Shared decision-making in stroke: an evolving approach to improved patient care

Implementation of a patient decision aid for discharge planning of hospitalized patients with stroke: aprocess evaluation using a mixed-methods approach

OBJECTIVES

To promote shared decision-making (SDM) during discharge planning of patients with stroke, a patient decision aid (PtDA) was implemented in seven Dutch hospitals. This mixed-methods process evaluation assessed: 1) PtDA use, 2) the SDM process, 3) facilitators and barriers influencing health care professional (HCP) adoption of the PtDA, and 4) HCP experiences with the PtDA.

METHODS

Rates of PtDA use were derived from hospital registries and PtDA log data. SDM levels in consultations were quantitatively assessed using OPTION-5 (score range 0-100); the SDM process was analyzed qualitatively. Facilitators and barriers were identified via the MIDI questionnaire. HCP experiences were explored through interviews.

RESULTS

PtDA use varied across hospitals, with 10-96 % of patients receiving it and 27-100 % of those ultimately using it. OPTION-5 scores were low in both pre-implementation (n = 68, median:0, Q1-Q3:0-0) and post-implementation consultations (n = 49, median:0, Q1-Q3:0-15). Barriers included lack of whole-team engagement and limited recognition of PtDA benefits. Frequent PtDA use was associated with HCP confidence and self-efficacy in SDM.

CONCLUSIONS

Successful PtDA implementation in stroke care requires whole-team engagement, emphasis on PtDA benefits, and enhancing HCP confidence and self-efficacy in SDM.

PRACTICE IMPLICATIONS

Highlighting positive SDM outcomes and patient benefits may encourage HCPs to adopt the PtDA.

Postoperative self-care ability of continuous nursing based on artificial intelligence for stroke patients with neurological injury

According to the statistics of relevant data, stroke is a relatively common cerebrovascular disease, and its incidence rate is as high as 185/100,000 to 219/100,000. Continuous care can improve the quality of life of stroke patients and reduce the rate of hospital visits and hospitalizations. In this study, patients in a local hospital of third-grade class-A hospital were used as cases. Artificial intelligence was used to conduct continuous nursing intervention for the patients who were discharged from the stroke by using the WeChat platform, regular follow-up and home care. Afterwards, the collected data were given a post-processing, independent-samples t-test for two groups. After 3 months of extended care, the BI (Barthel Index) score of the intervention group has increased by 23.87 points, and the depression self-rating scale score has decreased by 9.12 points. Compared with the control group, the patients' self-care ability, depression state, compliance with health guidance and laboratory indicators were also better than those in the control group, and the differences were statistically significant (P < 0.05). Compared with the control group, the trend of increasing the scores of each index was more significant in the intervention group.

Mediation Role of Behavioral Decision-Making Between Self-Efficacy and Self-Management Among Elderly Stroke Survivors in China: Cross-Sectional Study

Background: Identifying the factors that impact self-management is crucial, as elderly stroke survivors frequently face challenges in self-management. Self-efficacy and behavioral decision-making are reported as influencing factors of self-management, but their relationship within the elderly population remains unconfirmed. This study aimed to explore whether self-efficacy impacts self-management through the mediating role of behavioral decision-making among elderly stroke survivors. Methods: A cross-sectional design and convenience sampling method were used in this study. A total of 291 elderly stroke survivors were recruited from a tertiary hospital in Henan Province, China, between March and July of 2024. Questionnaires were distributed to collect sociodemographic, self-efficacy, behavioral decision-making, and self-management data. A path analysis and correlation analysis were used to analyze the data. This study adhered to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines. Results: Elderly stroke survivors reported having a moderate level of self-management. There was a positive correlation between self-efficacy, behavioral decision-making, and self-management (all p < 0.01). The mediation model indicated that behavioral decision-making mediated the association of self-efficacy and self-management in the regression model (95% CI 0.03 to 0.14), and the effect value was 0.08. It was also confirmed that behavioral decision-making mediated the impact of self-efficacy and self-management, accounting for 25.81% of the total effect. Conclusion: Self-efficacy is not solely a key factor influencing self-management in elderly stroke survivors, but it also improves their self-management behaviors by facilitating behavioral decision-making. As a result, healthcare professionals should consider self-efficacy and behavioral decision-making as crucial elements for assessing elderly stroke survivors during discharge and follow-up.

Information needs of people who have suffered a stroke or TIA and their preferred approaches of receiving health information: A scoping review

PURPOSE

We aimed to synthesize the information needs of people with stroke (PwS) in recurrent stroke prevention.

METHODS

In this scoping review we searched Medline (via PubMed), CINAHL, and PsycINFO from inception to June 5, 2023, to identify all studies describing the information needs of people 18 years and older who have suffered a stroke or transient ischemic attack within the past 5 years. We included qualitative and quantitative studies from developed countries published in German or English. Data analysis was performed following Arksey and O'Malley's methodological framework for scoping reviews.

FINDINGS

We screened 5822 records for eligibility and included 36 articles published between 1993 and 2023. None of the included studies used a comprehensive framework or defined information needs. Based on statements from PwS and their caregivers, PwS needed information on treatment, etiology, effects of stroke, prognosis, rehabilitation, discharge, life changes, care role, support options, information sources, and hospital procedures. The most frequently expressed needs were information on the treatment (77.8%) and stroke etiology (63.9%). The primary information source was healthcare professionals (85.7%), followed by written information (71.4%), family and friends (42.6%), and the internet (35.7%), with information provided directly by healthcare professionals being preferred. The timing of information transfer is often described as too early.

CONCLUSION

PwS are primarily interested in clinical information about stroke, for example, treatment and etiology, and less often in information about daily life, for example, rehabilitation, the role of care, or lifestyle changes. PwS prefer to receive information directly from healthcare professionals. Developing a shared understanding of PwS's information needs is crucial to implement suitable strategies and programs for dealing with these needs in clinical practice.

The Significance of a Cerebrovascular Accident Outcome Prediction Model for Patients, Family Members, and Health Care Professionals: Qualitative Evaluation Study

BACKGROUND

Patients with cerebrovascular accident (CVA) should be involved in setting their rehabilitation goals. A personalized prediction of CVA outcomes would allow care professionals to better inform patients and informal caregivers. Several accurate prediction models have been created, but acceptance and proper implementation of the models are prerequisites for model adoption.

OBJECTIVE

This study aimed to assess the added value of a prediction model for long-term outcomes of rehabilitation after CVA and evaluate how it can best be displayed, implemented, and integrated into the care process.

METHODS

We designed a mock-up version, including visualizations, based on our recently developed prediction model. We conducted focus groups with CVA patients and informal caregivers, and separate focus groups with health care professionals (HCPs). Their opinions on the current information management and the model were analyzed using a thematic analysis approach. Lastly, a Measurement Instrument for Determinants of Innovations (MIDI) questionnaire was used to collect insights into the prediction model and visualizations with HCPs.

RESULTS

The analysis of 6 focus groups, with 9 patients, 4 informal caregivers, and 8 HCPs, resulted in 10 themes in 3 categories: evaluation of the current care process (information absorption, expectations of rehabilitation, prediction of outcomes, and decision aid), content of the prediction model (reliability, relevance, and influence on the care process), and accessibility of the model (ease of understanding, model type preference, and moment of use). We extracted recommendations for the prediction model and visualizations. The results of the questionnaire survey (9 responses, 56% response rate) underscored the themes of the focus groups.

CONCLUSIONS

There is a need for the use of a prediction model to assess CVA outcomes, as indicated by the general approval of participants in both the focus groups and the questionnaire survey. We recommend that the prediction model be geared toward HCPs, as they can provide the context necessary for patients and informal caregivers. Good reliability and relevance of the prediction model will be essential for its wide adoption.

