Health professionals’ adherence to stroke clinical guidelines: A review of the literature

Bridging the gap: unique strategies to improve access and implementation of stroke rehabilitation in LMICs - a scoping review

PURPOSE

The demand for stroke rehabilitation is rising across Low- and Middle-Income Countries (LMICs). This review explores the determinants affecting access to and utilization of post-stroke physical rehabilitation in LMICs.

MATERIAL AND METHODS

A systematic literature search across multiple databases retrieved 463 articles, of which 35 studies included were from Asia, Africa, and South America met the inclusion criteria. During the review process, 2 additional relevant studies were identified and added. A descriptive synthesis was conducted to identify key determinants influencing rehabilitation access and use.

RESULTS

Three major categories of determinants emerged: (1) Contextual factors, including traditional/spiritual beliefs, reliance on alternative medicine, gender disparities, poor awareness, and environmental barriers; (2) Personal factors, such as apathy toward rehabilitation, lack of clinical guidance, and psychological challenges (fatigue, depression, cognitive impairment); (3) Resource-related factors, including high out-of-pocket costs, low provider pay, insufficient infrastructure, inadequate health policies, limited professional training, and poor rehabilitation curricula. Recommendations focus on capacity building, service delivery, extended support, and treatment content.

CONCLUSION

LMICs face unique, context-specific challenges in stroke rehabilitation, requiring tailored solutions. Addressing these barriers necessitates region-specific strategies that align with health system structures, governmental policies, economic resources, professional education, and clinical practice guidance.

Evaluating Acute Stroke Diagnosis Using Simulation Scenarios

STUDY OBJECTIVE

This study sought to explore the clinical and process factors that, alone or in combination, influence the accuracy of stroke diagnosis in the emergency department (ED) by applying a novel design of experiments methodology.

METHODS

We used design of experiments, a branch of applied statistics, to create a screening experiment comprised of patient simulation scenarios in which purposeful changes are made to prespecified factors thought to potentially influence the outcome of interest. We used 4 base case scenarios (typical and atypical acute ischemic stroke, intracerebral hemorrhage, and complex migraine [a stroke mimic]) and 12 prespecified clinical factors thought to influence stroke diagnosis (eg, patient age, history of seizure, and interruption occurring during patient assessment that the physician must attend to [distraction]) based on literature review and expert opinion. Experimental runs were designed using a modified fractional factorial design approach. Physicians, including postgraduate trainees from 3 health systems, were invited to participate. After each run, participants were asked to provide a diagnosis and their confidence in that diagnosis; both inperson and virtual assessments were conducted. We used multivariate regression to explore factor(s) influencing physician confidence in stroke diagnosis. Confidence was signed, with positive confidence corresponding to a stroke diagnosis and negative confidence to a nonstroke diagnosis, allowing confidence levels from the regression model to be translated to misdiagnosis.

RESULTS

A total of 27 physicians (12 neurology and 15 emergency medicine) completed 100 experimental runs. The typical ischemic stroke base case presentation was accurately diagnosed in every run, whereas the other 3 base cases were less accurately diagnosed. Stroke overdiagnosis occurred in the complex migraine case (83% false positive) and stroke underdiagnosis in the intracerebral hemorrhage case (36% false negative). Distraction during patient evaluation and the availability of a witness from whom relevant information could be obtained exhibited significant, independent effects on diagnostic confidence. Distractions of the physician had an even stronger influence on stroke diagnostic confidence when no witness was present.

CONCLUSIONS

Applying the design of experiments methods to simulated scenarios, we found that distraction and presence of a witness significantly influenced diagnostic confidence and thus, stroke diagnostic accuracy. These findings should inform future studies to understand the underlying mechanisms of ED misdiagnosis and in the design of future interventions to improve stroke diagnostic formulation.

Protocols for ischaemic stroke in Flemish hospitals: correlation between availability and content versus adherence

BACKGROUND

Stroke is globally one of the leading causes of mortality and disability. Adhering to evidence-based guidelines and protocols can improve the quality of care for ischaemic stroke patients. We aimed to compare the availability and content of specific protocols versus adherence to these key interventions in clinical daily practice among Flemish hospitals. We selected five key interventions for managing ischaemic stroke patients. These key interventions encompassed the measurement of body temperature, glycaemia monitoring, screening of swallowing function according to the Fever, Sugar, and Swallowing protocol (FeSS protocol), depression screening, and activities of daily living (ADL) screening (FeSS+ key interventions).

METHODS

A systematic quantitative and qualitative approach was designed to analyse specific protocols from 24 hospitals. A predefined data extraction matrix for the five FeSS+ key interventions was utilized for data collection. Using this matrix, protocols were scored according to the completeness of content, regarding the FeSS+ interventions. These scores were used to calculate a total protocol content score, i.e. a total score for the five FeSS+ interventions and an individual score for each key intervention separately, ranging between 0 and 1, per hospital. A score of 0 indicates absence of the FeSS+ interventions in the protocols, while a score of 1 signifies complete coverage of these interventions. In addition, we assessed the correlation between the availability and content of these protocols in relation to the adherence to interventions documented for 30 patients per hospital.

RESULTS

The mean total protocol content score was 0.40 ± 0.20, ranging from 0.64 ± 0.25 for glycaemia management to 0.1 ± 0.28 for ADL screening. With regard to the individual FeSS+ key interventions, we identified a correlation between protocol characteristics and adherence for glycaemia (rs = 0.42, P = .04), depression screening (rs = 0.43, P = .04), and ADL screening (rs = 0.44, P = 0.03). Total FeSS+-protocol content also correlated with adherence (r = 0.6140, P = .0014).

CONCLUSION

Protocol characteristics for the FeSS+ key interventions were variable and rather limited, especially for ADL and depression screening. The identified relationship between the content of protocols and adherence to interventions underscores the value of defining these activities in hospital documentation to improve stroke care.

Clinical Characteristics and Treatment of Patients Diagnosed with Pulmonary Arterial Hypertension: A Real-World Study in the USA, Europe and Japan

INTRODUCTION

This study aimed to describe the clinical characteristics of patients with pulmonary arterial hypertension, treatment received, and factors predicting initial or earlier combination therapy.

METHODS

The Adelphi Real World Pulmonary Arterial Hypertension (PAH) Disease Specific Programme™ is a cross-sectional survey with retrospective data collection conducted in the USA, Europe (France, Germany, Italy, Spain, and the UK), and Japan from March to August 2022. Physicians reported patient characteristics, treatment history, and reasons for treatment selection. Descriptive statistics were grouped by country and World Health Organization functional classification. A multivariable Cox regression analysis investigated factors predicting initial or earlier combination therapy use.

RESULTS

Data for 1173 patients was provided by 293 physicians. Patients' mean (standard deviation) age was 58.7 (13.8) years and 54.6% were female. Overall, 91.2% of patients were receiving, or had previously received, PAH-specific treatment. About three-quarters of the cohort were still taking the initial treatment strategy: for this group, 54% were prescribed monotherapy and 32% combination therapy; 15% of patients received supportive therapy alone. The proportion of patients receiving PAH-specific treatment was lowest in the USA (82.0%) and highest in France (94.6%). The proportion of patients receiving PAH on combination therapy was lowest in the USA (23.8%) and highest in Germany (36.5%). Treatment was prescribed for PAH in 87.6%, 89.8%, 89.3%, and 75.0% of patients who were functional class I, II, III, and IV, respectively, and combination therapy usage was more likely for those with more advanced functional class. Higher risk status, care by a pulmonologist, Japanese residence, more complete assessments, and hospitalization in the past 12 months were statistically associated with decreased time to combination therapy for PAH. Older age was statistically associated with increased time to combination therapy.

CONCLUSION

In this real-world, geographically diverse sample, monotherapy treatment was common, even among patients with advanced disease.

From guidelines to clinical practice in care for ischaemic stroke patients: A systematic review and expert opinion

BACKGROUND AND PURPOSE

Guidelines help physicians to provide optimal care for stroke patients, but implementation is challenging due to the quantity of recommendations. Therefore a practical overview related to applicability of recommendations can be of assistance.

METHODS

A systematic review was performed on ischaemic stroke guidelines published in scientific journals, covering the whole acute care process for patients with ischaemic stroke. After data extraction, experts rated the recommendations on dimensions of applicability, that is, actionability, feasibility and validity, on a 9-point Likert scale. Agreement was defined as a score of ≥8 by ≥80% of the experts.

RESULTS

Eighteen articles were identified and 48 recommendations were ultimately extracted. Papers were included only if they described the whole acute care process for patients with ischaemic stroke. Data extraction and analysis revealed variation in terms of both content and comprehensiveness of this description. Experts reached agreement on 34 of 48 (70.8%) recommendations in the dimension actionability, for 16 (33.3%) in feasibility and for 15 (31.3%) in validity. Agreement on all three dimensions was reached for seven (14.6%) recommendations: use of a stroke unit, exclusion of intracerebral haemorrhage as differential diagnosis, administration of intravenous thrombolysis, performance of electrocardiography/cardiac evaluation, non-invasive vascular examination, deep venous thrombosis prophylaxis and administration of statins if needed.

