Acceptability of two mobile applications to support cross-sectoral, person-centred and empowering stroke rehabilitation - a process evaluation

AIM

To evaluate the acceptability of two co-designed mobile applications Mit Sygehus [a knowledge-based solution] and Genoptræn.dk [a self-training solution] to support a cross-sectoral, person-centred and empowering stroke rehabilitation.

SETTING

The applications were implemented and tested throughout two stroke rehabilitation trajectories in Southern Denmark, comprising two acute, two sub-acute and two municipal stroke rehabilitation settings.

METHODS, PARTICIPANTS AND ANALYSIS

A process evaluation focusing on acceptability was conducted. Individual and dyadic interviews were performed with ten stroke survivors (three women and seven men, aged 50-84) with moderate stroke and seven significant others (five women and two men, aged 50-78) post-rehabilitation. A constructivist Grounded Theory analysis was used to explore what, why, when, and how the apps worked or did not work throughout the stroke rehabilitation trajectory and if adaptions were needed.

RESULTS

Participants found that Mit Sygehus provided adequate and sufficient knowledge and was easy to use, however, acceptability of Mit Sygehus declined throughout the rehabilitation process. Also, knowledge on 'return-to-work' and 're-gaining driver's license/permission to drive' needed to be developed. The content in Genoptræn.dk was perceived as acceptable, through content being person-centred, motivating and meaningful. Genoptræn.dk furthermore, supported the transfer between rehabilitation settings, provided a sense of progress throughout the rehabilitation process, facilitated positive habits regarding self-training, and relieved the burden on significant others. Genoptræn.dk was perceived most acceptable in the sub-acute rehabilitation setting and declined when rehabilitation continued in the municipal setting.

CONCLUSION

Stroke survivors and their significant others found Mit Sygehus and Genoptræn.dk acceptable to support cross-sectoral, person-centred and empowering stroke rehabilitation, however acceptability declined throughout the rehabilitation process. Further investigations are required to determine how cognitive rehabilitation can play a greater role in app-supported stroke rehabilitation and how the need for more long-term follow-up can be supported.

In search of self after stroke: a longitudinal qualitative study in the context of client-centred rehabilitation

PURPOSE

The aim was to illuminate the experiences of stroke survivors returning to everyday life in the year following stroke, in the context of client-centred rehabilitation.

METHODS

Four men who participated in a client-centred rehabilitation program were followed during the first year after stroke. Semi-structured interviews were conducted, allbut the first in the participants' home. The data were analysed using a grounded theory approach.

RESULTS

The results revealed a process with the overarching core category; The "new" self becomes reality through challenging everyday experiences, and five main categories driving the process: 1) Striving for structure in a "new" chaotic world, 2) Homecoming an ambiguous experience, 3) Reaching the "new" self through reflections of self-understanding, 4) Socialising in new circumstances, and 5) Realising a new reality.

CONCLUSIONS

While in hospital, stroke survivors can have unrealistic expectations. When at home they can begin to realise their actual capacity . To find a "new" self after a stroke can involve time-consuming and taxing processes of reflections of self-understanding. Engagement in self-selected meaningful and valued activities can support stroke survivors' reconstruction of the "new" self but not all stroke survivors may succeed in finding their "new" self during the first year after stroke.

Which items of the modified Barthel Index can predict functional independence at discharge from inpatient rehabilitation? A secondary analysis retrospective cohort study

The modified Barthel Index (mBI) is a well-established patient-centered outcome measure commonly administrated in rehabilitation settings to evaluate the functional status of patients at admission and discharge. This study aimed to detect which mBI items collected on admission can predict the total mBI at discharge from first inpatient rehabilitation in large cohorts of orthopedic (n = 1864) and neurological (n = 1684) patients. Demographic and clinical data (time since the acute event 11.8 ± 17.2 days) at patients' admission and mBI at discharge were collected. Univariate and multiple binary logistic regressions were performed to study the associations between independent and dependent variables for each cohort separately. In neurological patients, the shorter time between the acute event and rehabilitation admission, shorter length of stay, and being independent with feeding, personal hygiene, bladder, and transfers were independently associated with higher total mBI at discharge (R 2  = 0.636). In orthopedic patients, age, the shorter time between the acute event and rehabilitation admission, shorter length of stay, and being independent with personal hygiene, dressing, and bladder were independently associated with higher total mBI at discharge (R 2  = 0.622). Our results showed that different activities in neurological (i.e. feeding, personal hygiene, bladder, and transfer) and orthopedic sample (i.e. personal hygiene, dressing, and bladder) are positively associated with better function (measured by mBI) at the discharge. Clinicians have to take into account these predictors of functionality when they plan an appropriate rehabilitation treatment.

