Uncovering treatment burden as a key concept for stroke care: a systematic review of qualitative research

Experiences and challenges of people living with multiple long-term conditions in managing their care in primary care settings in Kerala, India: A qualitative study

BACKGROUND

Multimorbidity or multiple long-term conditions (MLTCs), the coexistence of two or more chronic conditions within an individual, presents a growing concern for healthcare systems and individuals' well-being. However, we know little about the experiences of those living with MLTCs in low- and middle-income countries (LMICs) such as India. We explore how people living with MLTCs describe their illness, their engagements with healthcare services, and challenges they face within primary care settings in Kerala, India.

METHODS

We designed a qualitative descriptive study and conducted in-depth, semi-structured interviews with 31 people (16 males and 15 females) from family health centres (FHCs) in Kerala. Interview data were recorded, transcribed, and thematic analysis using the Framework Method was undertaken.

FINDINGS

Two main themes and three sub-themes each were identified; (1) Illness impacts on life (a)physical issues (b) psychological difficulties (c) challenges of self-management and (2) Care-coordination maze (a)fragmentation and poor continuity of care (b) medication management; an uphill battle and (c) primary care falling short. All participants reported physical and psychological challenges associated with their MLTCs. Younger participants reported difficulties in their professional lives, while older participants found household activities challenging. Emotional struggles encompassed feelings of hopelessness and fear rooted in concerns about chronic illness and physical limitations. Older participants, adhering to Kerala's familial support norms, often found themselves emotionally distressed by the notion of burdening their children. Challenges in self-management, such as dietary restrictions, medication adherence, and physical activity engagement, were common. The study highlighted difficulties in coordinating care, primarily related to traveling to multiple healthcare facilities, and patients' perceptions of FHCs as fit for diabetes and hypertension management rather than their multiple conditions. Additionally, participants struggled to manage the task of remembering and consistently taking multiple medications, which was compounded by confusion and memory-related issues.

CONCLUSION

This study offers an in-depth view of the experiences of individuals living with MLTCs from Kerala, India. It emphasizes the need for tailored and patient-centred approaches that enhance continuity and coordination of care to manage complex MLTCs in India and similar LMICs.

'The burden is very much on yourself': A qualitative study to understand the illness and treatment burden of hearing loss across the life course

INTRODUCTION

Hearing loss is a chronic health condition that rises sharply with age. The way people respond to and cope with health conditions is influenced by their capacity to perform illness and treatment-related work. The aim was to explore the cumulative burdens of living with hearing loss and the resources mobilised to ease the burdens.

METHODS

A qualitative design was used with semi-structured interviews (online or in-person) with participants recruited through audiology services and nonclinical services, such as lip-reading classes. Forty-six participants with hearing loss aged between 16 and 96 years were interviewed. An abductive approach, informed by May et al.'s burden of treatment theory, was used to analyse the data.

RESULTS

The illness burden involved participants working to make sense of their hearing loss, engaging in emotional work in response to changes in sound, social interactions and identity and coping with the daily frustrations required to communicate with others. Abandonment and uncertainty characterised the treatment burden; participants engaged in emotional work to adjust to hearing technology and deal with the uncertainty of how their hearing might progress. To ameliorate the burdens, participants drew on internal resources (psychological, health literacy, cognitive) and external resources (social support, financial, information, technology).

CONCLUSIONS

The workload of hearing loss appears largely devolved to the patient and is not always visible. Our work indicates the need to widen approaches in audiological care through the implementation of lifeworld-led care, family-centred care and peer support to build support for those with hearing loss.

PATIENT OR PUBLIC CONTRIBUTION

We developed the project in consultation with members of the public who have lived experience of hearing loss recruited through Aston University and volunteer links to audiology services. We also consulted people more likely to be affected by hearing loss adults including adults with learning disabilities, older adults in residential care and people from South Asia (Bangladeshi, Indian and Pakistani communities). These individuals commented on the study aims, interview schedule and participant recruitment practices. One of our co-authors (expert by experience) contributed to the development and interpretation of themes and preparation of the final manuscript.