DISCUSSION AND CONCLUSION

Substantial variation in agreement was revealed on the three dimensions of the applicability of recommendations. This overview can guide stroke physicians in improving the care process and removing barriers where implementation may be hampered by validity and feasibility.

A Randomized Controlled Trial to Evaluate the Impact of an Exercise Therapy Program Based on Sports in People with Acquired Brain Injury: Discover Study Protocol

INTRODUCTION

Acquired brain injury (ABI) constitutes a significant and growing global public health concern. People with ABI often face a range of physical and psychosocial challenges that span the domains of "body structure and function", "activity", and "participation", as defined by the International Classification of Functioning, Disability, and Health. Multidisciplinary approaches based on exercise therapy with social leisure activities are essential to improve physical recovery and health-related quality of life after injury.

METHODS

Adults with ABI, aged > 18 years, in the subacute or chronic stage (within more than one month after the injury) will be recruited through a rehabilitation center. Adults will be randomized to receive either a racket sports-based exercise therapy program combined with usual care (sET) or usual care alone (UC) using a random number sequence with a 1:1 allocation ratio. sET intervention consists of an 8-week exercise therapy program focusing on different racket sports skills, 1 h in duration, 2 days/week. It will be delivered by a physiotherapist in tailored, face-to-face, group-based sessions. Primary outcomes will be the health-related quality of life (SF-36) and upper extremity motor function (Fugl-Meyer Assessment-Upper Extremity Scale).

DISCUSSION

The study proposes an intervention that combines sports-based exercise therapy with usual care. It aims to determine whether this intervention improves the health-related quality of life and upper limb motor function in adults with ABI compared with usual care alone. The results of this study may have clinical implications for the rehabilitation of this population.

Clinical Practice Guidelines (CPGs) for stroke rehabilitation from Low- and Middle-Income Countries (LMICs): Protocol for systematic review

INTRODUCTION

Stroke rehabilitation guidelines promoteclinical decision making, enhance quality of healthcare delivery, minimize healthcare costs, and identify gaps in current knowledge to guide future research. However, there are no published reviews that have exclusively evaluated the quality of existing Clinical Practice Guidelines (CPGs) for stroke rehabilitation from Low- and Middle-Income Countries (LMICs) or provided any insights into the cultural variation, adaptations, or gaps in implementation specific to LMICs.

OBJECTIVES

To identify CPGs developed by LMICs for stroke rehabilitation and evaluate their quality using AGREE-II and AGREE-REX tool.

METHODS

The review protocol is prepared in accordance with the PRISMA-P guidelines and the review was registered in PROSPERO (CRD42022382486). The search was run in Medline, EMBASE, CINHAL, PEDro for guidelines published between 2000 till July 2022. Additionally, SUMSearch, Google, and other guideline portals and gray literature were searched. The included studies were then subjected to data extraction for the following details: Study ID, title of the CPG, country of origin, characteristics of CPG (Scope-national/regional, level of care, multidisciplinary/uni-disciplinary), and information on stroke rehabilitation relevant recommendations. The quality of the included CPGs will be subsequently evaluated using AGREE-II and AGREE-REX tool.

RESULTS & CONCLUSION

This systematic review aims to explore the gaps in existing CPGs specific to LMICs and will aid in development/adaptation/contextualization of CPGs for implementation in LMICs.

The barriers and facilitators for the implementation of clinical practice guidelines in healthcare: an umbrella review of qualitative and quantitative literature

OBJECTIVES

To identify barriers and facilitators of clinical practice guidelines (CPGs) implementation, and map those factors to the theoretical domains framework (TDF) and behavior change wheel (BCW).

METHODS

We conducted an umbrella review of systematic reviews. PubMed, Embase, and the Cochrane Library were searched. Two investigators independently screened the studies, extracted the data, and assessed the methodological quality. The identified barriers and facilitators of CPG implementation were categorized and mapped to the TDF domains and BCW components.

RESULTS

Thirty-seven studies were included, and 193 barriers and 140 facilitators were identified. Intrinsic aspects (35 barriers and 28 facilitators) mainly included the CPGs' impracticality, complexity, and inaccessibility. Extrinsic aspects (158 barriers and 113 facilitators) mainly included lack of resources, training, funding, or awareness of CPG content in barriers; audits and feedback; strong leadership and management support; and educating and training about CPGs in facilitators. Environmental context and resources (n = 97, 19.48%) were the most reported barriers in TDF domains. Physical opportunity and social opportunity were the most frequently mentioned models in BCW.

CONCLUSION

Multiple barriers and facilitators for healthcare CPG implementation are identified, with further links to TDF and BCW. Future knowledge translation strategies should be developed accordingly in specified health care settings.

Improving stroke clinical guideline adherence in an Australian hospital using a clinician-led implementation process

BACKGROUND

Private hospitals in Australia manage 11% of acute and 48% of rehabilitation stroke admissions, yet little is known about implementation of stroke clinical guidelines in this setting. Clinical guidelines recommend that acute stroke patients be co-located in a stroke unit in a geographically defined area, rather than dispersed across the hospital.

OBJECTIVE

To investigate post-intervention adherence to clinical guidelines for stroke management, and to explore staff barriers and facilitators to guideline implementation.

METHODS

Observational study before-and-after local implementation of Australian stroke clinical guidelines. The primary outcome was a change in the proportion of patients who were physically co-located in an acute stroke unit. Secondary outcomes included changes in adherence to additional acute and rehabilitation guideline criteria, and staff identification of barriers and facilitators to guide implementation. Data were collected from medical record audits, health service information and staff surveys.

RESULTS

Co-location in an acute stroke unit did not change significantly after guideline implementation (49% adherence pre-intervention and 54% post-intervention). Across acute and rehabilitation wards, 15% (11/72) of guideline criteria improved (p < .05). These related to assessments of swallowing and neglect, presence of a stroke care co-ordinator and occupational therapist, post-discharge care plan, provision of patient education and return to driving. Facilitators to guideline implementation included staff education, collaboration, and dissemination of user-friendly stroke policies.

CONCLUSION

Stroke clinical guideline implementation led to a favorable uptake of some criteria, yet not all. Implementation was assisted by staff education, user-friendly stroke policies and multidisciplinary team collaboration.

TRIAL REGISTRATION

ANZCTR: registration number ACTRN12616000646448 (http://www.ANZCTR.org.au/ACTRN12616000646448.aspx).

An Intensive Exercise Program Using a Technology-Enriched Rehabilitation Gym for the Recovery of Function in People With Chronic Stroke: Usability Study

BACKGROUND

Rehabilitation improves poststroke recovery with greater effect for many when applied intensively within enriched environments. The failure of health care providers to achieve minimum recommendations for rehabilitation motivated the development of a technology-enriched rehabilitation gym (TERG) that enables individuals under supervision to perform high-intensity self-managed exercises safely in an enriched environment.

OBJECTIVE

This study aimed to assess the feasibility of the TERG approach and gather preliminary evidence of its effect for future research.

METHODS

This feasibility study recruited people well enough to exercise but living with motor impairment following a stroke at least 12 months previously. Following assessment, an 8-week exercise program using a TERG (eg, virtual reality treadmills, power-assisted equipment, balance trainers, and upper limb training systems) was structured in partnership with participants. The feasibility was assessed through recruitment, retention, and adherence rates along with participant interviews. Effect sizes were calculated from the mean change in standard outcome measures.

RESULTS

In total, 70 individuals registered interest, the first 50 were invited for assessment, 39 attended, and 31 were eligible and consented. Following a pilot study (n=5), 26 individuals (mean age 60.4, SD 13.3 years; mean 39.0, SD 29.2 months post stroke; n=17 males; n=10 with aphasia) were recruited to a feasibility study, which 25 individuals completed. Participants attended an average of 18.7 (SD 6.2) sessions with an 82% attendance rate. Reasons for nonattendance related to personal life, illness, weather, care, and transport. In total, 19 adverse events were reported: muscle or joint pain, fatigue, dizziness, and viral illness, all resolved within a week. Participants found the TERG program to be a positive experience with the equipment highly usable albeit with some need for individual tailoring to accommodate body shape and impairment. The inclusion of performance feedback and gamification was well received. Mean improvements in outcome measures were recorded across all domains with low to medium effect sizes.

CONCLUSIONS

This study assessed the feasibility of a holistic technology-based solution to the gap between stroke rehabilitation recommendations and provision. The results clearly demonstrate a rehabilitation program delivered through a TERG is feasible in terms of recruitment, retention, adherence, and user acceptability and may lead to considerable improvement in function, even in a chronic stroke population.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-doi.org/10.3389/fresc.2021.820929.

Healthcare professionals' perceived barriers and facilitators of implementing clinical practice guidelines for stroke rehabilitation: A systematic review

OBJECTIVE

To identify healthcare professionals' perceived barriers and facilitators to clinical practice guideline implementation within stroke rehabilitation.

DATA SOURCES

CINAHL, MEDLINE, EMBASE, AMED, Cochrane library, Academic Search Complete and Scopus. Additional papers were identified through hand searching.

