The uptake and costs of guidelines for stroke in a district of southern England

Communities of Practice: A Knowledge Translation Tool for Rehabilitation Professionals

Increased attention to evidence-based practice (EBP) among rehabilitation professionals closely corresponds to recent interest in knowledge translation, which connects quality research to rehabilitation practice aimed at improving the lives of people with disabilities. Despite the importance of knowledge translation for rehabilitation professionals, the concept is often overlooked or misunderstood. This article provides a brief review of knowledge translation to clarify potential misconceptions. In addition, communities of practice (CoPs) are introduced as a specific tool for knowledge translation. An overview of CoPs and guidelines for design, development, and use are reviewed. The flexibility and common ownership of CoPs provide an ideal approach for rehabilitation researchers, practitioners, and consumers to work together to develop knowledge and effective practice guidelines.

Costs of stroke using patient-level data: a critical review of the literature

BACKGROUND AND PURPOSE

With decision-analytic models becoming more popular to assess the cost-effectiveness of health care interventions, the need for robust estimates on the costs of cerebrovascular disease is paramount. This study reports the results from a literature review of the costs of cerebrovascular diseases, and assesses the quality of the published evidence against a set of defined criteria.

METHODS

A broad literature search was conducted. Those studies reporting mean/median costs of cerebrovascular diseases derived from patient-level data in a developed country setting were included. Data were abstracted using standardized reporting forms and assessed against 4 predefined criteria: use of adequate methodologies, use of a population-based study, inclusion of premorbid resource use, and reporting of costs by different patient subgroups.

RESULTS

A total of 120 cost studies were identified. The cost estimates of stroke were compared by taking into account the effects of inflation and price differentials between countries. Average costs of stroke ranged from $468 to $146 149. Differences in costs were also found within country, with estimates in the USA varying 20-fold. Although the costing methodologies used were generally appropriate, only 5 studies were based on population-based studies, which are the gold standard study design when comparing incidence, outcome, and costs.

CONCLUSIONS

This review showed large variations in the costs of stroke, mainly attributable to differences in the populations studied, methods, and cost categories included. The wide range of cost estimates could lead to selection bias in secondary health economic analyses, with authors including those costs that are more likely to produce the desired results.

A multidisciplinary guideline for the acute phase of stroke: barriers perceived by Dutch neurologists

RATIONALE, AIMS AND OBJECTIVES

Guidelines for stroke management should improve quality of care. Dissemination of guidelines, however, does not guarantee guideline adherence. The aim of this paper is to investigate barriers for guideline adherence to bring about suggestions for possible implementation strategies.

METHOD

Questionnaire survey among all Dutch neurologists working on neurology wards in general hospitals during the year 2000 in The Netherlands.

RESULTS

The neurologists expressed a high degree of agreement with the diagnostic and preventive recommendations, but expressed doubts with regard to the therapeutic recommendations, especially for the recombinant tissue plasminogen activator therapy. In general, barriers at the organizational and the multidisciplinary team level were most prominent.

CONCLUSIONS

Active implementation of the guidelines seems necessary. Implementation strategies should be focused on the different sources of barriers: the caregiver, the patient and the organization of care.

Variations in case fatality and dependency from stroke in western and central Europe. The European BIOMED Study of Stroke Care Group

BACKGROUND AND PURPOSE

There are significant variations in mortality rates from stroke in Europe. A European Union BIOMED Concerted Action was established to assess and determine the reasons for the variations in case fatality and disability after stroke.

METHODS

Hospital-based stroke registers were established in 12 centers in 7 western and central European countries to collect demographic, clinical, and resource use details at the time of first-ever stroke during 1993-1994. At 3 months, details of survival, activity of daily living score, and use of health services were recorded. Multinomial logistic regression was used to estimate the relationship between centers and outcome (dead, functionally independent, functionally dependent), with adjustment for case mix and resource use variables, and to predict outcomes for the full cohort. This should minimize the bias due to loss to follow-up.

RESULTS

A total of 4534 stroke events were registered. The mean age was 71.9 years (SD, 12.53). There were significant differences between centers for all case mix and resource use variables (P<0. 001). Multinomial logistic regression modeling of outcome indicated that for those patients initially unconscious (588), center was not significantly related to outcome (P=0.427). For those initially conscious, there were wide variations in death and dependency between centers after adjustment for case mix, type of bed, and use of CT scan. The predicted proportion dead at 3 months ranged from 42% (95% CI, 35% to 49%) in one UK center to 19% (95% CI, 14% to 24%) in France.

CONCLUSIONS

Areas with high mortality rates within western and central Europe have been identified for stroke outcome, and there appears to be opportunity for considerable health gain in certain centers. Adjustment for case mix and health service resource use does not explain these differences in outcome. Although there are true differences in outcome, the aspects of care that need to be altered to improve outcome remain unclear despite detailed data collection. Comparisons of outcome of the same design used in the present study do not allow rational policy decisions to be made.