV, Hobbs V, Aziz NA, Mullis R, Mant J. Primary care interventions and current service innovations in modifying long-term outcomes after stroke: a protocol for a scoping review. BMJ Open 2016; 6:e012840. [PMID: 27798023 PMCID: PMC5093648 DOI: 10.1136/bmjopen-2016-012840] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2016] [Revised: 08/25/2016] [Accepted: 09/20/2016] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION Interventions delivered by primary and/or community care have the potential to reach the majority of stroke survivors and carers and offer ongoing support. However, an integrative account emerging from the reviews of interventions addressing specific long-term outcomes after stroke is lacking. The aims of the proposed scoping review are to provide an overview of: (1) primary care and community healthcare interventions by generalist healthcare professionals to stroke survivors and/or their informal carers to address long-term outcomes after stroke, (2) the scope and characteristics of interventions which were successful in addressing long-term outcomes, and (3) developments in current clinical practice. METHODS AND ANALYSIS Studies that focused on adult community dwelling stroke survivors and informal carers were included. Academic electronic databases will be searched to identify reviews of randomised controlled trials (RCTs) and controlled trials, trials from the past 5 years; reviews of observational studies. Practice exemplars from grey literature will be identified through advanced Google search. Reports, guidelines and other documents of major health organisations, clinical professional bodies, and stroke charities in the UK and internationally will be included. Two reviewers will independently screen titles, abstracts and full texts for inclusion of published literature. One reviewer will screen search results from the grey literature and identify relevant documents for inclusion. Data synthesis will include analysis of the number, type of studies, year and country of publication, a summary of intervention components/service or practice, outcomes addressed, main results (an indicator of effectiveness) and a description of included interventions. ETHICS AND DISSEMINATION The review will help identify components of care and care pathways for primary care services for stroke. By comparing the results with stroke survivors' and carers' needs identified in the literature, the review will highlight potential gaps in research and practice relevant to long-term care after stroke.
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Affiliation(s)
- Dominika M Pindus
- Department of Public Health and Primary Care, University of Cambridge, Strangeways Research Laboratory, Cambridge, UK
| | - Lisa Lim
- Department of Public Health and Primary Care, University of Cambridge, Strangeways Research Laboratory, Cambridge, UK
| | - A Viona Rundell
- Department of Public Health and Primary Care, University of Cambridge, Strangeways Research Laboratory, Cambridge, UK
| | - Victoria Hobbs
- Department of Public Health and Primary Care, University of Cambridge, Strangeways Research Laboratory, Cambridge, UK
| | - Noorazah Abd Aziz
- Department of Public Health and Primary Care, University of Cambridge, Strangeways Research Laboratory, Cambridge, UK
- Department of Family Medicine, National University of Malaysia, Bandar Tun Razak Cheras, Kuala Lumpur, Malaysia
| | - Ricky Mullis
- Department of Public Health and Primary Care, University of Cambridge, Strangeways Research Laboratory, Cambridge, UK
| | - Jonathan Mant
- Department of Public Health and Primary Care, University of Cambridge, Strangeways Research Laboratory, Cambridge, UK
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Monks T, Worthington D, Allen M, Pitt M, Stein K, James MA. A modelling tool for capacity planning in acute and community stroke services. BMC Health Serv Res 2016; 16:530. [PMID: 27688152 PMCID: PMC5043535 DOI: 10.1186/s12913-016-1789-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2016] [Accepted: 09/23/2016] [Indexed: 11/17/2022] Open
Abstract
Background Mathematical capacity planning methods that can take account of variations in patient complexity, admission rates and delayed discharges have long been available, but their implementation in complex pathways such as stroke care remains limited. Instead simple average based estimates are commonplace. These methods often substantially underestimate capacity requirements. We analyse the capacity requirements for acute and community stroke services in a pathway with over 630 admissions per year. We sought to identify current capacity bottlenecks affecting patient flow, future capacity requirements in the presence of increased admissions, the impact of co-location and pooling of the acute and rehabilitation units and the impact of patient subgroups on capacity requirements. We contrast these results to the often used method of planning by average occupancy, often with arbitrary uplifts to cater for variability. Methods We developed a discrete-event simulation model using aggregate parameter values derived from routine administrative data on over 2000 anonymised admission and discharge timestamps. The model mimicked the flow of stroke, high risk TIA and complex neurological patients from admission to an acute ward through to community rehab and early supported discharge, and predicted the probability of admission delays. Results An increase from 10 to 14 acute beds reduces the number of patients experiencing a delay to the acute stroke unit from 1 in every 7 to 1 in 50. Co-location of the acute and rehabilitation units and pooling eight beds out of a total bed stock of 26 reduce the number of delayed acute admissions to 1 in every 29 and the number of delayed rehabilitation admissions to 1 in every 20. Planning by average occupancy would resulted in delays for one in every five patients in the acute stroke unit. Conclusions Planning by average occupancy fails to provide appropriate reserve capacity to manage the variations seen in stroke pathways to desired service levels. An appropriate uplift from the average cannot be based simply on occupancy figures. Our method draws on long available, intuitive, but underused mathematical techniques for capacity planning. Implementation via simulation at our study hospital provided valuable decision support for planners to assess future bed numbers and organisation of the acute and rehabilitation services. Electronic supplementary material The online version of this article (doi:10.1186/s12913-016-1789-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Thomas Monks
- NIHR CLAHRC Wessex, Faculty of Health Sciences, University of Southampton, Southampton, SO17 1BJ, UK.