REVIEW METHODS

The review followed the Preferred Reporting Item for Systematic Reviews and Meta-Analysis Protocols systematic review approach. Any empirical research that provided qualitative data on healthcare professionals' perceived factors influencing clinical guideline implementation in stroke rehabilitation was included. One reviewer screened all titles and abstract reviews (n = 669). Another two reviewers independently screened 30% of title and abstract reviews, followed by full-text reviews (n = 61). Study quality was assessed using the mixed-method appraisal tool.

RESULTS

Data from 10 qualitative, six quantitative and six mixed-method studies published between 2000 and 2022, involving 1576 participants in total, were analysed and synthesised using modified thematic synthesis approach. The majority of participants were therapists n = 1297 (occupational therapists, physiotherapists, speech and language therapists). Organisational factors (time constraints, resources) alongside healthcare professionals' lack of knowledge and skills were the most cited barriers to guideline implementation. Contradictory attitudes and beliefs towards stroke guidelines applicability to real-life clinical practice and their evidence base were reported. Organisational support in the form of training, local protocols, performance monitoring and leadership were reported as perceived facilitators.

CONCLUSION

Barriers and facilitators are multifactorial and were identified at guideline, individual, team and organisational levels. There is a need to translate perceived barriers and facilitators into implementation interventions especially addressing organisational-level barriers.

Developing spinal cord injury physiotherapy clinical practice guidelines: a qualitative study to determine how physiotherapists and people living with spinal cord injury use evidence

STUDY DESIGN

Generic qualitative design.

OBJECTIVES

Australian and New Zealand SCI physiotherapists are developing clinical practice guidelines for the physiotherapy management of people living with spinal cord injury. To guide the development of the guidelines it was important to understand how physiotherapists and people living with spinal cord injury use evidence to choose interventions and the potential barriers and facilitators to the uptake of the clinical practice guidelines.

SETTING

Spinal Cord Injury Centres in Sydney, Australia and New Zealand.

METHODS

Focus groups and interviews with physiotherapists and people living with spinal cord injury were recorded, transcribed, and subjected to thematic analysis.

RESULTS

A total of 75 participants took part in the study, 45 physiotherapists and 30 people living with spinal cord injury. Three main themes were identified from the data: (1) Types and sources of evidence that influence treatment choices, (2) the many factors determining treatment choices, and (3) ways in which clinical practice guidelines could influence treatment.

CONCLUSIONS

Clinical practice guidelines have the potential to reduce the barriers identified by physiotherapists in accessing and interpreting research evidence on interventions for people living with spinal cord injury. Supported implementation of guidelines is required to demonstrate their benefit and encourage physiotherapists to factor in evidence when balancing the multiple factors influencing choice of physiotherapy intervention.

The implementation of clinical guidelines concerning return to work after myocardial infarction

PURPOSE

To examine the implementation, clinical effects, and adherence of occupational physicians to the clinical practice guidelines (CPG) published in 2003 in Israel, regarding return to work following acute myocardial infarction (AMI).

METHODS

We analyzed 3 populations referred to Maccabi Health Services occupational clinics for fitness for work examinations following AMI, either before the guidelines were published (group 1), after their first publications in 2003 (group 2) or after they were re-published in Harefuah Journal in 2007 (group3).

RESULTS

The documentation among groups 1,2,3 of different parameters like years of education (18.8%, 45.1%. 57.5%, p < 0.001), type of occupation (86.5%, 98.2%, 100.0%, p < 0.001) and New York Heart Association (NYHA) class (69.8%, 81.4%, 92.5%, p < 0.001) has all improved respectively over the years. No significant difference in sick leave was noted between the three populations.

CONCLUSION

The CPG should be interdisciplinary in the phase of writing and publication. Economical resources are needed in order to implement CPG.Implications for RehabilitationThe clinical practice guidelines should be interdisciplinary in the phase of writing and should involve all rehabilitation professionals as a team.The clinical practice guidelines need disseminating widely alongside a resource plan in order to implement it.

Variation in stroke care at the hospital level: A cross-sectional multicenter study

Introduction

Stroke is one of the leading causes of mortality and disability. Improving patient outcomes can be achieved by improving stroke care and adherence to guidelines. Since wide variation in adherence rates for stroke guidelines still exists, we aimed to describe and compare stroke care variability within Belgian hospitals.

Materials and methods

An observational, multicenter study was performed in 29 Belgian hospitals. We retrospectively collected patient characteristics, quality indicators, and time metrics from the last 30 consecutive patients per hospital, diagnosed with ischemic stroke in 2019 with structured questionnaires. Mean adherence ratios (%) ± SD (minimum - maximum) were calculated.

Results

We analyzed 870 patient records from 29 hospitals. Results showed large inter- and intrahospitals variations in adherence for various indicators. Almost all the patients received brain imaging (99.7%) followed by admission at a stroke unit in 82.9% of patients. Of patients not receiving thrombolysis, 92.5% of patients were started on antithrombotic drugs. Indicators with moderate median adherence but large interhospital variability were glycemia monitoring [82.3 ± 16.7% (26.7-100.0%)], performing clinical neurological examination and documentation of stroke severity [63.1 ± 36.8% (0-100%)], and screening for activities of daily living [51.1 ± 40.3% (0.0-100.0%)]. Other indicators lacked adequate adherence: swallowing function screening [37.0 ± 30.4% (0.0-93.3%)], depression screening [20.2 ± 35.8% (0.0-100%)], and timely body temperature measurement [15.1 ± 17.0% (0.0-60%)].

Conclusion

We identified high adherence to guidelines for some indicators, but lower rates with large interhospital variability for other recommendations also based on robust evidence. Improvement strategies should be implemented to improve the latter.

Current physical therapy practice and implementation factors regarding the evidence-based 'Rehabilitation of Mobility after Stroke (ReMoS)' guideline in Germany: a cross-sectional online survey

BACKGROUND

Evaluation of the current physical therapy practice for German stroke rehabilitation with respect to the 'Rehabilitation of Mobility after Stroke (ReMoS)' guideline recommendations and the associated implementation factors.

METHODS

A descriptive cross-sectional study employing an online survey was performed among German physical therapists in 2019. The survey consisted of three sections with open and closed questions: 1) self-reported use of ReMoS recommendations, 2) barriers of guideline use and 3) socio-demographic characteristics. The benchmark level for guideline adherent physical therapy was set at > 80%.

RESULTS

Data from 170 questionnaires were eligible for analysis. Participants' mean age was 41.6 years, 69.4% were female, while 60.1% had no academic degree. The ReMoS guideline was unknown to 52.9% of the responders. Out of all the 46 ReMoS guideline recommendations, only 'intensive walking training without a treadmill' was reported to be performed in a guideline adherent manner. Respondents usually denied any personal limitations, such as limited knowledge, or that the ReMoS guideline did not fit their routine practice.

CONCLUSIONS

Among German physical therapists, the ReMoS guideline is not well-known and many interventions are not performed as recommended, illustrating the discrepancies between the ReMoS guideline recommendations and current physical therapy practice. Interventions aimed at overcoming this gap should consider both knowledge of existing barriers and facilitators of guideline usage.

TRIAL REGISTRATION

The study was retrospectively registered to the German Clinical Trials Register ( DRKS00026681 ).

Tailored GuideLine Implementation in STrokE Rehabilitation (GLISTER) in Germany. Protocol of a Mixed Methods Study Using the Behavior Change Wheel and the Theoretical Domains Framework

Objective

Evidence-based guidelines are important for informing clinical decision-making and improving patient outcomes. There is inconsistent usage of guidelines among physical therapists involved in stroke rehabilitation, suggesting the existence of a gap between theory and practice. Addressing the German guideline "evidence-based rehabilitation of mobility after stroke (ReMoS)," the aims of this project are (1) to describe the current physical therapy practice within the context of stroke rehabilitation in Germany, (2) to evaluate barriers and facilitators of guideline usage, (3) to develop, and (4) to pilot test a theory-based, tailored implementation intervention for the benefit of guideline recommendations.

Materials and Methods

This study uses a stepwise mixed methods approach for implementing a local guideline. A self-reported online questionnaire will be used to survey the current physical therapy practice in stroke rehabilitation. The same survey and systematic-mixed methods review will be used to evaluate the barriers and facilitators of guideline usage quantitatively. Semi-structured interviews will add a qualitative perspective on factors that influence ReMoS guideline implementation. The Behavior Change Wheel and Theoretical Domains Framework will be used to support the development of a tailored implementation intervention which will be pilot tested in a controlled study. Patient and physical therapy-related outcomes, as well as the appropriateness, such as acceptance and feasibility of the tailored implementation intervention, will be analyzed.

Conclusion

This will be the first endeavor to implement a guideline in German stroke rehabilitation with a focus on changing care provider behavior based on the knowledge of current practice and determining factors using a tailored and theory-based intervention.

An exploration of barriers and enablers to the conduct and application of research among complementary and alternative medicine stakeholders in Australia and New Zealand: A qualitative descriptive study

BACKGROUND

Most studies examining complementary and alternative medicine (CAM) stakeholder engagement with evidence-based practice have relied on quantitative research methods, which often fail to capture the nuances of this phenomena. Using qualitative methods, this study aimed to explore the experiences of CAM stakeholders regarding the barriers and enablers to the conduct and application of research.