Clinician and patient experiences with shared decision-making to promote daily arm use for individuals with chronic stroke: an exploratory qualitative study

Purpose

To explore the attitudes and experiences of clinicians and individuals with chronic stroke on the use of shared decision-making (SDM) during upper extremity rehabilitation to improve daily arm use in the home environment. Specifically, we aimed to describe clinician and client perspectives regarding the facilitators and barriers to using SDM within the context of a self-directed upper extremity intervention for individuals living in the community with chronic stroke.

Methods

Data were collected within the context of an interventional study examining the feasibility of the Use My Arm-Remote intervention. Focus group interviews were conducted with the clinicians (n = 3) providing the intervention and individual semi-structured interviews with the participants (n = 15) of the study. All interview data were collected after the end of the intervention period. Data were analyzed using thematic analysis.

Results

The following themes were identified: (1) Equal partnership; (2) Enhancing clinician confidence; and (3) This is different. Facilitators and barriers were identified within each theme. Key facilitators for clinicians were competence with SDM and patient characteristics; while facilitators for patients were open and trusting relationships with clinicians and personalized experience. Key barriers to SDM for clinicians were lack of expertise in SDM and participant buy in; while patients identified a lack of foundational knowledge of stroke rehabilitation as a potential barrier.

Conclusions

Key barriers were analyzed using the consolidated framework for advancing implementation science to interpret results and identify strategies for enhancing the implementation of SDM in a virtual setting. The CFIR-ERIC tool highlighted the need for targeted educational meetings and materials to address the training and educational needs of both clinicians and patients for future iterations of this intervention.

The Perspectives of Individuals with Chronic Stroke on Motor Recovery: A Qualitative Analysis

The priorities of individuals with chronic stroke are not always reflected in clinical practice. This study provides insight into meaningful factors related to long-term motor recovery in stroke survivors. Thirty individuals with chronic stroke participated in semi-structured interviews about movement, recovery, and barriers to and facilitators of mobility and paretic arm use. The interviews were analyzed using inductive thematic analysis. Three categories, the individual, environment, and task, defined five emergent themes. Individual: (1) mindset is a strong and consistent influencer of daily physical activity and overall recovery; (2) severe physical impairment limits physical activity and recovery, regardless of other factors; and (3) a negative perception of disability impacts mindset and willingness to move in public. Environment: (4) social and physical environments influence physical activity and recovery. Task: (5) participation in meaningful activities increases physical activity and promotes long-term recovery. Strategies to incorporate paretic arm use, exercise, and encouragement from others facilitate physical activity. Insufficient paretic limb function, environmental obstacles, and fear are barriers to physical activity. Neurorehabilitation must address the factors that are meaningful to stroke survivors. Building motor capacity is essential and must be integrated with factors such as a positive mindset and proper environment. Individual differences reinforce the need for personalized care.

Physiotherapists' decision-making about transition to independent walking in hospital after stroke: a qualitative study

PURPOSE

Physiotherapists working in hospitals have a key role in decisions about when a person with stroke is safe to walk independently. The aim of this study was to explore the factors influencing decision-making of physiotherapists in this situation.

METHODS

A qualitative design with semi-structured interviews and reflexive thematic analysis was used. Fifteen physiotherapists with recent experience working in inpatient stroke rehabilitation participated.

RESULTS

Multiple factors influence decision-making about walking independence after stroke in hospitals. Four themes were identified: (1) Assessment of walking safety involves observation of walking function and consideration of complex individual factors; (2) Perspectives on risk vary, and influence whether a person is considered safe to walk; (3) Institutional culture involves background pressures that may influence decision-making; and (4) Physiotherapists adopt a structured, individualised mobility progression to manage risk. Physiotherapists consistently use observation of walking and understanding of attention and perception in this decision-making. There can sometimes be a conflict between goals of independence and of risk avoidance, and decisions are made by personal judgements.

CONCLUSIONS

Decision-making about independent walking for people in a hospital after a stroke is complex. Improved guidance about clinical assessment of capacity and determining acceptable risk may enable physiotherapists to engage more in shared decision-making.IMPLICATIONS FOR REHABILITATIONRegaining independence in walking after a stroke comes with the potential risk of falls.Assessment of walking safety should be specific to the complexity of the situation and consider perception and cognition.Benefits of activity and autonomy, and the risk of falls need to be considered in decisions about walking independence.Patients with the capacity to understand consequences and accept risk can be active participants in determining what is sufficiently safe.

Co-designing resources for rehabilitation via telehealth for people with moderate to severe disability post stroke

OBJECTIVES

The COVID-19 pandemic necessitated rapid transition to telehealth. Telehealth presents challenges for rehabilitation of stroke survivors with moderate-to-severe physical disability, which traditionally relies on physical interactions. The objective was to co-design resources to support delivery of rehabilitation via telehealth for this cohort.

DESIGN

Four-stage integrated knowledge translation co-design approach. Stage 1: Research team comprising researchers, clinicians and stroke survivors defined the research question and approach. Stage 2: Workshops and interviews were conducted with knowledge users (participants) to identify essential elements of the program. Stage 3: Resources developed by the research team. Stage 4: Resources reviewed by knowledge users and adapted.

PARTICIPANTS

Twenty-one knowledge users (clinicians n = 11, stroke survivors n = 7, caregivers n = 3) RESULTS: All stakeholders emphasised the complexities of telehealth rehabilitation for stroke and the need for individualised programs. Shared decision-making was identified as critical. Potential risks and benefits of telehealth were acknowledged and strategies to ameliorate risks and deliver effective rehabilitation were identified. Four freely available online resources were co-designed; three resources to support clinicians with shared decision-making and risk management and a decision-aid to support stroke survivors and caregivers throughout the process. Over six months, 1129 users have viewed the webpage; clinician resources were downloaded 374 times and the decision-aid was downloaded 570 times.

CONCLUSIONS

The co-design process identified key elements for delivery of telehealth rehabilitation to stroke survivors with moderate-to-severe physical disability and led to development of resources to support development of an individualised telehealth rehabilitation plan. Future research should evaluate the effectiveness of these resources. CONTRIBUTION OF PAPER.

Explorative observational study of Dutch patient-clinician interactions: operationalisation of personal perspective elicitation as part of shared decision-making in real-life audio-recorded consultations

OBJECTIVES

Patients' preferences, values and contexts are important elements of the shared decision-making (SDM) process. We captured those elements into the concept of 'personal perspective elicitation' (PPE), which reflects the need to elicit patients' preferences, values and contexts in patient-clinician conversations. We defined PPE as: 'the disclosure (either elicited by the clinician or spontaneously expressed by the patient) of information related to the patient's personal preferences, values and/or contexts potentially relevant to decision-making'. Our goal was to operationalise the concept of PPE through the evaluation of preferences, values and contexts and explore how PPE occurs in clinical encounters.

DESIGN

Cross-sectional study: observational coding based on a novel coding scheme of audio-recorded outpatient clinical encounters where encounter patient decision aids were applied.

SETTING

We audio-recorded patient-clinician interactions at three Dutch outpatient clinics. PPE was analysed using a novel observational coding scheme, distinguishing preferences, contexts and four Armstrong taxonomy value types (global, decisional, external and situational). We measured SDM using the Observer OPTION5.

PARTICIPANTS

Twenty patients who suffered from psoriasis or ovarian cysts; four clinicians.

RESULTS

We included 20 audio-recordings. The mean Observer OPTION5 score was 57.5 (SD:10.1). The audio-recordings gave a rich illustration of preferences, values and contexts that were discussed in the patient-clinician interactions. Examples of identified global values: appearance, beliefs, personality traits. Decisional values were related to the process of decision-making. External values related to asking advice from for example, the clinician or significant others. An identified situational value: a new job ahead. Contexts related to how the illness impacted the life (eg, sexuality, family, sports, work life) of patients.

CONCLUSIONS

The operationalisation of PPE, an important aspect of SDM, explores which preferences, values and contexts were discussed during patient-clinician interactions where an ePDA was used. The coding scheme appeared feasible to apply but needs further refinement.