| | - David Worthington
- Lancaster University Management School, Lancaster University, Lancaster, LA1 4YX, UK
| | - Michael Allen
- NIHR CLAHRC South West Peninsula, University of Exeter Medical School, University of Exeter, Exeter, EX1 2LU, UK
| | | | - Ken Stein
- NIHR CLAHRC South West Peninsula, University of Exeter Medical School, University of Exeter, Exeter, EX1 2LU, UK
| | - Martin A James
- NIHR CLAHRC South West Peninsula, University of Exeter Medical School, University of Exeter, Exeter, EX1 2LU, UK
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Liu H, Lindley R, Alim M, Felix C, Gandhi DBC, Verma SJ, Tugnawat DK, Syrigapu A, Ramamurthy RK, Pandian JD, Walker M, Forster A, Anderson CS, Langhorne P, Murthy GVS, Shamanna BR, Hackett ML, Maulik PK, Harvey LA, Jan S. Protocol for process evaluation of a randomised controlled trial of family-led rehabilitation post stroke (ATTEND) in India. BMJ Open 2016; 6:e012027. [PMID: 27633636 PMCID: PMC5030603 DOI: 10.1136/bmjopen-2016-012027] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
INTRODUCTION We are undertaking a randomised controlled trial (fAmily led rehabiliTaTion aftEr stroke in INDia, ATTEND) evaluating training a family carer to enable maximal rehabilitation of patients with stroke-related disability; as a potentially affordable, culturally acceptable and effective intervention for use in India. A process evaluation is needed to understand how and why this complex intervention may be effective, and to capture important barriers and facilitators to its implementation. We describe the protocol for our process evaluation to encourage the development of in-process evaluation methodology and transparency in reporting. METHODS AND ANALYSIS The realist and RE-AIM (Reach, Effectiveness, Adoption, Implementation and Maintenance) frameworks informed the design. Mixed methods include semistructured interviews with health providers, patients and their carers, analysis of quantitative process data describing fidelity and dose of intervention, observations of trial set up and implementation, and the analysis of the cost data from the patients and their families perspective and programme budgets. These qualitative and quantitative data will be analysed iteratively prior to knowing the quantitative outcomes of the trial, and then triangulated with the results from the primary outcome evaluation. ETHICS AND DISSEMINATION The process evaluation has received ethical approval for all sites in India. In low-income and middle-income countries, the available human capital can form an approach to reducing the evidence practice gap, compared with the high cost alternatives available in established market economies. This process evaluation will provide insights into how such a programme can be implemented in practice and brought to scale. Through local stakeholder engagement and dissemination of findings globally we hope to build on patient-centred, cost-effective and sustainable models of stroke rehabilitation. TRIAL REGISTRATION NUMBER CTRI/2013/04/003557.