METHODS

This research was guided by a qualitative descriptive framework. CAM practitioners and researchers of multiple CAM disciplines from across Australia and New Zealand were invited to share their personal perspectives of the study phenomena. Semi-structured interviews were conducted via Zoom, which were audio-recorded and transcribed verbatim. Rigour strategies were applied to ensure the credibility of results. The transcript was analysed using thematic analysis.

RESULTS

CAM stakeholders identified an array of barriers and enablers to the conduct and application of research within their disciplines. The barriers and enablers that emerged were found to be inter-connected with two similar constructs: capacity and culture. Captured within the construct of capacity were five themes-lack of resources, inadequate governance/leadership, lack of competency, bias directed from outside and within CAM, and lack of time for research. Within the construct of culture were two themes-intrinsic perceptions in CAM, and lack of communication within and outside CAM.

CONCLUSIONS

Promoting evidence-based practice and engaging with research in CAM continues to face challenges. This study, for the first time, has highlighted the multitude of interlinked barriers that confront CAM stakeholders when engaging with research. These findings highlight the need for a concerted and targeted approach to tackle these challenges.

Strategies for the implementation of clinical practice guidelines in public health: an overview of systematic reviews

Background

As a source of readily available evidence, rigorously synthesized and interpreted by expert clinicians and methodologists, clinical guidelines are part of an evidence-based practice toolkit, which, transformed into practice recommendations, have the potential to improve both the process of care and patient outcomes. In Brazil, the process of development and updating of the clinical guidelines for the Brazilian Unified Health System (Sistema Único de Saúde, SUS) is already well systematized by the Ministry of Health. However, the implementation process of those guidelines has not yet been discussed and well structured. Therefore, the first step of this project and the primary objective of this study was to summarize the evidence on the effectiveness of strategies used to promote clinical practice guideline implementation and dissemination.

Methods

This overview used systematic review methodology to locate and evaluate published systematic reviews regarding strategies for clinical practice guideline implementation and adhered to the PRISMA guidelines for systematic review (PRISMA).

Results

This overview identified 36 systematic reviews regarding 30 strategies targeting healthcare organizations, healthcare providers and patients to promote guideline implementation. The most reported interventions were educational materials, educational meetings, reminders, academic detailing and audit and feedback. Care pathways—single intervention, educational meeting—single intervention, organizational culture, and audit and feedback—both strategies implemented in combination with others—were strategies categorized as generally effective from the systematic reviews. In the meta-analyses, when used alone, organizational culture, educational intervention and reminders proved to be effective in promoting physicians' adherence to the guidelines. When used in conjunction with other strategies, organizational culture also proved to be effective. For patient-related outcomes, education intervention showed effective results for disease target results at a short and long term.

Conclusion

This overview provides a broad summary of the best evidence on guideline implementation. Even if the included literature highlights the various limitations related to the lack of standardization, the methodological quality of the studies, and especially the lack of conclusion about the superiority of one strategy over another, the summary of the results provided by this study provides information on strategies that have been most widely studied in the last few years and their effectiveness in the context in which they were applied. Therefore, this panorama can support strategy decision-making adequate for SUS and other health systems, seeking to positively impact on the appropriate use of guidelines, healthcare outcomes and the sustainability of the SUS.

Time-Based Decision Making for Reperfusion in Acute Ischemic Stroke

Decision making in the extended time windows for acute ischemic stroke can be a complex and time-consuming process. The process of making the clinical decision to treat has been compounded by the availability of different imaging modalities. In the setting of acute ischemic stroke, time is of the essence and chances of a good outcome diminish by each passing minute. Navigating the plethora of advanced imaging modalities means that treatment in some cases can be inefficaciously delayed. Time delays and individually based non-programmed decision making can prove challenging for clinicians. Visual aids can assist such decision making aimed at simplifying the use of advanced imaging. Flow charts are one such visual tool that can expedite treatment in this setting. A systematic review of existing literature around imaging modalities based on site of occlusion and time from onset can be used to aid decision making; a more program-based thought process. The use of an acute reperfusion flow chart helping navigate the myriad of imaging modalities can aid the effective treatment of patients.

Emerging agents for the treatment and prevention of stroke: progress in clinical trials

INTRODUCTION

Recent years have witnessed unprecedented progress in stroke care, but unmet needs persist regarding the efficacy of acute treatment and secondary prevention. Novel approaches are being tested to enhance the efficacy of thrombolysis or provide neuroprotection in non-thrombolized patients.

AREAS COVERED

The current review highlights pharmaceutical agents under evaluation in clinical trials concerning the acute, subacute, and chronic phase post-stroke. We examine the evidence in favor of tenecteplase as an alternative thrombolytic drug to alteplase, nerinetide as a promising neuroprotective agent, and glibenclamide for reducing edema in malignant hemispheric infarction. We discuss the use of ticagrelor and the promising novel category of factor XI inhibitors in the subacute phase after stroke. We offer our insights on combined rivaroxaban and antiplatelet therapy, PCSK-9 inhibitors, and other non-statin hypolipidemic agents, as well as novel antidiabetic agents that have been shown to reduce cardiovascular events in the long-term.

EXPERT OPINION

Current approaches in stroke treatment and stroke prevention have already transformed stroke care from a linear one-for-all treatment paradigm to a more individualized approach that targets specific patient subgroups with novel pharmaceutical agents. This tendency enriches the therapeutic armamentarium with novel agents developed for specific stroke subgroups.

ABBREVIATIONS

IVT: intravenous thrombolysis; RCTs: randomized-controlled clinical trials; TNK: Tenecteplase; COVID-19: Coronavirus 2019 Disease; EXTEND-IA TNK: The Tenecteplase versus Alteplase Before Endovascular Therapy for Ischemic Stroke trial; AIS: acute ischemic stroke; NNT: number needed to treat; MT: mechanical thrombectomy; sICH: symptomatic intracranial hemorrhage; mRS: modified Rankin Scale; AHA/ASA: American Heart Association/American Stroke Association; ESO: European Stroke Organization; NA-1: Nerinetide; ENACT: Evaluating Neuroprotection in Aneurysm Coiling Therapy; CTA: CT angiography; TIA: transient ischemic attack; CHANCE: Clopidogrel in High-risk patients with Acute Non-disabling Cerebrovascular Events; LOF: loss-of-function; PRINCE: Platelet Reactivity in Acute Nondisabling Cerebrovascular Events; THALES: Acute Stroke or Transient Ischemic Attack Treated with Ticagrelor and ASA [acetylsalicylic acid] for Prevention of Stroke and Death; CHANCE-2: Clopidogrel With Aspirin in High-risk Patients With Acute Non-disabling Cerebrovascular Events II; FXI: Factor XI; PACIFIC-STROKE: Program of Anticoagulation via Inhibition of FXIa by the Oral Compound BAY 2433334-NonCardioembolic Stroke study; COMPASS: Cardiovascular Outcomes for People Using Anticoagulation Strategies; CANTOS-ICAD: Combination Antithrombotic Treatment for Prevention of Recurrent Ischemic Stroke in Intracranial Atherosclerotic Disease; SAMMPRIS: Stenting and Aggressive Medical Therapy for Preventing Recurrent Stroke in Intracranial Stenosis; WASID: Warfarin-Aspirin Symptomatic Intracranial Disease; SPARCL: Stroke Prevention by Aggressive Reduction in Cholesterol Levels; LDL-C: low-density lipoprotein cholesterol; TST: Treat Stroke to Target; IMPROVE-IT: Improved Reduction of Outcomes: Vytorin Efficacy International Trial; PCSK9: proprotein convertase subtilisin-kexin type 9; FOURIER: Further Cardiovascular Outcomes Research with PCSK9 Inhibition in Subjects with Elevated Risk; CLEAR: Cholesterol Lowering via Bempedoic acid, an ACL-inhibiting Regimen; REDUCE-IT: Reduction of Cardiovascular Events With EPA Intervention Trial; STRENGTH: Outcomes Study to Assess STatin Residual Risk Reduction With EpaNova in HiGh CV Risk PatienTs With Hypertriglyceridemia; ACCORD: Action to Control Cardiovascular Risk in Diabetes; ADVANCE: Action in Diabetes and Vascular Disease: Preterax and Diamicron Modified Release Controlled Evaluation; VADT: Veterans Affairs Diabetes Trial; GLP-1R: Glucagon-like peptide-1 receptor; SGLT2: sodium-glucose cotransporter 2; CONVINCE: COlchicine for preventioN of Vascular Inflammation in Non-CardioEmbolic stroke; PROBE: Prospective Randomized Open-label Blinded Endpoint assessment.

Why allied health professionals use evidence-based clinical guidelines in stroke rehabilitation: A systematic review and meta-synthesis of qualitative studies

OBJECTIVE

To capture qualitative research about the perspectives and reasoning of allied health professionals about variability in the use of clinical guidelines in stroke rehabilitation.

DATA SOURCES

Ovid Medline, Psychinfo, Cochrane, Ovid Emcare, Scopus and Web of Science.

METHOD

The review protocol followed the Enhancing Transparency in Reporting the Synthesis of Qualitative Research (ENTREQ) statement. Qualitative or mixed methods research that provided qualitative data about use of clinical guidelines delivered by allied health professionals in stroke rehabilitation was included. Clinical guidelines included any evidence-based documents that guided allied health stroke rehabilitation practice. All studies were screened in duplicate at title and abstract and then at full text. Included studies were appraised using the McMaster Critical Appraisal Tool.