Referral-based transition to subsequent rehabilitation at home after stroke: one-year outcomes and use of healthcare services

Background

There is a lack of knowledge about patients’ journeys across the stroke care continuum, especially regarding the transition from inpatient to outpatient care and rehabilitation. Therefore, the aim of the present study was to explore and describe patterns of healthcare use over a one-year period, health outcomes at 3 and 12 months for patients following a referral-based transition to subsequent rehabilitation in the home, and the caregiver burden on their significant others. A further aim was to explore factors associated with the use of rehabilitation and healthcare after the referral-based transition to continued rehabilitation in the home for people recovering from a stroke.

Methods

Data regarding healthcare use during the first 12 months post-stroke was collected from the Region Stockholm computerized register. Data on patient characteristics, disease-related data, and functioning were retrieved drawn from medical records and questionnaires. Descriptive statistics were used to present healthcare use, participants’ characteristics, disease-related data, and patient functioning. Multivariable regression models were created to explore associations between the total number of outpatient contacts, total visits with the neurorehabilitation team, and the independent variables.

Results

The mean age for the 190 participants was 73 years for men and 78 years for women. Twenty-one participants (11%) had an acute rehospitalization within 30 days after discharge, and 41 participants (21%) were re-hospitalized within 90 days. Twenty-two (12%) of the participants had no visits with the neurorehabilitation team, 73 (39%) participants had 1–3 visits, 57 (30%) had 4–16 visits, and 38 (20%) had ≥17 visits. Female sex and length of hospital stay were associated with a higher number of visits with the neurorehabilitation team. Living alone, higher self-rated recovery, and being able to walk independently were associated with a lower number of visits with the neurorehabilitation team. Female sex, having home help services before the stroke, longer length of hospital stay, and more comorbidities were associated with a higher number of outpatient contacts.

Conclusions

The findings indicate that there is no generic pattern of healthcare use during the first-year post-stroke in patients receiving referral-based transition to continued rehabilitation in the home. The different patterns of healthcare use seemed to mirror the participants’ level of functioning. However, there is a need to further investigate how follow-up and rehabilitation correspond to the needs of patients and their significant others in the short- and long-term perspective.

Trial registration

ClinicalTrials.gov, registration number: NCT02925871. Date of registration: October 6, 2016.

Person-centred care transitions for people with stroke: study protocol for a feasibility evaluation of codesigned care transition support

BACKGROUND

Care transitions following stroke should be bridged with collaboration between hospital staff and home rehabilitation teams since well-coordinated transitions can reduce death and disability following a stroke. However, health services are delivered within organisational structures, rather than being based on patients' needs. The aim of this study protocol is to assess the feasibility, operationalised here as fidelity and acceptability, of a codesigned care transition support for people with stroke.

METHODS

This study protocol describes the evaluation of a feasibility study using a non-randomised controlled design. The codesigned care transition support includes patient information using videos, leaflets and teach back; what-matters-to me dialogue; a coordinated rehabilitation plan; bridged e-meeting; and a message system for cross-organisational collaboration. Patients with stroke, first time or recurrent, who are to be discharged home from hospital and referred to a rehabilitation team in primary healthcare for continued rehabilitation in the home will be included. One week after stroke, data will be collected on the primary outcome, namely satisfaction with the care transition support, and on the secondary outcome, namely health literacy and medication adherence. Data on use of healthcare will be obtained from a register of healthcare contacts. The outcomes of patients and significant others will be compared with matched controls from other geriatric stroke and acute stroke units, and with matched historic controls from a previous dataset at the intervention and control units. Data on acceptability and fidelity will be assessed through interviews and observations at the intervention units.

ETHICS AND DISSEMINATION

Ethical approvals have been obtained from the Swedish Ethical Review Authority. The results will be published open-access in peer-reviewed journals. Dissemination also includes presentation at national and international conferences.

DISCUSSION

The care transition support addresses a poorly functioning part of care trajectories in current healthcare. The development of this codesigned care transition support has involved people with stroke, significant other, and healthcare professionals. Such involvement has the potential to better identify and reconceptualise problems, and incorporate user experiences.

TRIAL REGISTRATION NUMBER

http://www.clinicaltrials.gov id: NCT02925871. Date of registration 6 October 2016.

PROTOCOL VERSION

1.

Dependency in Activities of Daily Living During the First Year After Stroke

Background: Dependency in personal activities of daily living (ADL) is a common short-term and long-term consequence of stroke and requires targeted rehabilitation. As the duration of hospital stay has become shorter in recent decades, early identification of patients who require rehabilitation has become vital. To our knowledge, no study has investigated whether ADL dependency in the very early stages after admission to the stroke unit can explain ADL dependency 3 and 12 months later. This knowledge would facilitate planning for very early discharge and patient-centered rehabilitation.

Objective: This study evaluated whether ADL dependency within 2 days after stroke could explain ADL dependency at 3 and 12 months after stroke.