Whole-cycle management of women with epilepsy of child-bearing age: ontology construction and application

BACKGROUND

The effective management of epilepsy in women of child-bearing age necessitates a concerted effort from multidisciplinary teams. Nevertheless, there exists an inadequacy in the seamless exchange of knowledge among healthcare providers within this context. Consequently, it is imperative to enhance the availability of informatics resources and the development of decision support tools to address this issue comprehensively.

MATERIALS AND METHODS

The development of the Women with Epilepsy of Child-Bearing Age Ontology (WWECA) adhered to established ontology construction principles. The ontology's scope and universal terminology were initially established by the development team and subsequently subjected to external evaluation through a rapid Delphi consensus exercise involving domain experts. Additional entities and attribute annotation data were sourced from authoritative guideline documents and specialized terminology databases within the respective field. Furthermore, the ontology has played a pivotal role in steering the creation of an online question-and-answer system, which is actively employed and assessed by a diverse group of multidisciplinary healthcare providers.

RESULTS

WWECA successfully integrated a total of 609 entities encompassing various facets related to the diagnosis and medication for women of child-bearing age afflicted with epilepsy. The ontology exhibited a maximum depth of 8 within its hierarchical structure. Each of these entities featured three fundamental attributes, namely Chinese labels, definitions, and synonyms. The evaluation of WWECA involved 35 experts from 10 different hospitals across China, resulting in a favorable consensus among the experts. Furthermore, the ontology-driven online question and answer system underwent evaluation by a panel of 10 experts, including neurologists, obstetricians, and gynecologists. This evaluation yielded an average rating of 4.2, signifying a positive reception and endorsement of the system's utility and effectiveness.

CONCLUSIONS

Our ontology and the associated online question and answer system hold the potential to serve as a scalable assistant for healthcare providers engaged in the management of women with epilepsy (WWE). In the future, this developmental framework has the potential for broader application in the context of long-term management of more intricate chronic health conditions.

Shared decision making in older people after severe stroke

Stroke is a major cause of death and lifelong disability. Although stroke treatments have improved, many patients are left with life-changing deficits. Shared decision making and consent are fundamental to good medical practice. This is challenging because stroke often causes mental incapacity, prior views might not be known and prognosis early after stroke is often uncertain. There are no large trials of shared decision making after severe stroke, so we need to rely on observational data to inform practice. Core ethical principles of autonomy, beneficence, non-maleficence and justice must underpin our decision making. 'Surrogate' decision makers will need to be involved if a patient lacks capacity, and prior expressed views and values and beliefs need to be taken into account in decision making. Patients and surrogates often feel shocked at the sudden nature of stroke, and experience grief including anticipatory grief. Health care professionals need to acknowledge these feelings and provide support, be clear about what decisions need to be made and provide sufficient information about the stroke, and the risks and benefits of treatments being considered. Shared decision making can be emotionally difficult for health care professionals and so working in a supportive environment with compassionate leadership is important. Further research is needed to better understand the nature of grief and what sort of psychological support would be most helpful. Large randomised trials of shared decision making are also needed.

Neurosurgical perioperative management of frail elderly patients

With the rapid increase in global aging, the prevalence of frailty is increasing and frailty has emerged as an emerging public health burden. Frail elderly patients suffer from reduced homeostatic reserve capacity, which is associated with a disproportionate decline in physical status after exposure to stress and an increased risk of adverse events. Frailty is closely associated with changes in the volume of the white and gray matter of the brain. Sarcopenia has been suggested to be an important component of frailty, and reductions in muscle strength and muscle mass lead to reductions in physical function and independence, which are critical factors contributing to poor prognosis. Approximately 10-32% of patients undergoing neurological surgery are frail, and the risk of frailty increases with age, which is significantly associated with the occurrence of adverse postoperative events (major complications, total duration of hospitalization, and need for discharge to a nursing facility). The postoperative mortality rate in severely frail patients is 9-11 times higher than that in non-frail individuals. Therefore, due attention must be paid to neurosurgical frailty and muscle assessment in elderly patients. Specialized interventions in the perioperative period of neurosurgery in frail elderly patients may improve their postoperative prognosis.

A tension between surrendering and being involved: An interview study on person-centeredness in clinical reasoning in the acute stroke setting

OBJECTIVE

To explore how stroke survivors experience and prefer to participate in clinical reasoning processes in the acute phase of stroke care.

METHODS

An explorative qualitative design was used. Individual interviews were conducted with 11 stroke survivors in the acute phase of care and analyzed using reflexive thematic analysis.

RESULTS

The analysis identified five themes: What's going on with me?; Being a recipient of care and treatment; The need to be supported to participate; To be seen and strengthened; and Collaboration and joint understanding.

CONCLUSION

Stroke survivors experience many attributes of person-centeredness in the acute phase of care but, according to their stories, their participation in clinical reasoning can be further supported. The tension between surrendering and the desire to be more actively involved in the care needs to be considered to facilitate participation in clinical reasoning.

PRACTICE IMPLICATIONS

Stroke survivors' participation in clinical reasoning in the acute phase can be facilitated by health professionals noticing signs prompting a shift towards increased willingness to participate. Furthermore, health professionals need to take an active role, sharing their expertise and inviting the stroke survivors to share their perspective. The findings can contribute to further develop person-centered care in acute settings.

A Qualitative Study of the Values, Needs, and Preferences of Patients Regarding Stroke Care: The ValueCare Study

Introduction

An in-depth understanding of patient perspectives contributes to high-quality, value-based health care. The aim of this study was to explore the values, needs, and preferences of stroke patients across the continuum of care.

Methods

We performed a qualitative study, as part of the larger ValueCare study, involving 36 patients who have had ischemic stroke within the past 18 months at the time of recruitment. Data were collected between December 2020 and April 2021 via one-to-one telephone interviews. All interviews were audio-taped and transcribed verbatim. The interview data were analysed using a thematic approach.

Results

The analysis resulted in five themes: (1) patients' values about health care, (2) information and education, (3) psychological support, (4) follow-up care, and (5) continuity and coordination of care. Patients valued a compassionate professional who is responsive to their needs. Furthermore, patients indicated a need for tailored health information, psychosocial services, pro-active follow-up care and improved coordination of care.

Discussion and conclusion

Stroke patients emphasised the need for tailored information, psychological support, pro-active follow-up, and improved coordination of care. It is advocated for professionals to use a value-based care approach in order to satisfy the individual needs of patients with regard to information, communication, and follow-up care.

Shared Decision-Making to Improve Health-Related Outcomes for Adults with Stroke Disease

Stroke is one of the leading causes of disability and death worldwide, a severe medical condition for which new solutions for prevention, monitoring, and adequate treatment are needed. This paper proposes a SDM framework for the development of innovative and effective solutions based on artificial intelligence in the rehabilitation of stroke patients by empowering patients to make decisions about the use of devices and applications developed in the European project ALAMEDA. To develop a predictive tool for improving disability in stroke patients, key aspects of stroke patient data collection journeys, monitored health parameters, and specific variables covering motor, physical, emotional, cognitive, and sleep status are presented. The proposed SDM model involved the training and consultation of patients, medical staff, carers, and representatives under the name of the Local Community Group. Consultation with LCG members, consists of 11 representative people, physicians, nurses, patients and caregivers, which led to the definition of a methodological framework to investigate the key aspects of monitoring the patient data collection journey for the stroke pilot, and a specific questionnaire to collect stroke patient requirements and preferences. A set of general and specific guidelines specifying the principles by which patients decide to use wearable sensing devices and specific applications resulted from the analysis of the data collected using the questionnaire. The preferences and recommendations collected from LCG members have already been implemented in this stage of ALAMEDA system design and development.