RESULTS

Data from 850 allied health professionals in 22 qualitative research studies from seven different countries were analysed and synthesised. Four themes were developed including: context necessitates strategy, all clients are different, systemic changes are needed and need a good reason to change something. The findings aligned with the four arms of evidence-base practice. Allied health professionals use clinical guidelines when they align with their reasoning and match the 'sweet spot' for client goals and circumstance. Clinical guideline use is attributed to sufficient resourcing, time and motivation and a strong research culture within health systems.

CONCLUSIONS

Variabilities in clinical guideline use by allied health professionals are due to their clinical reasoning, contextual factors, client characteristics and enabling health systems.

Dysphagia screening in residential care settings: A scoping review

BACKGROUND

Older adults with dysphagia are at a higher risk of experiencing serious complications where dysphagia is not identified and adequately managed. Nursing personnel are critical for timely identification and management of dysphagia and prevention of these subsequent serious complications in residential care settings.

OBJECTIVES

To identify dysphagia screening tools used in residential care and to establish whether validated and used as per guidelines, their diagnostic accuracy and reliability and to identify the prevalence rate of dysphagia in this setting.

DESIGN

A scoping review based on Arksey & O'Malley (2005) methodological framework.

DATA SOURCES

An electronic search of databases CINAHL, Pubmed and Scopus was conducted. Reference lists were checked in all identified articles for additional studies. Peer-reviewed publications describing the process of identifying dysphagia and using a screening protocol in residential care settings were considered for inclusion.

REVIEW METHODS

All identified studies were screened by reading of titles, keywords and abstracts. Those articles that were deemed eligible for inclusion were read in full.

RESULTS

Nineteen quantitative studies and one mixed-methods study out of 1,674 articles were included in the review. Thirteen different instruments for dysphagia screening were identified, with the Modified Water Swallow Test being the most commonly used. Other diagnostic procedures, such as fiberoptic endoscopic evaluation of swallowing, pulse oximetry or cervical auscultation, were implemented along with the administration of a dysphagia screening tool in six studies. The 3-Ounce Water Swallow Test, the Yale Swallow Protocol and the Gugging Swallowing Screen were identified as the instruments with the best clinical accuracy values. The reported prevalence of dysphagia in this setting ranged from 15% to 70%.

CONCLUSIONS

Formal dysphagia screening in residential care settings is not common practice. The dysphagia screening tools identified in this review are not validated for use in this setting. The implementation of dysphagia screening protocols specific to this population may facilitate identification of dysphagia and avoid complications.

Barriers and facilitators to implementing stepped psychological care for people with aphasia: Perspectives of stroke health professionals

Background Concomitant aphasia and depression after stroke is highly prevalent, but there is a lack of psychological care in stroke rehabilitation for people with aphasia and family members. Evidence-based frameworks such as stepped psychological care may be viable, but the barriers and facilitators to translating this framework into aphasia rehabilitation practice are unknown.Aim The aim of this study was to identify, from the perspective of stroke health professionals, the barriers and facilitators to implementing stepped psychological care for depression after post-stroke aphasia.Method Five semi-structured focus groups of stroke health professionals were conducted (n = 39) across the stroke care continuum. Verbatim transcripts were analyzed using Interpretive Description.Results Barriers and facilitators were identified within three core themes: knowledge, skills, and attitudes have the most impact on implementing stepped psychological care; the physical environment impacts on managing depression and communication disability for people with aphasia; and the support and leadership of the health organization influence change in any implementation of a stepped psychological care approach. Barriers included: no experience with stepped psychological care; limited understanding of aphasia and communication support; lack of adequate physical space and resources; lack of psychologists. Facilitators included: specialist training; enhancement of physical spaces; communication tools; leadership; funding; specialized staff.Conclusion Addressing the identified barriers and facilitators to stepped psychological care will improve the viability of implementing this evidence-based framework after post-stroke aphasia. Change may be driven through specialist training for health professionals in communication support; mood assessment and treatments; modification of physical space; and accessible resources.

"It's Difficult, There's No Formula": Qualitative Study of Stroke Related Communication Between Primary and Secondary Healthcare Professionals

Introduction:

Stroke survivors have complex health needs requiring long-term, integrated care. This study aimed to elicit generalists’ and specialists’ experience of stroke-related interprofessional communication, including perceived barriers and enablers.

Design and Setting:

Qualitative study involving generalist (primary care) and specialist services (acute and community) in England. Six focus groups (n = 48) were conducted.

Method:

Healthcare professionals were purposively selected and invited to participate. Audio-recordings were transcribed verbatim and analysed using Framework Analysis.

Results:

Four themes were identified: 1) Generalists and specialists have overlapping roles but are working in silos; 2) Referral decision-making process as influential to generalist-specialist communication; 3) Variable quality of communication; and 4) Improved dialogue between generalist and specialist services.

Conclusions:

Generalists and specialists recognise the need for better communication with each other. Current care is characterised by silo-based working that ignores the contribution of other sectors. Failure to bridge this communication gap will result in people with stroke continuing to experience unmet stroke needs and fragmented care.

A multifaceted continuing professional development intervention to move stroke rehabilitation guidelines into professional practice: A feasibility study

INTRODUCTION

Rehabilitation post-stroke is critical for maximizing patient outcomes. This study assessed the feasibility of implementing and evaluating a continuing professional development (CPD) intervention aimed at increasing the uptake of stroke best practice guidelines among physiotherapists (PTs), occupational therapists (OTs) and speech-language pathologists (SLPs) in six university-affiliated stroke rehabilitation centers in Quebec, Canada.

METHOD

Twelve stroke best practice recommendations with reflective tools were sent weekly by e-mail. Participants' eligibility criteria included: a) profession; b) practicing more than 1 year in a stroke rehabilitation program; c) fluency in French or English; and d) basic computer literacy. Feasibility (operationalized via participation, satisfaction and relevance), cognitive impact, perceived application in practice and expected patient outcomes were measured over 24 weeks using three questionnaires and analyzed using descriptive statistics.

RESULTS

The sample totaled 62 of 133 eligible (47%) clinicians. Satisfaction, relevance and cognitive impact of delivered information varied across disciplines and recommendations. Agreement with the recommendations was high across disciplines. On average, three-interdisciplinary recommendations (related to post-stoke depression, post-stoke fatigue and patients' and caregivers' learning needs) were rated as the most relevant for at least one patient. The majority of clinicians would use the recommendations for a specific patient and expected health benefits by applying those recommendations.

CONCLUSION

This study demonstrated the feasibility of assessing the impact of a CPD intervention in stroke rehabilitation uptake and informed the design of a research program aimed at increasing the use of stroke evidence-based rehabilitation interventions.

Associations Between Adherence to the Physical Activity and Exercise Program Applied in the LAST Study and Functional Recovery After Stroke

OBJECTIVE

To investigate the associations between participants' adherence to a physical activity and exercise program after stroke and functional recovery 18 months after inclusion.

DESIGN

Secondary analyses of the intervention arm in the multisite randomized controlled trial Life After Stroke (LAST).

SETTING

Primary health care services in 3 Norwegian municipalities.

PARTICIPANTS

Of the participants enrolled (N=380), 186 (48.9%) were randomized to the intervention. The study sample comprised community dwelling individuals included 3 months after stroke, with mean age of 71.7 ± 11.9 years and 82 (44.1%) women. According to the National Institutes of Health Stroke Scale, 97.3% were diagnosed as having mild (National Institutes of Health Stroke Scale<8) and 2.7% with moderate (8-16 on the National Institutes of Health Stroke Scale) stroke.

INTERVENTION

Monthly coaching by physiotherapists encouraging participants to adhere to 30 minutes of daily physical activity and 45-60 minutes of weekly exercise.

MAIN OUTCOME MEASURES

The primary outcome was Motor Assessment Scale (MAS). Secondary outcome measures were 6-minute walk test, Timed Up and Go (TUG), Berg Balance Scale (BBS), and the physical domains of the Stroke Impact Scale (SIS). Adherence was assessed by combining participants' training diaries and physiotherapists' reports.

RESULTS

The relationship between adherence and functional recovery was analyzed with simple and multiple linear regression models. Adjusted for age, sex, dependency, and cognition, results showed statistically significant associations between adherence and functional outcomes after 18 months, as measured by MAS, TUG, BBS, and SIS (P≤.026).

CONCLUSIONS

Increased adherence to physical activity and exercise was associated with improved functional recovery after mild to moderate stroke. This emphasizes the importance of developing adherence-enhancing interventions. Dose-response studies are recommended for future research.

Guidelines for Medical Nutrition Therapy in Gestational Diabetes Mellitus: Systematic Review and Critical Appraisal

BACKGROUND

Medical nutrition therapy is the cornerstone of gestational diabetes mellitus treatment. However, guidelines often present contradictory guidance to health care practitioners.

OBJECTIVE

To systematically review and critically appraise medical nutrition therapy guidelines for treating patients with gestational diabetes mellitus.