Methods: This longitudinal cohort study included patients with stroke who were treated at a stroke unit in the Sahlgrenska University Hospital (Gothenburg, Sweden) between May 2011 and March 2016. The primary independent variable was ADL dependency at 36–48 h after admission to the stroke unit, which was assessed using a Barthel Index (BI) score of ≤90. The dependent variables were self-reported personal ADL dependency at 3 and 12 months after stroke. Binary logistic regression analyses were performed.

Results: Of 366 eligible patients (58% male; median age 71 years), a majority (76%) had mild stroke and 60% were ADL dependent 36–48 h after stroke. Univariable and multivariable logistic regression analyses showed that patients who were dependent within the first 2 days after stroke had higher odds for being dependent 3 months as well as 12 months after stroke.

Conclusion: The results indicated that dependency in personal ADL during the first 2 days can explain dependency at 3- and 12-month post-stroke. Therefore, early ADL assessments post-stroke can be used for understanding rehabilitation needs after stroke.

Perceived Quality of Care Transitions between Hospital and the Home in People with Stroke

OBJECTIVES

To explore the perceived quality of care transitions from hospital to the home with referral to subsequent rehabilitation in the home, and factors associated with low perceived quality, in people with stroke.

DESIGN

Observational study.

SETTING AND PARTICIPANTS

Eligible were patients with a suspected acute stroke admitted to 1 of 4 inpatient hospital units in the Stockholm region and discharged home with referral to a neurorehabilitation team in primary care.

METHODS

Data on perceived quality of care transition was collected with the Care Transition Measure (CTM-15) 1 week after discharge. Additional data were mainly retrieved from medical records. To analyze difference in mean total score of the CTM-15 between participants' characteristics, length of hospital stay, disease-related data, and functioning, the Mann-Whitney U test and independent sample t test were used for dichotomized variables and 1-way analysis of variance and the Tukey post hoc test for variables with more than 2 groups. To analyze differences between participants with low and high perceived quality per item, univariable regression analyses were performed. Thereafter, multivariable regression models were created to explore associations between low perceived quality and the independent variables.

RESULTS

Mean age of the 189 participants was 75 years and 91% had a mild or very mild stroke. The majority perceived most areas of the care transition to be of high quality. Nevertheless, several areas for improvement were identified. People with a more severe stroke perceived the quality of the care transition to be lower in comparison with those with a mild stroke. The association was weak between patient or clinical characteristics and the perceived quality.

CONCLUSION AND IMPLICATIONS

Our findings suggest that preparation for discharge and information and support for self-management postdischarge should be enhanced in the referral-based care transition after stroke. Special attention should be given to people with severe stroke.

Mobile Geriatric Teams - A Cost-Effective Way Of Improving Patient Safety And Reducing Traditional Healthcare Utilization Among The Frail Elderly? A Randomized Controlled Trial

Background

Demographic changes combined with costly technological progress put a financial strain on the healthcare sector in the industrialized world. Hence, there is a constant need to develop new cost-effective treatment procedures in order to optimize the use of available resources. As a response, the concept of a Mobile Geriatric Team (MGT) has emerged not only nationally but also internationally during the last decade; however, scientific evaluation of this initiative has been very scarce. Thus, the objective of this study was to perform a mixed methods analysis, including a prospective, controlled and randomized quantitative evaluation, in combination with an interview-based qualitative assessment, to measure the effectiveness and user satisfaction of MGT.

Materials and methods

Community-dwelling, frail elderly people were randomized to an intervention group (n=31, mean age 84) and a control group (n=31, mean age 86). A two-year retrospective quantitative data collection and a prospective one-year follow-up on healthcare utilization were combined with qualitative interviews. Non-parametric statistics and difference-in-difference (DiD) analyses were applied to the quantitative data. Qualitative data were analyzed using content analysis.

Results

No significant group differences in healthcare utilization were found before inclusion. Post intervention, primary care contact (including MGTs) increased for the MGT group. Inpatient care decreased dramatically for both groups. Hence, the increase in primary care contact for MGT patients was not accompanied by a reduction in inpatient care compared to the control group. Utilization of non-primary care was lower (p< 0.01) post-intervention in both groups.

Conclusion

There appears to be a "natural" variation in healthcare needs over time among frail elderly people. Hence, it is vital to perform open, controlled clinical studies in tandem with the implementation of new caregiving strategies. The MGT initiative was clearly appreciated but did not fully achieve the desired reduction in healthcare utilization in this study.

Trial registration

Retrospectively registered 09/10/2018, ClinicalTrials.gov ID NCT03662945.

Guidelines for Adult Stroke Rehabilitation and Recovery: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association

PURPOSE

The aim of this guideline is to provide a synopsis of best clinical practices in the rehabilitative care of adults recovering from stroke.