Getting to know our patients and what matters: exploring the elicitation of patient values, preferences, and circumstances in neurological rehabilitation

PURPOSE

Patient values, preferences, and circumstances are critical to decision-making in both patient-centred and evidence-based practice models of healthcare. Despite the established importance of integrating these patient attributes, the ways they are elicited in rehabilitation remain unclear. This study aimed to explore how health professionals elicit and share patients' 'values', 'preferences', and 'circumstances', and what they understand by the terms.

METHODS

This exploratory qualitative descriptive study used interviews with 13 clinicians from interprofessional teams in inpatient neurological rehabilitation. Data were analysed using a general inductive approach.

RESULTS

Participants understood 'values' to mean what is important and meaningful; 'preferences' as likes/dislikes and choices; and 'circumstances' as the social, physical, and environmental context surrounding the person. Formal and informal strategies were used to gather information directly from patients or indirectly from other sources. The processes of eliciting and communicating this information were influenced by relationships and relied on contributions from many people. Elicitation involved a flexible approach tailored to the individual and considering each unique context.

CONCLUSION

The strategies used and the approach used to implement these strategies were both essential to eliciting patient values, preferences, and circumstances in neurological rehabilitation. These findings offer insights into the practices of interprofessional rehabilitation clinicians. Implications for rehabilitationEliciting patient values, preferences, and circumstances involves a combination of strategies and approaches that are applied gradually throughout the continuum of rehabilitation.These processes are flexible, and strategies should be tailored to individual patients/families and phases of rehabilitation.Clinicians should be attentive to informal opportunities to gather valuable information throughout rehabilitation.Establishing positive relationships and using effective communication is foundational to these processes.

A procedure for predicting, illustrating, communicating, and optimizing patient-centered outcomes of epilepsy surgery using nomograms and Bayes' theorem

Clinicians have an ethical obligation to obtain and convey relevant information about possible treatment outcomes in a manner that can be comprehended by patients. This contributes to the processes of informed consent and shared prospective decision-making. In epilepsy neurosurgery, there has historically been an emphasis on studying clinician-centered (e.g., seizure- and cognition-related) outcomes and using these data to inform recommendations and, by extension, to frame pre-surgical counseling with respect to patients' decisions about elective neurosurgery. In contrast, there is a relative dearth of available data related to patient-centered outcomes of epilepsy neurosurgery, such as functional (e.g., employment) status, and there is also a lack of methods to communicate these data to patients. Here, illustrated using a hypothetical case scenario, we present a potential solution to the latter of these problems using principles of evidence-based neuropsychology; published data on patient employment status before and after epilepsy neurosurgery; and Bayes' theorem. First, we reviewed existing literature on employment outcomes following epilepsy neurosurgery to identify and extract data relevant to our hypothetical patient, clinical question, and setting. Then, we used the base rate (prior probability) of post-surgical unemployment, contingency tables (to derive likelihood ratios), and Bayes' theorem to compute the conditional (posterior) probability of post-surgical employment status for our hypothetical patient scenario. Finally, we translated this information to an intuitive visual format (Bayesian nomogram) that can support evidence-based pre-surgical counseling. We propose that the application of our patient-centered decision-support process and visual aid will improve clinician-patient communication about prospective risks and benefits of epilepsy neurosurgery and will empower clinicians and patients to make informed decisions about whether or not to pursue elective neurosurgery with a greater degree of confidence and with more realistic and concrete expectations about possible outcomes. We further propose that clinicians and patients would benefit from incorporating this evidence-based framework into a broader sequence of function-focused epilepsy treatment that includes pre-surgical assessments and interventions ("prehabilitation"), neurosurgery, and post-surgical cognitive/vocational rehabilitation.

Ability of patients with acute ischemic stroke to recall given information on intravenous thrombolysis: Results of a prospective multicenter study

Introduction:

Intravenous thrombolysis (IVT) is an on label treatment for selected patients with acute ischemic stroke (AIS). As major bleeding or allergic shock may occur, the need to ensure patients’ informed consent for IVT is a matter of debate.

Patients and methods:

Prospective investigator-initiated multi-center observational study to assess the ability of AIS patients to recall information, provided by a physician during a standardized educational talk (SET) on IVT use. The recall of 20 pre-defined items was assessed in AIS after 60–90 min ( n = 93) or 23–25 h ( n = 40) after SET. About 40 patients with subacute stroke, 40 non-stroke patients, and 23 relatives of AIS patients served as controls, and were surveyed 60–90 min after SET.

Results:

Within 60–90 min after SET, AIS patients (median age 70 years, 31% female, median NIHSS score on admission 3 points) who were considered capable to provide informed consent recalled 55% (IQR 40%–66.7%) of the provided SET items. In multivariable linear regression analysis recapitulation by AIS patients was associated with their educational level (β = 6.497, p < 0.001), self-reported excitement level (β = 1.879, p = 0.011) and NIHSS score on admission (β = −1.186, p = 0.001). Patients with subacute stroke (70 years, 40% female, median NIHSS = 2) recalled 70% (IQR 55.7%–83.6%), non-stroke patients (75 years, 40% female) 70% (IQR 60%–78.7%), and AIS relatives (58 years, 83% female) 70% (IQR 60%–85%). Compared to subacute stroke patients, AIS patients less often recalled the frequency of IVT-related bleeding (21% vs 43%), allergic shock (15% vs 39%), and bleeding-related morbidity and mortality (44% vs 78%). AIS patients recalled 50% (IQR 42.3%–67.5%) of the provided items 23–25 h after SET.

Conclusion:

AIS patients eligible for IVT remember about half of all SET-items after 60–90 min or 23–25 h, respectively. The fact that the recapitulation of IVT-associated risks is particularly poor should be given special consideration.

Decision-making aids for upper limb interventions in neurological rehabilitation: a scoping review

PURPOSE

To summarise the range and nature of decision-making aids that guide upper limb (UL) neurorehabilitation.

METHODS

Our scoping review followed Arksey and O'Malley's 6-step framework. Electronic databases were systematically searched; grey literature was hand-searched. Included papers were: (1) published in English; (2) related to UL rehabilitation for people with upper motor neuron conditions; and (3) provided a description of, or research on, a decision-making aid that guides therapists when choosing between two or more intervention approaches, techniques, or applications of a technique. Levels of evidence were rated. An expert panel of occupational therapists working in UL neurorehabilitation was consulted.

RESULTS

The 24 included articles described 15 decision-making aids with varying breadth and depth of the assessment process and suggested interventions. Six aids had published research, but lacked high quality evidence. The expert panel identified four key decision-making aids as being clinically useful. Preferred aids either included client-centred goal-setting within a holistic assessment or matched specific intervention options to distinct UL assessment results. Prompts to re-evaluate client performance are desirable.

CONCLUSION

Few decision-making aids guide therapists to holistically assess and make specific intervention decisions across all domains of UL neurorehabilitation. Their usefulness depends on the purpose, setting, and therapist experience.Implications for rehabilitationConsidering the complexity and heterogeneity of upper limb (UL) neurorehabilitation, a selection of evidence-based and purpose-designed decision-making aids may assist therapists across different experience levels and practice settings to choose individualised interventions.Decision-making aids for UL interventions in neurorehabilitation may be more clinically useful if they include a holistic and client-centred information gathering process that focuses on daily life goals.Decision-making aids should illustrate a clear clinical picture based on UL assessment results, with corresponding UL intervention recommendations provided.Inclusion of a cyclic process to re-evaluate client performance and function could also enhance the usefulness of a decision-making aid.

Prognosis Predictions by Families, Physicians, and Nurses of Patients with Severe Acute Brain Injury: Agreement and Accuracy

BACKGROUND

Effective shared decision-making relies on some degree of alignment between families and the medical team regarding a patient's likelihood of recovery. Patients with severe acute brain injury (SABI) are often unable to participate in decisions, and therefore family members make decisions on their behalf. The goal of this study was to evaluate agreement between prognostic predictions by families, physicians, and nurses of patients with SABI regarding their likelihood of regaining independence and to measure each group's prediction accuracy.