DESIGN

We searched Medline, the Cochrane Library, Guidelines International Network, and Google Scholar to retrieve clinical practice guidelines (CPGs) for medical nutrition therapy in gestational diabetes mellitus from professional or governmental organizations, published in English, between January 1, 2007, and November 24, 2018. CPGs were reviewed and appraised using the Appraisal of Guidelines, Research, and Evaluation II instrument.

RESULTS

Of 1,286 retrieved articles, 21 CPGs fulfilled the inclusion criteria. CPGs of the Academy of Nutrition and Dietetics, Diabetes Canada, and Malaysia Health Technology Assessment Section received the greatest overall scores and the highest scores concerning rigor of recommendations development. Many CPGs failed to involve multidisciplinary teams in their development, including patients, and often, dietitians. Applicability of the recommendations was low, lacking facilitators and tools to enhance implementation. Many CPGs demonstrated low editorial independence by failing to disclose funding and competing interests. More medical nutrition therapy recommendations were incorporated in the Academy of Nutrition and Dietetics and Malaysia Health Technology Assessment Section CPGs. The Malaysia Health Technology Assessment Section, Diabetes Canada, Academy of Nutrition and Dietetics, and Endocrine Society guidelines were recommended by the review panel herein without modifications. Overall, the CPGs suggested the consumption of adequate protein and the selection of foods with low glycemic index, divided into three main meals and two to four snacks. Weight gain recommendations were mostly based on the Institute of Medicine body mass index thresholds.

CONCLUSIONS

With few exceptions, the main developmental limitations of the appraised CPGs involved low rigor of recommendations development, lack of multidisciplinary stakeholder involvement, low applicability, and inadequate editorial independence. This indicates a need for developing more clear, unbiased, practical, and evidence-based CPGs.

Moving stroke rehabilitation evidence into practice: a systematic review of randomized controlled trials

OBJECTIVE

The aim of this study was to investigate the effectiveness of interventions aimed at moving research evidence into stroke rehabilitation practice through changing the practice of clinicians.

DATA SOURCES

EMBASE, CINAHL, Cochrane and MEDLINE databases were searched from 1980 to April 2019. International trial registries and reference lists of included studies completed our search.

REVIEW METHODS

Randomized controlled trials that involved interventions aiming to change the practice of clinicians working in stroke rehabilitation were included. Bias was evaluated using RevMan to generate a risk of bias table. Evidence quality was evaluated using GRADE criteria.

RESULTS

A total of 16 trials were included (250 sites, 14,689 patients), evaluating a range of interventions including facilitation, audit and feedback, education and reminders. Of which, 11 studies included multicomponent interventions (using a combination of interventions). Four used educational interventions alone, and one used electronic reminders. Risk of bias was generally low. Overall, the GRADE criteria indicated that this body of literature was of low quality. This review found higher efficacy of trials which targeted fewer outcomes. Subgroup analysis indicated moderate-level GRADE evidence (103 sites, 10,877 patients) that trials which included both site facilitation and tailoring for local factors were effective in changing clinical practice. The effect size of these varied (odds ratio: 1.63-4.9). Education interventions alone were not effective.

CONCLUSION

A large range of interventions are used to facilitate clinical practice change. Education is commonly used, but in isolation is not effective. Multicomponent interventions including facilitation and tailoring to local settings can change clinical practice and are more effective when targeting fewer changes.

Hospital organizational context and delivery of evidence-based stroke care: a cross-sectional study

Background

Organizational context is one factor influencing the translation of evidence into practice, but data pertaining to patients with acute stroke are limited. We aimed to determine the associations of organizational context in relation to four important evidence-based stroke care processes.

Methods

This was a mixed methods cross-sectional study. Among 19 hospitals in Queensland, Australia, a survey was conducted of the perceptions of stroke clinicians about their work using the Alberta Context Tool (ACT), a validated measure covering 10 concepts of organizational context, and with additional stroke-specific contextual questions. These data were linked to the Australian Stroke Clinical Registry (AuSCR) to determine the relationship with receipt of evidence-based acute stroke care (acute stroke unit admission, use of thrombolysis for those with acute ischemic stroke, receipt of a written care plan on discharge, and prescription of antihypertensive medications on discharge) using quantile regression. Exploratory cluster analysis was used to categorize hospitals into high and low context groups based on all of the 10 ACT concepts. Differences in adherence to care processes between the two groups were examined.

Results

A total of 215 clinicians completed the survey (50% nurses, 37% allied health staff, 10% medical practitioners), with 81% being in their current role for at least 1 year. There was good reliability (∞ 0.83) within the cohort to allow pooling of professional groups. Greater ACT scores, especially for social capital (μ 9.00, 95% confidence interval [CI] 4.86 to 13.14) and culture (μ 7.33, 95% CI 2.05 to 12.62), were associated with more patients receiving stroke unit care. There was no correlation between ACT concepts and other care processes. Working within higher compared to lower context environments was associated with greater proportions of patients receiving stroke unit care (88.5% vs. 69.0%) and being prescribed antihypertensive medication at discharge (62.5% vs. 52.0%). Staff from higher context hospitals were more likely to value medical and/or nursing leadership and stroke care protocols.

Conclusions

Overall organizational context, and in particular aspects of culture and social capital, are associated with the delivery of some components of evidence-based stroke care, offering insights into potential pathways for improving the implementation of proven therapies.

Electronic supplementary material

The online version of this article (10.1186/s13012-018-0849-z) contains supplementary material, which is available to authorized users.

AGREEing on Guidelines for Nutrition Management of Adult Severe Burn Patients

BACKGROUND

Severe burns are associated with a plethora of profound metabolic, immunologic, and physiologic responses, demanding prompt and adequate management. The objective of the present study was to review, compare, and critically appraise medical nutrition therapy guidelines for adult patients with severe burns, and produce salient points for the future update of relevant guidelines.

METHODS

A total of 8 clinical practice guidelines developed by the American Burn Association (ABA), the European Burn Association (EBA), the European Society for Parenteral and Enteral Nutrition (ESPEN), the Midlands National Health Service, the Society for Critical Care Medicine (SCCM)/American Society for Parenteral and Enteral Nutrition (ASPEN), the Spanish Society of Intensive Care Medicine and Coronary Units and Spanish Society of Parenteral and Enteral Nutrition, the Indian Association for Parenteral and Enteral Nutrition (IAPEN), and the International Society for Burn Injury regarding medical nutrition therapy in burn patients was independently reviewed by a team of 4 multidisciplinary researchers using the Appraisal of Guidelines for Research & Evaluation (AGREE II) instrument.

RESULTS

From the appraised guidelines, the SCCM/ASPEN guidelines received the greatest scoring in the majority of AGREE domains compared with ABA, EBA, and IAPEN, which obtained the lowest scores. On the other hand, the ESPEN guidelines provided the majority of information concerning nutrition support and medical nutrition therapy.

CONCLUSION

Our study identified gaps in most nutrition guidelines and emphasized methodologic issues that could improve the quality of future guidelines concerning nutrition support among adult severe burn patients.

Implementing a protocol for a research impact assessment of the Centre for Research Excellence in Stroke Rehabilitation and Brain Recovery

Background

There is growing recognition that the wider benefits of research (economic, social and health impacts) should be assessed and valued alongside traditional research performance metrics such as peer-reviewed papers. Translation of findings into policy and practice needs to accelerate and pathways to impact need to be better understood. This research protocol outlines a mixed methods study to apply the Framework to Assess the Impact from Translational health research (FAIT) to the Centre for Research Excellence in Stroke Rehabilitation and Brain Recovery (CRE-Stroke). FAIT is purpose-designed to encourage research translation and assess research impact but lacks validation.

Methods/Design

Phase 1 involves application of the FAIT-modified programme logic model to each CRE-Stroke research stream including identifying process, output and impact metrics, as well as end users of the research. A scoping review will inform potential impacts anticipated from CRE-Stroke. In Phase 2, audit and feedback on achievements against plans will track and encourage research translation. Logic models will be updated to account for changes in the research pathways over time. In Phase 3, three proven methods for measuring research impact – Payback, economic assessment and narratives – will be applied to each research stream and the data triangulated and reported in Phase 4. The feasibility of applying FAIT will also be assessed as part of Phase 3.

Discussion

Use of prospective, comprehensive research impact frameworks for large interdisciplinary programmes of research is rare. FAIT’s application to CRE-Stroke will provide opportunity for the impact of CRE-Stroke to be assessed and a range of impacts beyond standard academic achievements to be reliably reported. The feasibility of FAIT’s application will also be assessed and, if necessary, refined. The usefulness of FAIT for encouraging research translation will also be described and may prove useful for other programmes looking to implement a research impact framework.