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Affiliation(s)
- Hueiming Liu
- The George Institute for Global Health, Sydney, New South Wales, Australia
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Richard Lindley
- The George Institute for Global Health, Sydney, New South Wales, Australia
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Mohammed Alim
- George Institute for Global Health, Hyderabad, Telangana, India
| | | | | | | | | | | | | | | | | | | | - Craig S Anderson
- The George Institute for Global Health, Sydney, New South Wales, Australia
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
- Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | | | | | | | - Maree L Hackett
- The George Institute for Global Health, Sydney, New South Wales, Australia
| | - Pallab K Maulik
- George Institute for Global Health, Hyderabad, Telangana, India
- The George Institute for Global Health, Oxford University, Oxford, UK
| | - Lisa A Harvey
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Stephen Jan
- The George Institute for Global Health, Sydney, New South Wales, Australia
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
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Greenwood R, Caine D, Hammerbeck U, Leff A, Playford D, Stevenson V, Ward N. Restorative Neurology, Rehabilitation and Brain Injury. Neurology 2016. [DOI: 10.1002/9781118486160.ch18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Affiliation(s)
| | - Diana Caine
- National Hospital for Neurology & Neurosurgery
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Santana S, Rente J, Neves C, Redondo P, Szczygiel N, Larsen T, Jepsen B, Langhorne P. Early home-supported discharge for patients with stroke in Portugal: a randomised controlled trial. Clin Rehabil 2016; 31:197-206. [PMID: 26837431 PMCID: PMC5302124 DOI: 10.1177/0269215515627282] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To evaluate an early home-supported discharge service for stroke patients. DESIGN We carried out a prospective, randomised, open-label, blinded-endpoint trial (allocation ratio of 1:1) with patients assigned to either an early home-supported discharge service or usual care. SETTING The study was undertaken in Aveiro, Portugal, between April 2009 and April 2013. SUBJECTS We included stroke patients aged 25-85 years admitted to the stroke unit with an initial Functional Independence Measure of up to 100, who gave informed consent. INTERVENTIONS Patients in the early home-supported discharge group began their rehabilitation intervention in the stroke unit and the early home-supported discharge team worked with them at home for a maximum of one month. Patients in the control group received usual services. MAIN MEASURES The primary outcome measure was the Functional Independence Measure at six months after stroke. RESULTS We randomised 190 patients of whom 34 were lost to follow-up. There were no significant differences (p > 0.5) in the average scores of Functional Independence Measure between the early home-supported discharge (69 ±22; mean ±SD) and the control groups (71 ±17) measured at baseline; and between the early home-supported discharge (107 ±20) and the control groups (107 ±25) measured at six months. The number of individuals with a low Functional Independence Measure score (<60) in the early home-supported discharge group compared with the control group was higher at admission (34/95 vs. 26/95) and lower at follow-up (2/74 vs. 5/78). CONCLUSIONS It was feasible to implement early home-supported discharge procedures in a Southern European setting, but we have not shown convincing differences in disability at six months.
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Affiliation(s)
| | - José Rente
- 2 Hospital Infante D. Pedro Stroke Unit, Aveiro, Portugal
| | | | | | | | | | - Birgitte Jepsen
- 4 Ringe Neurorehabilitation Unit, University Hospital of Odense, Odense, Denmark
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49
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O'Connell Francischetto E, Damery S, Davies S, Combes G. Discharge interventions for older patients leaving hospital: protocol for a systematic meta-review. Syst Rev 2016; 5:46. [PMID: 26984024 PMCID: PMC4793488 DOI: 10.1186/s13643-016-0222-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2015] [Accepted: 03/07/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND There is an increased need for additional care and support services for the elderly population. It is important to identify what support older people need once they are discharged from hospital and to ensure continuity of care. There is a large evidence base focusing on enhanced discharge services and their impact on patients. The services show some potential benefits, but there are inconsistent findings across reviews. Furthermore, it is unclear what elements of enhanced discharge interventions could be most beneficial to older people. This meta-review aims to identify existing systematic reviews of discharge interventions for older people, identify potentially effective elements of enhanced discharge services for this patient group and identify areas where further work may still be needed. METHODS/DESIGN The search will aim to identify English language systematic reviews that have assessed the effectiveness of discharge interventions for older people. The following databases will be searched: Medline, Embase, PsycINFO, HMIC, Social Policy and Practice, CINAHL, the Cochrane Library, ASSIA, Social Science Citation Index and the Grey Literature Report. The search strategy will comprise the keywords 'systematic reviews', 'older people' and 'discharge'. Discharge interventions must aim to support older patients before, during and/or after discharge from hospital. Outcomes of interest will include mortality, readmissions, length of hospital stay, patient health status, patient and carer satisfaction and staff views. Abstract, title and full text screening will be conducted independently by two reviewers. Data extracted from reviews will include review characteristics, patient population, review quality score, outcome measures and review findings, and a narrative synthesis will be conducted. DISCUSSION This review will identify existing reviews of discharge interventions and appraise how these interventions can impact outcomes in older people such as readmissions, health status, length of hospital stay and mortality. The review could inform practice and will help identify where further research is needed. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42015025737.