METHODS

This observational cohort study, conducted from 01/2018 to 07/2020, was based in the neuroscience and medical/cardiac intensive care units of a single center. Patient eligibility included a diagnosis of SABI-specifically stroke, traumatic brain injury, or hypoxic ischemic encephalopathy-and a Glasgow Coma Scale ≤ 12 after hospital day 2. At enrollment, families, physicians, and nurses were asked separately to predict a patient's likelihood of recovering to independence within 6 months on a 0-100 scale, regardless of whether a formal family meeting had occurred. True outcome was based on modified Rankin Scale assessment through a family report or medical chart review. Prognostic agreement was measured by (1) intraclass correlation coefficient; (2) mean group prediction comparisons using paired Student's t-tests; and (3) prevalence of concordance, defined as an absolute difference of less than 20 percentage points between predictions. Accuracy for each group was measured by calculating the area under a receiver operating characteristic curve (C statistic) and compared by using DeLong's test.

RESULTS

Data were collected from 222 patients and families, 45 physicians, and 103 nurses. Complete data on agreement and accuracy were available for 187 and 177 patients, respectively. The intraclass correlation coefficient, in which 1 indicates perfect correlation and 0 indicates no correlation, was 0.49 for physician-family pairs, 0.40 for family-nurse pairs, and 0.66 for physician-nurse pairs. The difference in mean predictions between families and physicians was 23.5 percentage points (p < 0.001), 25.4 between families and nurses (p < 0.001), and 1.9 between physicians and nurses (p = 0.38). Prevalence of concordance was 39.6% for family-physician pairs, 30.0% for family-nurse pairs, and 56.2% for physician-nurse pairs. The C statistic for prediction accuracy was 0.65 for families, 0.82 for physicians, and 0.76 for nurses. The p values for differences in C statistics were < 0.05 for family-physician and family-nurse groups and 0.18 for physician-nurse groups.

CONCLUSIONS

For patients with SABI, agreement in predictions between families, physicians, and nurses regarding likelihood of recovery is poor. Accuracy appears higher for physicians and nurses compared with families, with no significant difference between physicians and nurses.

Development of a patient decision aid for discharge planning of hospitalized patients with stroke

Background

Patient involvement in discharge planning of patients with stroke can be accomplished by providing personalized outcome information and promoting shared decision-making. The aim of this study was to develop a patient decision aid (PtDA) for discharge planning of hospitalized patients with stroke.

Methods

A convergent mixed methods design was used, starting with needs assessments among patients with stroke and health care professionals (HCPs). Results of these assessments were used to develop the PtDA with integrated outcome information in several co-creation sessions. Subsequently, acceptability and usability were tested to optimize the PtDA. Development was guided by the International Patient Decision Aids Standards (IPDAS) criteria.

Results

In total, 74 patients and 111 HCPs participated in this study. A three-component PtDA was developed, consisting of:

1) a printed consultation sheet to introduce the options for discharge destinations, containing information that can be specified for each individual patient;

2) an online information and deliberation tool to support patient education and clarification of patient values, containing an integrated “patients-like-me” model with outcome information about discharge destinations;

3) a summary sheet to support actual decision-making during consultation, containing the patient’s values and preferences concerning discharge planning.

In the acceptability test, all qualifying and certifying IPDAS criteria were fulfilled. The usability test showed that patients and HCPs highly appreciated the PtDA with integrated outcome information.

Conclusions

The developed PtDA was found acceptable and usable by patients and HCPs and is currently under investigation in a clinical trial to determine its effectiveness.

Experiences with information provision and preferences for decision making of patients with acute stroke

OBJECTIVE

The aim of this study was to gain insight into experiences of patients with acute stroke regarding information provision and their preferred involvement in decision-making processes during the initial period of hospitalisation.

METHODS

A sequential explanatory design was used in two independent cohorts of patients with stroke, starting with a survey after discharge from hospital (cohort 1) followed by observations and structured interviews during hospitalisation (cohort 2). Quantitative data were analysed descriptively.

RESULTS

In total, 72 patients participated in this study (52 in cohort 1 and 20 in cohort 2). During hospitalisation, the majority of the patients were educated about acute stroke and their treatment. Approximately half of the patients preferred to have an active role in the decision-making process, whereas only 21% reported to be actively involved. In cohort 2, 60% of the patients considered themselves capable to carefully consider treatment options.

CONCLUSIONS

Active involvement in the acute decision-making process is preferred by approximately half of the patients with acute stroke and most of them consider themselves capable of doing so. However, they experience a limited degree of actual involvement.

PRACTICE IMPLICATIONS

Physicians can facilitate patient engagement by explicitly emphasising when a decision has to be made in which the patient's opinion is important.

Ethical considerations in the management of poststroke aphasia

From the onset of the first signs of stroke, patients are faced with a chain of events that requires quick decision-making to ensure that lifesaving care is administered. Considering that acute stroke is often associated with altered mental status and changes in cognitive-linguistic abilities, ethical dilemmas may arise when patients are unable to provide input in their own care and must rely on surrogate decision-makers to act on their behalf. Although the most critical, lifesaving decisions are made acutely, for the patients who go on to have residual chronic cognitive-linguistic deficits, loss of language, and/or impaired cognition may mean that a healthcare power of attorney or other proxy is needed to assist with medical decision-making. This chapter discusses ethical concerns surrounding the care of stroke survivors, with a focus on how poststroke cognitive-linguistic deficits can complicate this topic; clinical recommendations are provided.

Intravenous Thrombolysis After First-Ever Ischemic Stroke and Reduced Incident Dementia Rate

BACKGROUND AND PURPOSE

The use of intravenous thrombolysis is associated with improved clinical outcomes. Whether thrombolysis is associated with reduced incidence of poststroke dementia remains uncertain. We sought to estimate if the use of thrombolysis following first-ever ischemic stroke was associated with a reduced rate of incident dementia using a pragmatic observational design.

METHODS

We included first-ever ischemic stroke patients from the Ontario Stroke Registry who had not previously been diagnosed with dementia. The primary outcome was incident dementia ascertained by a validated diagnostic algorithm. We employed inverse probability of treatment-weighted Cox proportional hazard models to estimate the cause-specific hazard ratio for the association of thrombolysis and incident dementia at 1 and 5 years following stroke.

RESULTS

From July 2003 to March 2013, 7072 patients with ischemic stroke were included, 3276 (46.3%) were female and mean age was 71.0 (SD, 12.8) years. Overall, 38.2% of the cohort (n=2705) received thrombolysis, 77.2% (n=2087) of which was administered within 3 hours of stroke onset. In the first year following stroke, thrombolysis administration was associated with a 24% relative reduction in the rate of developing dementia (cause-specific hazard ratio, 0.76 [95% CI, 0.58-0.97]). This association remained significant at 5 years (cause-specific hazard ratio, 0.79 [95% CI, 0.66-0.91]) and at the end of follow-up (median 6.3 years; cause-specific hazard ratio, 0.79 [95% CI, 0.68-0.89]).

CONCLUSIONS

Thrombolysis administration following first-ever ischemic stroke was independently associated with a reduced rate of dementia. Incident dementia should be considered as a relevant outcome when evaluating risk/benefit of thrombolysis in ischemic stroke patients.

Effects of Telerehabilitation on Patient Adherence to a Rehabilitation Plan: Protocol for a Mixed Methods Trial

Background

Strong evidence supports beginning stroke rehabilitation as soon as the patient’s medical status has stabilized and continuing following discharge from acute care. However, adherence to rehabilitation treatments over the rehabilitation phase has been shown to be suboptimal.

Objective

The aim of this study is to assess the impact of a telerehabilitation platform on stroke patients’ adherence to a rehabilitation plan and on their level of reintegration into normal social activities, in comparison with usual care. The primary outcome is patient adherence to stroke rehabilitation (up to 12 weeks), which is hypothesized to influence reintegration into normal living. Secondary outcomes for patients include functional recovery and independence, depression, adverse events related to telerehabilitation, use of services (up to 6 months), perception of interprofessional shared decision making, and quality of services received. Interprofessional collaboration as well as quality of interprofessional shared decision making will be measured with clinicians.