Implementation of a politically initiated national clinical guideline for cardiac rehabilitation in hospitals and municipalities in Denmark

A politically initiated national clinical guideline was launched in Denmark in 2013 to improve quality and equality of cardiac rehabilitation (CR) services. The guideline is to be implemented in both hospital and community (municipality) settings due to shared responsibility for provision of CR services. Little is known about implementation outcomes of a guideline in these two settings. We aimed to study this by determining the extent to which Danish CR services in hospitals and municipalities adhered to national recommendations following the launch of the guideline. The study employed an observational, longitudinal design. Data were gathered by a questionnaire survey to compare CR services at baseline, measured in 2013 immediately before the guideline was launched, with CR services at a two-year follow up in 2015. All Danish hospital departments offering CR services (N = 36) and all municipalities (N = 98) were included. Data were analysed using inferential statistics. Hospitals reported improvement of both content and quality of CR services. Municipalities reported no change in content of services, and lower level of fulfilment of one quality aspect. The results suggest that the guideline had different impact in hospitals and municipalities and that the differences in content and quality of services between the two settings increased in the study period, thus contradicting the guideline´s aim of uniform, evidence-based content of CR services across settings.

Evaluation of antihypertensive adherence and its determinants at primary healthcare facilities in rural South Africa

Aim: To evaluate adherence to antihypertensive treatment in rural South Africa and identify potential determinants given concerns with adherence and its impact in this priority disease area. Patients & methods: Face-to-face interviews with hypertensive patients and rating their adherence to treatment using defined categorized responses. Associations between adherence and patient characteristics assessed and sensitivity analyses performed. Results: 54.6% of patients were adherent to treatment. Controlled blood pressure (BP; odds ratios [OR] = 2.1; 95% CI: 1.1, 3.8; p = 0.019), comorbidity (OR = 2.0; 95% CI: 1.1, 3.6; p = 0.032) and smoking (OR = 0.3; 95% CI: 0.1, 0.8; p = 0.018) were associated with adherence. Conclusion: Adherence and BP control were suboptimal, only smoking was an independent risk factor for adherence. Adherent patients were twice as likely to have controlled BP, although results were sensitive to the definition of adherence. Initiatives are in place to improve adherence, which will be monitored.

Systematic review of clinical practice guidelines to identify recommendations for rehabilitation after stroke and other acquired brain injuries

OBJECTIVES

Rehabilitation clinical practice guidelines (CPGs) contain recommendation statements aimed at optimising care for adults with stroke and other brain injury. The aim of this study was to determine the quality, scope and consistency of CPG recommendations for rehabilitation covering the acquired brain injury populations.

DESIGN

Systematic review.

INTERVENTIONS

Included CPGs contained recommendations for inpatient rehabilitation or community rehabilitation for adults with an acquired brain injury diagnosis (stroke, traumatic or other non-progressive acquired brain impairments). Electronic databases (n=2), guideline organisations (n=4) and websites of professional societies (n=17) were searched up to November 2017. Two independent reviewers used the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument, and textual syntheses were used to appraise and compare recommendations.

RESULTS

From 427 papers screened, 20 guidelines met the inclusion criteria. Only three guidelines were rated high (>75%) across all domains of AGREE-II; highest rated domains were 'scope and purpose' (85.1, SD 18.3) and 'clarity' (76.2%, SD 20.5). Recommendations for assessment and for motor therapies were most commonly reported, however, varied in the level of detail across guidelines.

CONCLUSION

Rehabilitation CPGs were consistent in scope, suggesting little difference in rehabilitation approaches between vascular and traumatic brain injury. There was, however, variability in included studies and methodological quality.

PROSPERO REGISTRATION NUMBER

CRD42016026936.

Non-guideline-recommended prescribing of proton pump inhibitors: implications for the future and reducing over usage

Drs Godman and Fadare review the paper by Mares-Garcia and colleagues in Spain regarding the extent of non-guideline recommended prescribing (NGRP) of proton pump inhibitors (PPIs) in ambulatory care. NGRP of PPIs is an increasing public health concern given the implications of overuse of PPIs on infection rates, osteoporosis and chronic kidney disease as well as increasing polypharmacy rates. Costs are less of an issue especially where there are low prices for generic PPIs; the main focus is on improving the quality of PPI prescribing. Encouragingly, Mares-Garcia and colleagues identified key factors associated with NGRP, providing direction to others.

Prescription patterns and adequacy of blood pressure control among adult hypertensive patients in Kenya; findings and implications

BACKGROUND

Hypertension is a major cause of global morbidity and mortality, with high prevalence rates in Africa including Kenya. Consequently, it is imperative to understand current treatment approaches and their effectiveness in practice. Currently, there is paucity of such data in Kenya, which is a concern. The aim is to describe prescribing patterns and adequacy of blood pressure (BP) control in adult hypertensive patients to guide future practice.

METHOD

Retrospective study of patients attending a sub-county outpatient clinic combined with qualitative interviews.

RESULTS

247 hypertensive patients, predominantly female, mean age 55.8 years on antihypertensive therapy for 1-5 years, were analyzed. ACEIs and thiazide diuretics were the most commonly prescribed drugs, mainly as combination therapy. Treatment typically complied with guidelines, mainly for stage 2 hypertension (75%). BP control was observed in 46% of patients, with a significant reduction in mean systolic (155 to 144 mmHg) and diastolic (91 to 83 mmHg) BP (P < 0.001). Patients on ≥2 antihypertensive drugs were more likely to have uncontrolled BP (OR:1.9, p = 0.021).

CONCLUSION

Encouragingly good adherence to guidelines was helped by training. Poor blood pressure control in the majority needs to be addressed. Additional training of prescribers and follow-up of measures to improve BP control will be introduced and followed up.

Health professionals' views on the barriers and enablers to evidence-based practice for acute stroke care: a systematic review

BACKGROUND

Adoption of contemporary evidence-based guidelines for acute stroke management is often delayed due to a range of key enablers and barriers. Recent reviews on such barriers focus mainly on specific acute stroke therapies or generalised stroke care guidelines. This review examined the overall barriers and enablers, as perceived by health professionals which affect how evidence-based practice guidelines (stroke unit care, thrombolysis administration, aspirin usage and decompressive surgery) for acute stroke care are adopted in hospital settings.

METHODOLOGY

A systematic search of databases was conducted using MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase, PsycINFO, Cochrane Library and AMED (Allied and Complementary Medicine Database from 1990 to 2016. The population of interest included health professionals working clinically or in roles responsible for acute stroke care. There were no restrictions to the study designs. A quality appraisal tool for qualitative studies by the Joanna Briggs Institute and another for quantitative studies by the Centre for Evidence-Based Management were used in the present study. A recent checklist to classify barriers and enablers to health professionals' adherence to evidence-based practice was also used.

RESULTS

Ten studies met the inclusion criteria out of a total of 9832 search results. The main barriers or enablers identified included poor organisational or institutional level support, health professionals' limited skills or competence to use a particular therapy, low level of awareness, familiarity or confidence in the effectiveness of a particular evidence-based therapy, limited medical facilities to support evidence uptake, inadequate peer support among health professionals', complex nature of some stroke care therapies or guidelines and patient level barriers.

CONCLUSIONS

Despite considerable evidence supporting various specific therapies for stroke care, uptake of these therapies is compromised by barriers across organisational, patients, guideline interventions and health professionals' domains. As a result, we recommend that future interventions and health policy directions should be informed by these findings in order to optimise uptake of best practice acute stroke care. Further studies from low- to middle-income countries are needed to understand the barriers and enablers in such settings.

TRIAL REGISTRATION

The review protocol was registered in the international prospective register of systematic reviews, PROSPERO 2015 (Registration Number: CRD42015023481 ).

Barriers to evidence-based acute stroke care in Ghana: a qualitative study on the perspectives of stroke care professionals

OBJECTIVE

Despite major advances in research on acute stroke care interventions, relatively few stroke patients benefit from evidence-based care due to multiple barriers. Yet current evidence of such barriers is predominantly from high-income countries. This study seeks to understand stroke care professionals' views on the barriers which hinder the provision of optimal acute stroke care in Ghanaian hospital settings.

DESIGN

A qualitative approach using semistructured interviews. Both thematic and grounded theory approaches were used to analyse and interpret the data through a synthesis of preidentified and emergent themes.

SETTING

A multisite study, conducted in six major referral acute hospital settings (three teaching and three non-teaching regional hospitals) in Ghana.

PARTICIPANTS

A total of 40 participants comprising neurologists, emergency physician specialists, non-specialist medical doctors, nurses, physiotherapists, clinical psychologists and a dietitian.

RESULTS

Four key barriers and 12 subthemes of barriers were identified. These include barriers at the patient (financial constraints, delays, sociocultural or religious practices, discharge against medical advice, denial of stroke), health system (inadequate medical facilities, lack of stroke care protocol, limited staff numbers, inadequate staff development opportunities), health professionals (poor collaboration, limited knowledge of stroke care interventions) and broader national health policy (lack of political will) levels. Perceived barriers varied across health professional disciplines and hospitals.

CONCLUSION

Barriers from low/middle-income countries differ substantially from those in high-income countries. For evidence-based acute stroke care in low/middle-income countries such as Ghana, health policy-makers and hospital managers need to consider the contrasts and uniqueness in these barriers in designing quality improvement interventions to optimise patient outcomes.

Predictors of Vascular Cognitive Impairment Poststroke in a Middle Eastern (Bahrain) Cohort: A Proposed Case-Control Comparison

BACKGROUND

Poststroke dementia and cognitive impairment are associated with poor long-term outcomes after stroke. The contribution of genetic factors such as the presence of apolipoprotein (ApoE) ɛ4 allele and its association with cognitive impairment poststroke remains inconclusive, particularly in Middle Eastern regions.