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Affiliation(s)
- Elaine O'Connell Francischetto
- NIHR CLAHRC West Midlands - Theme 4 Chronic Diseases, School of Health & Population Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK.
| | - Sarah Damery
- NIHR CLAHRC West Midlands - Theme 4 Chronic Diseases, School of Health & Population Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
| | - Sarah Davies
- Behavioural Brain Sciences Unit, Institute of Child Health, University College London, 30 Guilford Street, London, WC1N 1EH, UK
| | - Gill Combes
- NIHR CLAHRC West Midlands - Theme 4 Chronic Diseases, School of Health & Population Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
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50
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Yan LL, Li C, Chen J, Miranda JJ, Luo R, Bettger J, Zhu Y, Feigin V, O'Donnell M, Zhao D, Wu Y. Prevention, management, and rehabilitation of stroke in low- and middle-income countries. eNeurologicalSci 2016; 2:21-30. [PMID: 29473058 PMCID: PMC5818135 DOI: 10.1016/j.ensci.2016.02.011] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2015] [Revised: 02/26/2016] [Accepted: 02/29/2016] [Indexed: 12/28/2022] Open
Abstract
Although stroke incidence in high-income countries (HICs) decreased over the past four decades, it increased dramatically in low- and middle-income countries (LMICs). In this review, we describe the current status of primary prevention, treatment, and management of acute stroke and secondary prevention of and rehabilitation after stroke in LMICs. Although surveillance, screening, and accurate diagnosis are important for stroke prevention, LMICs face challenges in these areas due to lack of resources, awareness, and technical capacity. Maintaining a healthy lifestyle, such as no tobacco use, healthful diet, and physical activity are important strategies for both primary and secondary prevention of stroke. Controlling high blood pressure is also critically important in the general population and in the acute stage of hemorrhagic stroke. Additional primary prevention strategies include community-based education programs, polypill, prevention and management of atrial fibrillation, and digital health technology. For treatment of stroke during the acute stage, specific surgical procedures and medications are recommended, and inpatient stroke care units have been proven to provide high quality care. Patients with a chronic condition like stroke may require lifelong pharmaceutical treatment, lifestyle maintenance and self-management skills, and caregiver and family support, in order to achieve optimal health outcomes. Rehabilitation improves physical, speech, and cognitive functioning of disabled stroke patients. It is expected that home- or community-based services and tele-rehabilitation may hold special promise for stroke patients in LMICs.
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Affiliation(s)
- Lijing L. Yan
- Global Health Research Center, Duke Kunshan University, Kunshan, China
- Duke Global Health Institute, Duke University, Durham, USA
- The George Institute for Global Health at Peking University Health Science Center, Beijing, China
| | - Chaoyun Li
- Global Health Research Center, Duke Kunshan University, Kunshan, China
| | - Jie Chen
- Institute for Medical Humanities, Peking University Health Science Center, Beijing, China
| | - J. Jaime Miranda
- CRONICAS Center of Excellence for Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru
- Department of Medicine, School of Medicine, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Rong Luo
- The George Institute for Global Health at Peking University Health Science Center, Beijing, China
| | - Janet Bettger
- Duke School of Nursing, Duke University, Durham, USA
- Duke Clinical Research Institute, Duke University, Durham, USA
| | - Yishan Zhu
- The George Institute for Global Health at Peking University Health Science Center, Beijing, China
| | - Valery Feigin
- National Institute for Stroke and Applied Neuroscience, Auckland University of Technology, Auckland, New Zealand
| | | | - Dong Zhao
- Department of Epidemiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Yangfeng Wu
- The George Institute for Global Health at Peking University Health Science Center, Beijing, China
- Department of Epidemiology and Biostatistics, Peking University School of Public Health and Clinical Research Institute, Beijing, China
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