Methods

In this interrupted time series with a convergent qualitative component, rehabilitation teams will be trained to develop rehabilitation treatment plans that engage the patient and family, while taking advantage of a telerehabilitation platform to deliver the treatment. The intervention will be comprised of 220 patients who will take part in stroke telerehabilitation with an interdisciplinary group of clinicians (telerehabilitation group) versus face-to-face standard of care (control group: n=110 patients).

Results

Our Research Ethics Board approved the study in June 2020. Data collection for the control group is underway, with another year planned before we begin the intervention phase.

Conclusions

This study will contribute to the minimization of both knowledge and practice gaps, while producing robust, in-depth data on the factors related to the effectiveness of telerehabilitation in a stroke rehabilitation continuum. Findings will inform best practice guidelines regarding telecare services and the provision of telerehabilitation, including recommendations for effective interdisciplinary collaboration regarding stroke rehabilitation.

Trial Registration

ClinicalTrials.gov NCT04440215; https://clinicaltrials.gov/ct2/show/NCT04440215

International Registered Report Identifier (IRRID)

DERR1-10.2196/32134

Involvement of Specialist Palliative Care in a Stroke Unit in Austria-Challenges for Families and Stroke Teams

Purpose: Severe stroke poses vast challenges. Appropriate goals of care according to individual preferences and values have to be developed under time restrictions—often impeded by limited ability to communicate and the need for decisions by surrogates. The aim of our study was to explore the decision-making process and the involvement of specialist palliative care in the acute phase of severe stroke.

Methods: Twenty patients suffering from severe ischemic stroke treated in an Austrian acute inpatient stroke unit were included in a prospective study. Their families were interviewed with a questionnaire (FS-ICU 24), which covered satisfaction with care and decision-making. With a second questionnaire, decision-making processes within the stroke team were investigated.

Results: A palliative approach and early integration of specialist palliative care in severe ischemic stroke results in individualized therapeutic goals, including withholding therapeutic or life-sustaining measures, especially in patients with pre-existing illness.

Conclusions: Family members benefit from understandable and consistent information, emotional support, and a professional team identifying their needs. Stroke unit professionals need skills as well as knowledge and strategies in order to make decisions and provide treatment at the end-of-life, when there may be ethical or legal issues. Close cooperation with specialist palliative care services supports both treatment teams and families with communication and decision-making for patients with severe ischemic stroke.

Factors Associated With Patient Engagement in Shared Decision-Making for Stroke Prevention Among Older Adults with Atrial Fibrillation

OBJECTIVE

To examine the extent of, and factors associated with, patient engagement in shared decision-making (SDM) for stroke prevention among patients with atrial fibrillation (AF).

METHODS

We used data from the Systematic Assessment of Geriatric Elements-Atrial Fibrillation study which includes older ( ≥65 years) patients with AF and a CHA2DS2-VASc≥2. Participants reported engagement in SDM by answering whether they actively participated in choosing to take an oral anticoagulant (OAC) for their condition. Multiple logistic regression was used to assess associations between sociodemographic, clinical, geriatric, and psychosocial factors and patient engagement in SDM.

RESULTS

A total of 807 participants (mean age 75 years; 48% female) on an OAC were studied. Of these, 61% engaged in SDM. Older participants (≥80 years) and those cognitively impaired were less likely to engage in SDM, while those very knowledgeable of their AF associated stroke risk were more likely to do so than respective comparison groups.

CONCLUSIONS

A considerable proportion of older adults with AF did not engage in SDM for stroke prevention with older patients and those cognitively impaired less likely to do so. Clinicians should identify patients who are less likely to engage in SDM, promote patient engagement, and foster better patient-provider communication which may enhance long-term patient outcomes.

Palliative care after stroke: A review

BACKGROUND

Palliative care is an integral aspect of stroke unit care. In 2016, the American Stroke Association published a policy statement on palliative care and stroke. Since then there has been an expansion in the literature on palliative care and stroke.

AIM

Our aim was to narratively review research on palliative care and stroke, published since 2015.

RESULTS

The literature fell into three broad categories: (a) scope and scale of palliative care needs, (b) organization of palliative care for stroke, and (c) shared decision making. Most literature was observational. There was a lack of evidence about interventions that address specific palliative symptoms or improve shared decision making. Racial disparities exist in access to palliative care after stroke. There was a dearth of literature from low- and middle-income countries.

CONCLUSION

We recommend further research, especially in low- and middle-income countries, including research to explore why racial disparities in access to palliative care exist. Randomized trials are needed to address specific palliative care needs after stroke and to understand how best to facilitate shared decision making.

The Experiences of Couples Affected by Stroke and Nurses Managing Patient Rehabilitation: A Descriptive Study in Singapore

BACKGROUND

Stroke in a family affects both patients and their spousal caregivers. Despite advances in the medical management of stroke, less is known about the social and cultural factors that impact couples regarding stroke recovery.

PURPOSE

The purpose of this study was to explore the experiences of stroke from the perspectives of couples affected by stroke and the nurses managing patient rehabilitation.

METHODS

An interpretive descriptive study was conducted. Purposive sampling was used to enroll 17 participants, comprising eight nurses, five spousal caregivers, and four stroke survivors. Individual, in-depth interviews were performed at a rehabilitation hospital in Singapore in June 2018.

RESULTS

The primary theme was the diverse meanings of stroke recovery attributed to limited conversations about the care decisions made by couples and rehabilitation nurses. The second theme was the challenges in nursing responsibilities that hindered the recovery of patients with stroke.

CONCLUSIONS/IMPLICATIONS FOR PRACTICE

The meaning of recovery differs between patients and their informal and formal care providers. This issue should be explored in patient-provider conversations, as these conversations highlight the values and preferences that affect the stroke recovery trajectory. Enhancing shared decision making by patients, spousal caregivers, and healthcare providers during the stroke trajectory may promote the alignment of values that are critical to the stroke recovery experience. Further research into whether and how to incorporate shared decision making in rehabilitation hospital settings as an interventional component is warranted to better support stroke survivors before discharge.

"Everyone needs rehab, but…": exploring post-stroke rehabilitation referral and acceptance decisions

PURPOSE

To explore the decision-making processes and experiences of acute and rehabilitation clinicians, regarding referral and acceptance of patients to rehabilitation after stroke.

MATERIALS AND METHODS

Multi-site rapid ethnography, involving observation of multidisciplinary case conferences, interviews with acute stroke and rehabilitation clinicians, and review of key documents within five (5) acute stroke units (ASUs) in Queensland, Australia. A cyclical, inductive content analysis was performed.

RESULTS

Seven key themes were identified, revealing the complex nature of post-stroke rehabilitation referral and acceptance decision making. Although the majority of clinicians felt that all patients could benefit from rehabilitation, they acknowledged this could not always be the case. Rehabilitation potential and goals were considered by clinicians, but decision making was impacted by ASU context and team processes, rehabilitation service availability and access procedures, and the relationships between the acute and rehabilitation clinicians. Patients and families were not actively involved in the decision-making processes.

CONCLUSIONS

Post-stroke rehabilitation decision making in Queensland, Australia involves complex processes and compromise. Decisions are not based solely on patients' rehabilitation needs, and patients and families are not actively involved in the decision-making process. Mechanisms are required to streamline access procedures, and improve shared decision making with patients.IMPLICATIONS FOR REHABILITATIONReferral decision making for post-stroke rehabilitation is complex and not always based solely on patients' needs.Clear and straightforward access procedures and positive relationships between acute and rehabilitation clinicians have a positive impact on referral decision making.Stroke services should review their processes to ensure shared decision making is facilitated when patients require access to rehabilitation.