OBJECTIVE

The aim of this study is to examine all correlates and potential predictors of cognitive impairment including self-awareness and regulation deficits in stroke patients and compare these functions with healthy older adults from a Middle Eastern population.

METHODS

A prospective stroke sample of 200 patients (case group) and 100 healthy aging individuals (control group) will be recruited from the largest medical complex in Bahrain. A neuropsychological battery of cognitive assessments (global, executive, and metacognition) will be conducted on all participants. Participants will be categorized into 4 subgroups (nonvascular cognitive impairment, vascular cognitive impairment with no dementia, vascular dementia, and mixed dementia) using standardized cognitive assessment scores and the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, dementia criteria. Biomarkers will include ApoE genotype, soluble form of receptor for advanced glycation end products, neprilysin, beta-secretase 1, biochemistry, and hematology measurements.

RESULTS

The primary study outcome is to determine early risk factors for cognitive impairment after stroke in a Bahraini cohort. The study has received full ethical approval from the Bahrain Ministry of Health and from the affiliated university.

CONCLUSIONS

With increasing stroke incidence rates in the Middle East, this research study will provide useful biological and epidemiological data for future development and planning of health policies and guidelines for stroke care within the Gulf region.

Research-based evidence in stroke rehabilitation: an investigation of its implementation by physiotherapists and occupational therapists

PURPOSE

Stroke rehabilitation is a multidimensional process that is designed to facilitate restoration of and/or adaptation to loss of functioning. The use of research-based evidence in informed decision-making is insufficient. Occupational therapy and physiotherapy constitute important contributions to rehabilitation. The study aim was to investigate characteristics of the implementation of research-based evidence in stroke rehabilitation by occupational therapists and physiotherapists, using the International Classification of Functioning, Disability and Health as a conceptual framework.

METHOD

A prospective cohort study, including all service levels within stroke rehabilitation. Consecutive patients with stroke admitted to a university hospital between May and December 2012 were enrolled by 13 therapists. Documentation of daily practice was collected from medical records. Analysis compared the therapists' documentation with the national clinical guidelines for physiotherapy and occupational therapy in the rehabilitation of adults with brain injury.

RESULTS

The study included 131 patients. The therapists' praxis was seen to be in agreement with the majority of the national clinical guidelines. However, joint goal-setting and evaluation using standardized measures were seldom documented.

CONCLUSIONS

Although the therapists recognize evidence-based practice as a framework for achieving quality in rehabilitation, findings suggest that they do not employ research-based evidence to the fullest extent. Implications for Rehabilitation In order to individualize the rehabilitation offered, more attention and focus on involving and giving words to patients' expectations, perceptions, experiences, and perspectives is needed. With the intention of enabling meaningful participation the health professionals need to pay more attention to the importance of environmental factors. Both guidelines and clinical practice should consider all components of the International Classification of Functioning, Disability and Health when formulating, and implementing, recommendations in rehabilitation praxis in order to aim for rehabilitation that is based both on evidence and a holistic approach.

Individual and Regional-level Factors Contributing to Variation in Length of Stay After Cerebral Infarction in Six European Countries

Using patient-level data for cerebral infarction cases in 2007, gathered from Finland, Hungary, Italy, the Netherlands, Scotland and Sweden, we studied the variation in risk-adjusted length of stay (LoS) of acute hospital care and 1-year mortality, both within and between countries. In addition, we analysed the variance of LoS and associations of selected regional-level factors with LoS and 1-year mortality after cerebral infarction. The data show that LoS distributions are surprisingly different across countries and that there is significant deviation in the risk-adjusted regional-level LoS in all of the countries studied. We used negative binomial regression to model the individual-level LoS, and random intercept models and ordinary least squares regression for the regional-level analysis of risk-adjusted LoS, variance of LoS, 1-year risk-adjusted mortality and crude mortality for a period of 31-365 days. The observed variations between regions and countries in both LoS and mortality were not fully explained by either patient-level or regional-level factors. The results indicate that there may exist potential for efficiency gains in acute hospital care of cerebral infarction and that healthcare managers could learn from best practices.

Assessing feasibility and acceptability of study procedures: getting ready for implementation of national stroke guidelines in out-patient health care

Background

Even though Swedish national guidelines for stroke care (SNGSC) have been accessible for nearly a decade access to stroke rehabilitation in out-patient health care vary considerably. In order to aid future interventions studies for implementation of SNGSC, this study assessed the feasibility and acceptability of study procedures including analysis of the context in out-patient health care settings.

Methods

The feasibility and acceptability of recruitment, observations and interviews with managers, staff and patients were assessed, as well as the feasibility of surveying health care records.

Results

To identify patients from the the hospitals was feasible but not from out-patient care where a need to relieve clinical staff of the recruitment process was identified. Assessing adherence to guidelines and standardized evaluations of patient outcomes through health care records was found to be feasible and suitable assessment tools to evaluate patient outcome were identified. Interviews were found to be a feasible and acceptable tool to survey the context of the health care setting.

Conclusion

In this feasibility study a variety of qualitative and quantitative data collection procedures and measures were tested. The results indicate what can be used as a set of feasible and acceptable data collection procedures and suitable measures for studying implementation of stroke guidelines in an out-patient health care context.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-015-1177-5) contains supplementary material, which is available to authorized users.

Secondary prevention after ischaemic stroke: the ASPIRE-S study

BACKGROUND

Survivors of ischaemic stroke (IS) are at high-risk for future vascular events. Comprehensive information on the adequacy of secondary prevention after IS is lacking despite the knowledge that appropriate secondary prevention improves long-term patient outcomes. ASPIRE-S (Action on Secondary Prevention Interventions and Rehabilitation in Stroke) aimed to prospectively assess secondary prevention in patients 6 months following IS.

METHODS

Consenting patients admitted with IS to three Dublin hospitals were recruited over 1 year, from October 2011. At 6 months post IS a comprehensive assessment was completed, modelled on the EUROASPIRE protocol for evaluation of the adequacy of secondary prevention in post-discharge cardiac patients. This assessment included measurements of blood pressure, body mass index and fasting lipid and glucose profiles. Secondary preventive medications and smoking status were also documented.

RESULTS

Three hundred two patients (58 % male) participated, of whom 256 (85 %) were followed-up at 6 months. Mean age was 69 years (range 22-95). At follow-up, 68 % of patients had a BMI >25 kg/m(2) and 16.4 % were still smoking. Almost two-thirds (63.4 %) had a blood pressure >140/90 and 23 % had low-density-lipoprotein >2.5 mmol/L. 28 % of diabetic patients had HbA1c ≥ 7 %. Ninety seven percent of patients were on anti-platelet and/or anticoagulant therapy. Of those with atrial fibrillation, 82 % were anti-coagulated (mean INR of 2.4). Ninety-five percent were on lipid-lowering therapy and three-quarters were on anti-hypertensive therapy.

CONCLUSION

This prospective multi-centre survey of IS patients demonstrated a high prevalence of remaining modifiable risk factors at 6 months post stroke, despite the widespread prescription of secondary preventive medications. There is scope to improve preventive measures after IS (in particular blood pressure) by incorporating evidence-based guidelines into quality assurance cycles in stroke care.

Who does it first? The uptake of medical innovations in the performance of thrombolysis on ischemic stroke patients in Germany: a study based on hospital quality data

Background

Since 2000, systemic thrombolysis has been the only approved curative and causal treatment for acute ischemic stroke. In 2009, the guidelines of the German Society for Neurology were updated and the therapeutic window for performing thrombolysis was extended. The implementation of new therapies is influenced by many factors. We analyzed the factors at the organizational level that influence the implementation of thrombolysis in stroke patients.

Methods

The data published by the majority of German hospitals in their structured quality reports was assessed. We calculated a regression model in order to measure the influence of hospital/department-level characteristics (e.g., teaching status, ownership, location, and number of hospital beds) on the implementation of thrombolysis in 2006 (this is the earliest point in time that can be analyzed on this data basis). In order to measure the effect of the guideline update in 2009 on the thrombolysis rate (TR) change between 2008 and 2010, we performed a Wilcoxon signed-rank test and utilized a regression model.

Results

In 2006, 61.5% of a total of 286 neurology departments performed systemic thrombolysis to treat ischemic strokes. The influencing factors for the use of systemic thrombolysis in 2006 were the existence of a stroke unit (+) and a hospital size of between 500 and 1,000 beds (−). A significant increase of the mean departmental TR (thrombolysis rate) from 6.7% to 9.2% between 2008 and 2010 was observed after the guideline update in 2009. For the departments performing thrombolysis in 2008 and 2010, our analysis could not show any additional influencing factors on a structural level that would explain the TR rise during the period 2008–2010.

Conclusions

Because ischemic stroke patients benefit from systemic thrombolysis, it is necessary to examine possible barriers at the organizational level that hinder the implementation. Our data shows that, organizational factors have an influence on the implementation of thrombolysis. However, the recent guideline update resulted in a TR rise that occurred at all hospitals, regardless of the measured structural conditions, as our analysis could not identify any structural factors that might have influenced the TR after the guideline update.