METHODS

Writing group members were nominated by the committee chair on the basis of their previous work in relevant topic areas and were approved by the American Heart Association (AHA) Stroke Council's Scientific Statement Oversight Committee and the AHA's Manuscript Oversight Committee. The panel reviewed relevant articles on adults using computerized searches of the medical literature through 2014. The evidence is organized within the context of the AHA framework and is classified according to the joint AHA/American College of Cardiology and supplementary AHA methods of classifying the level of certainty and the class and level of evidence. The document underwent extensive AHA internal and external peer review, Stroke Council Leadership review, and Scientific Statements Oversight Committee review before consideration and approval by the AHA Science Advisory and Coordinating Committee.

RESULTS

Stroke rehabilitation requires a sustained and coordinated effort from a large team, including the patient and his or her goals, family and friends, other caregivers (eg, personal care attendants), physicians, nurses, physical and occupational therapists, speech-language pathologists, recreation therapists, psychologists, nutritionists, social workers, and others. Communication and coordination among these team members are paramount in maximizing the effectiveness and efficiency of rehabilitation and underlie this entire guideline. Without communication and coordination, isolated efforts to rehabilitate the stroke survivor are unlikely to achieve their full potential.

CONCLUSIONS

As systems of care evolve in response to healthcare reform efforts, postacute care and rehabilitation are often considered a costly area of care to be trimmed but without recognition of their clinical impact and ability to reduce the risk of downstream medical morbidity resulting from immobility, depression, loss of autonomy, and reduced functional independence. The provision of comprehensive rehabilitation programs with adequate resources, dose, and duration is an essential aspect of stroke care and should be a priority in these redesign efforts. (Stroke.2016;47:e98-e169. DOI: 10.1161/STR.0000000000000098.).

Activity limitations experienced by people with stroke who receive inpatient rehabilitation: differences between 2001, 2005, and 2011

OBJECTIVE

To determine whether there were differences in characteristics and activity limitations relevant to physiotherapists among people receiving inpatient rehabilitation after stroke in 2001, 2005, and 2011.

DESIGN

A multicenter observational study of 3 periods.

SETTING

Inpatient rehabilitation units (N=15).

PARTICIPANTS

Adult stroke survivors (N=738) admitted over 3 periods (2001, 2005, 2011).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Characteristics, hospital metrics, and Motor Assessment Scale (MAS) scores were recorded on admission and discharge.

RESULTS

All 3 cohorts were similar in terms of sex, side affected by stroke, and length of time from stroke onset to rehabilitation admission. Stroke participants in the 2005 cohort were older than those in the 2011 and 2001 cohorts. Participants in the 2011 cohort had a longer inpatient rehabilitation length of stay, experienced lower average MAS gains per day (F>3.298, P<.038), and experienced more activity limitations in basic functional tasks involving bed mobility, standing up, and sitting balance on admission and discharge, and in walking and arm function at discharge only compared with earlier cohorts.

CONCLUSIONS

In 2011, on average, people admitted for rehabilitation after stroke were approximately the same age as patients in 2005 and 2001 and it took approximately 2 weeks for all of these patients to be admitted to a rehabilitation unit, but patients in 2011 had a longer inpatient rehabilitation length of stay compared with patients in 2005 and 2001. In addition, activity limitations at inpatient rehabilitation admission and discharge appear to be worse, particularly for activities such as rolling, sitting up over the edge of the bed, and balanced sitting.

What aspects of rehabilitation provision contribute to self-reported met needs for rehabilitation one year after stroke--amount, place, operator or timing?

Background and Objective

To a large extent, people who have suffered a stroke report unmet needs for rehabilitation. The purpose of this study was to explore aspects of rehabilitation provision that potentially contribute to self‐reported met needs for rehabilitation 12 months after stroke with consideration also to severity of stroke.

Methods

The participants (n = 173) received care at the stroke units at the Karolinska University Hospital, Sweden. Using a questionnaire, the dependent variable, self‐reported met needs for rehabilitation, was collected at 12 months after stroke. The independent variables were four aspects of rehabilitation provision based on data retrieved from registers and structured according to four aspects: amount of rehabilitation, service level (day care rehabilitation, primary care rehabilitation and home‐based rehabilitation), operator level (physiotherapist, occupational therapist, speech therapist) and time after stroke onset. Multivariate logistic regression analyses regarding the aspects of rehabilitation were performed for the participants who were divided into three groups based on stroke severity at onset.

Results

Participants with moderate/severe stroke who had seen a physiotherapist at least once during each of the 1st, 2nd and 3rd–4th quarters of the first year (OR 8.36, CI 1.40–49.88 P = 0.020) were more likely to report met rehabilitation needs.

Conclusion

For people with moderate/severe stroke, continuity in rehabilitation (preferably physiotherapy) during the first year after stroke seems to be associated with self‐reported met needs for rehabilitation.