The Experiences and Evaluation of a Complex Intervention for Couples Coping With Stroke

ABSTRACT

BACKGROUND: Globally, stroke is a leading cause of death and disability. With a strong sense of filial responsibility, Asian caregivers are committed to caring for their ill family members. In response, the 3H (Head, Heart, Hands) intervention was developed and implemented in Singapore to support couples in their coping after a stroke. The purpose of this study is to explore the experiences of the participants taking part in the 3H intervention and evaluate the intervention after they had participated in it. METHODS: An interpretive descriptive design was used. Semistructured qualitative interviews were conducted with 7 patients and 7 spousal caregivers. Data were analyzed using conventional content analysis. RESULTS: The participants' experience was described as one of becoming more prepared to face the storm. The "storm" resulted from a stroke, where the participants were worried and uncertain about their future. After participating in the intervention, the couples' coping processes had improved. They coped by breaking the silence and engaging in conversations, cultivating a sense of support, and conveniently fulfilling their educational needs. It was evaluated that extending the 3H intervention for community nursing is necessary to strengthen the care transition of couples from the hospital to home. CONCLUSION: New knowledge has been gained that the 3H intervention is useful and may be implemented in a clinical context before a patient's discharge from hospital. As a result of participating in the 3H intervention, effective coping was evident where participants engaged in conversations, cultivated a sense of support, and fulfilled their educational needs. Primary healthcare professionals should pay more attention to the difficulties and needs of this group of people, provide more resources to support them, and improve their quality of life.

The cognitive augmented mobility program (CAMP): feasibility and preliminary efficacy

BACKGROUND

Best evidence suggests incorporating task-specific training, aerobics, and strengthening to improve mobility and gait in persons with stroke (PWS). Related research suggests incorporating cognitive problem-solving strategy training may lead to better skill maintenance and transfer. The present study examined the feasibility and preliminary outcomes of an evidence-based cognitive augmented mobility program (CAMP) for PWS.

METHODS

A single-arm pre-post and follow-up design was conducted, in two blocks (NCT03683160). Participants completed an exercise intervention with an integrated cognitive strategy component and had weekly 1:1 sessions with a physiotherapist trained in Cognitive Orientation to daily Occupational Performance (CO-OP), focusing on goal practice and cognitive strategy use. CAMP consisted of a pre-intervention education and goal-setting session and 16 90-minute sessions held in a group format, 2x/wk for 8 weeks. Assessments were conducted 1 week prior to beginning the intervention, 1 week post-intervention, and at a 4-5 week follow-up.

RESULTS

CAMP was found to be feasible with 96% session attendance and strong participant satisfaction. Pre to post-CAMP intervention, a large effect was found for endurance (r = 0.53), balance (r = 0.59), mobility (r = 0.63) and goal attainment (r = 0.63) indicators, and large effects were maintained at follow-up for balance, mobility, and goal attainment. A medium effect was found for functional independence (r = 0.38), gait speed (r = 0.39), and balance confidence (r = 0.38). A small effect was found for participation (r = 0.27) and overall stroke recovery (r = 0.25).

CONCLUSIONS

Preliminary results suggest CAMP is feasible; there may be a beneficial effect of combining best evidence for mobility and fitness with cognitive strategy training. The positive results for skill maintenance and transfer suggest further investigation is warranted.

The considerations, experiences and support needs of family members making treatment decisions for patients admitted with major stroke: a qualitative study

Background

Treatment decision-making by family members on behalf of patients with major stroke can be challenging because of the shock of the diagnosis and lack of knowledge of the patient’s treatment preferences. We aimed to understand how, and why, family members made certain treatment decisions, and explored their information and support needs.

Method

Semi-structured interviews with family members (n = 24) of patients with major stroke, within 2 weeks of hospital admission. Data were analysed thematically.

Results

Families’ approach to treatment decision-making lay on a spectrum according to the patient’s state of health pre-stroke (i.e. patient’s prior experience of illness and functional status) and any views expressed about treatment preferences in the event of life-threatening illness. Support and information needs varied according to where they were on this spectrum. At one extreme, family members described deciding not to initiate life-extending treatments from the outset because of the patients’ deteriorating health and preferences expressed pre-stroke. Information from doctors about poor prognosis was merely used to confirm this decision. In the middle of the spectrum were family members of patients who had been moderately independent pre-stroke. They described the initial shock of the diagnosis and how they had initially wanted all treatments to continue. However, once they overcame their shock, and had gathered relevant information, including information about poor prognosis from doctors, they decided that life-extending treatments were no longer appropriate. Many reported this process to be upsetting and expressed a need for psychological support. At the other end of the spectrum were family members of previously independent patients whose preferences pre-stroke had not been known. Family members described feeling extremely distressed at such an unexpected situation and wanting all treatments to continue. They described needing psychological support and hope that the patient would survive.

Conclusion

The knowledge that family members’ treatment decision-making approaches lay on a spectrum depending on the patient’s state of health and stated preferences pre-stroke may allow doctors to better prepare for discussions regarding the patient’s prognosis. This may enable doctors to provide information and support that is tailored towards family members’ needs.

Implementing a shared decision-making and cognitive strategy-based intervention: Knowledge user perspectives and recommendations

The aim of this study was to employ knowledge user perspectives to develop recommendations that facilitate implementation of a complex, shared decision-making (SDM)-based intervention in an interprofessional setting. This study was part of a larger knowledge translation (KT) study in which interprofessional teams from five freestanding, academically affiliated, rehabilitation hospitals were tasked with implementing a cognitive strategy-based intervention approach that incorporates SDM known as Cognitive Orientation to daily Occupational Performance (CO-OP) to treat survivors of stroke. At the end of the 4-month CO-OP KT implementation support period, 10 clinicians, two from each site, volunteered as CO-OP site champions. A semi-structured focus group was conducted with 10 site champions 3 months following the implementation support period. To meet the study objective, an exploratory qualitative research design was used. The focus group session was audio-recorded, transcribed verbatim and analyzed through the lens of the integrated promoting action on research implementation in health services (iPARIHS) framework. The focus group participants (n = 8) consisted of occupational therapists, physical therapists, and speech language pathologists. Ten recommendations for CO-OP implementation were extracted and co-constructed from the focus group transcript. The recommendations reflected all four iPARHIS constructs: Facilitation, Context, Innovation, and Recipients. Implementation recommendations, from the knowledge user perspective, highlight that context-specific facilitation is key to integrating a novel, complex intervention into interprofessional practice. Facilitators should lay out a framework for training, communication and implementation that is structured but still provides flexibility for iterative learning and active problem-solving within the relevant practice context.

Factors related to met needs for rehabilitation 6 years after stroke

INTRODUCTION

Research on stroke rehabilitation mainly concerns the first year of recovery, and there is a lack of knowledge regarding long-term rehabilitation needs and associated factors.

AIM

The aim was to explore the perceived needs for rehabilitation services of people six years after stroke and factors associated with having rehabilitation services needs met.

METHODS

The study was a 6-year follow up of a prospective study on the rehabilitation process after stroke. Data on perceived needs for rehabilitation, personal factors, disease specific factors, and patient-reported disability were collected through face-to-face interviews in the participants' homes. Logistic regression models were created to explore associations between having rehabilitation services needs met in 11 problem areas (dependent variable) and the independent variables: involvement in decisions regarding care and treatment, sex, age, sense of coherence, self-defined level of private financing, stroke severity, frequency of social everyday activities, perceived impact of stroke, and life satisfaction.

RESULTS

The 121 participants had a mean age of 63 years at stroke onset and 58% were men. In all problem areas the majority (53-88%) reported having needs met at six years after stroke, however 47% reported unmet needs regarding fatigue and 45% regarding mobility. A lower perceived impact on participation was found to be associated with having rehabilitation services needs met in seven problem areas: mobility, falls, pain, fatigue, concentration, memory, and sight. The strongest association for having needs met was found for the independent variable, involvement in care and treatment, within the three problem areas mobility, falls, and speaking.

CONCLUSION

In a long-term perspective, there were several modifiable factors associated with having rehabilitation services needs met. The most prominent were perceived involvement in care and treatment, and perceived participation. These factors had a stronger association with having rehabilitation services needs met than disease specific factors six years after stroke.

Should We Judge Stroke Risk by Static or Dynamic Risk Scores? A Focus on the Dynamic Nature of Stroke and Bleeding Risks in Patients With Atrial Fibrillation

Atrial fibrillation (AF) is the most prevalent cardiac arrhythmia and a major risk factor for stroke. The number of patients with AF is predicted to increase in the next few decades. AF has also negative impact on quality of life as well as it significantly increases the risk of cardiovascular disease and overall mortality. Because the stroke is a pivotal outcome of AF, its prevention with the use of anticoagulation therapy constitutes an important component of AF management. The decision on oral anticoagulants' prescription should be based on appropriate risk stratification to allow for comprehensive assessment of benefit/hazard ratio of stroke and bleeding along with patients' preference. Several risk scores for stroke and bleeding as well as for stroke and systemic embolism have been developed, mainly in patients on vitamin K antagonists. AF guidelines stress the need for repetitive evaluation of thromboembolic and bleeding risks to tailor optimal AF management. Indeed, risk is not a static "one off" process and it should be adjusted for dynamic nature of risk factors. However, most risk scores are calculated according to baseline characteristics of patients, but the older the patients get, the more comorbidities they acquire, which influences stroke risk significantly. Hence, the default management of every patient with AF should include a regular reassessment of stroke and bleeding risk factors.

Psychometric properties of the Arabic version of the 9-item Shared Decision-Making Questionnaire: the entire process from translation to validation

OBJECTIVE

To translate the German 9-item Shared Decision-Making Questionnaire (SDM-Q-9) to Arabic and assess its psychometric properties for measuring Arabic-speaking patients' perceptions of the shared decision-making (SDM) process.

DESIGN

Multicentre cross-sectional study.

SETTING

Secondary healthcare settings; outpatient clinics of 10 major hospitals were selected in four emirates in the United Arab Emirates (Abu Dhabi, Dubai, Sharjah and Umm Al Quwain).

PARTICIPANTS

Patients with chronic diseases who attended outpatient clinics of participating hospitals.

MEASUREMENTS

The original German SDM-Q-9 was translated to Arabic. International multiphase translation guidelines and the process of cross-cultural adaptation of self-reported measures were used. Various psychometric properties were assessed, including reliability (internal consistency), and construct validity (exploratory factor analysis [EFA] and confirmatory factor analysis [CFA]).

RESULTS

The final Arabic version of the SDM-Q-9 was tested among 516 secondary care patients. Internal consistency yielded a Cronbach's alpha of 0.929 for the whole scale. EFA showed a one-factorial solution, Kaiser-Meyer-Olkin measure of sampling adequacy was 0.907 and Bartlett's test of sphericity was significant (χ2=3413.69, df=36, p<0.0005). For the CFA, two different models were tested; Model 1 included the nine items and Model 2 was monofactorial that included items 2-9 and thus excluded item 1. Both models were adequate as they produced similar indices.

CONCLUSIONS

The Arabic version of SDM-Q-9 showed excellent reliability and acceptable validity parameters among secondary care patients. The newly translated Arabic questionnaire is the first psychometrically tested tool that can be used in the 22 member states of the Arab league to assess patients' perspectives on the SDM process.

Implementing a function-based cognitive strategy intervention within inter-professional stroke rehabilitation teams: Changes in provider knowledge, self-efficacy and practice

BACKGROUND

The Cognitive Orientation to daily Occupational Performance (CO-OP) approach is a complex rehabilitation intervention in which clients are taught to use problem-solving cognitive strategies to acquire personally-meaningful functional skills, and health care providers are required to shift control regarding treatment goals and intervention strategies to their clients. A multi-faceted, supported, knowledge translation (KT) initiative was targeted at the implementation of CO-OP in inpatient stroke rehabilitation teams at five freestanding rehabilitation hospitals. The study objective was to estimate changes in rehabilitation clinicians' knowledge, self-efficacy, and practice related to implementing CO-OP.

METHODS

A single arm pre-post and 6-month follow up study was conducted. CO-OP KT consisted of a 2-day workshop, 4 months of implementation support, a consolidation session, and infrastructure support. In addition, a sustainability plan was implemented. Consistent with CO-OP principles, teams were given control over specific implementation goals and strategies. Multiple choice questions (MCQ) were used to assess knowledge. A self-efficacy questionnaire with 3 subscales (Promoting Cognitive Strategy Use, PCSU; Client-Focused Therapy, CFT; Top-Down Assessment and Treatment, TDAT) was developed for the study. Medical record audits were used to investigate practice change. Data analysis for knowledge and self-efficacy utilized mixed effects models. Medical record audits were analyzed with frequency counts and chi-squares.

RESULTS

Sixty-five health care providers consisting mainly of occupational and physical therapists entered the study. Mixed effects models revealed intervention effects for MCQs, CFT, and PCSU at post intervention and follow-up, but no effect on TDAT. No charts showed any evidence of CO-OP use at baseline, compared to 8/40 (20%) post intervention. Post intervention there was a trend towards reduction in impairment goals and significantly more component goals were set (z = 2.7, p = .007).

Shared decision making in mild cognitive impairment

Shared decision making (SDM) occurs when patients and clinicians consider patients' values and preferences while discussing medical evidence to inform healthcare decisions. SDM enables patients with mild cognitive impairment (MCI) to express values and preferences when making current healthcare decisions and presents a unique opportunity to inform future decision making in the case of further cognitive decline. However, clinicians often fail to facilitate SDM with patients with MCI. This review describes research pertaining to value solicitation, weighing of the medical evidence, and medical decision making for individuals with MCI, explores the role of caregivers, identifies barriers to and facilitators of SDM in MCI, and suggests strategies to optimize SDM for persons with MCI in neurology clinical practice. Further research is needed to identify more strategies for decision support for individuals affected by cognitive impairment.

Patients' preferences for new versus old anticoagulants: a mixed-method vignette-based study

BACKGROUND

For both patients and clinicians, differences between older and new anticoagulants have major implications for treatment selection, day-to-day management of therapy and adherence.

AIMS

To explore patients' preferences for warfarin versus direct oral anticoagulant (DOAC) therapy.

METHODS

Mixed-method study involving anticoagulated older patients admitted to hospital. Part A comprised a vignette-based questionnaire; patients were asked whether they preferred Medicine A (warfarin) or Medicine B (DOAC). Part B interviews explored patients' satisfaction with their current anticoagulant. Responses were thematically analysed.

RESULTS

Forty patients participated: 23 warfarin-treated, 17 DOAC-treated. Collectively, Parts A and B identified that most patients were satisfied with their current therapy (warfarin or DOAC), expressing reluctance to change to alternatives. Among patients who were able to numerically rate their satisfaction with therapy, most were 'satisfied' with their current anticoagulant, although warfarin-treated patients were slightly less 'satisfied' (median score 3.5) than those on DOACs (median score 5.0). Despite this, warfarin-treated patients still preferred their current therapy (over DOACs) due to familiarity and the security of regular international normalised ratio (INR) monitoring; those who preferred DOACs cited previous warfarin-related bleeding and unstable INRs as key reasons. DOAC-treated patients who preferred warfarin perceived regular monitoring as a major advantage; only those having had negative experiences with warfarin clearly preferred DOACs.

CONCLUSION

Most patients accepted their currently prescribed anticoagulant, be it warfarin or DOACs. Features of specific anticoagulants, such as regular monitoring with warfarin, were perceived variably - some patients cited them as advantages and others as disadvantages. The clearest preference identified was for the agent already being taken.