Exploring the experience of cognitive changes among community-dwelling stroke survivors: a qualitative study

PURPOSE

Cognitive deficits are common among stroke survivors and impact their functional independence. Despite the prevalence of cognitive deficits after stroke, cognitive function is largely overlooked in post-stroke care. The aim of this qualitative study was to explore the experiences of individuals living with post-stroke cognitive changes to understand the impact of these changes on their daily lives.

MATERIALS AND METHODS

Semi-structured interviews were conducted with a purposeful sample of thirteen community-dwelling adults 50 years and older with chronic stroke who self-identified cognitive changes post-stroke. Interviews were transcribed and an inductive thematic analysis was completed.

RESULTS

Four key themes were identified: 1) inability to maintain everyday activities; 2) experiencing emotional responses to living with post-stroke cognitive changes; 3) a shrinking social world and; 4) seeking care for cognitive health post-stroke.

CONCLUSIONS

Post-stroke cognitive changes were described by participants as a driving force behind negative shifts in their daily lives, emotional health, and social connections after stroke. Despite seeking care for their post-stroke cognitive changes, many participants were unable to find support in mainstream healthcare. There is a demonstrated need to further elucidate the gaps in care for post-stroke cognitive deficits and implement community interventions targeting cognitive health post-stroke.

A multidisciplinary approach to improve adherence to medical recommendations in older adults at hospital discharge: The APPROACH study protocol

INTRODUCTION

Poor comprehension and medication adherence are common in older people, especially after hospitalizations, in case of changes or prescriptions of new therapeutic regimes. This randomized controlled trial aims to evaluate the effectiveness of an integrated approach in improving older individuals' adherence to medical recommendations after hospital discharge.

METHODS

Data from an expected sample of 360 older inpatients (and their caregivers) will be collected. Medical recommendations' understanding will be tested before and after the routine explanation received by in-charge physicians. Participants will be randomized in the control (usual care) and intervention group. The intervention consists of educational training by a multidisciplinary team (occupational therapist, dietician, and physician, in consultation with a pharmacologist) at hospital discharge and, after hospital discharge, receiving a phone recall checking for therapy adherence and having the possibility to contact the study team for potential related concerns. After 7 days, medication adherence will be assessed through structured phone interviews comparing ongoing and prescribed medications and by administering the 4-item validated Morisky, Green, Levine scale and the Medication adherence report scale (MARS-5). At 30 and 90 days from discharge, data on medication adherence, falls, rehospitalizations, and vital status will be collected through phone interviews and hospital records.

TRIAL REGISTRATION

Registration: NCT05719870 (clinicaltrial.gov). https://classic.clinicaltrials.gov/ct2/show/NCT05719870.

Relationship between medication burden and medication experience in stable patients with schizophrenia: the mediating effect of medication belief

BACKGROUND

Individuals with schizophrenia require prolonged antipsychotic medication treatment. But more than 50% of individuals with schizophrenia experience adverse medication experiences during their antipsychotic treatments. Such individuals often adjust or discontinue medication, leading to disease relapse and impaired social functioning. Psychiatric nurses should pay close attention to the medication experiences of individuals with schizophrenia. This research explore the relationship between medication burden and medication experience, as well as the mediating effect of medication belief in stable patients with schizophrenia.

METHODS

A convenience sample of hospitalized stable patients with schizophrenia were selected from Daqing Third Hospital and Baiyupao Hospital from September 2023 to December 2023. A survey was conducted with them using a questionnaire consisting of general information questionnaire, The Subjective Well-being Under Neuroleptic Treatment Scale(SWN), The Living with Medicines Questionnaire(LMQ), Beliefs about Medicines Questionnaire-Specific (BMQ-Specific). Pearson correlation analysis was used to explore the correlation between LMQ, BMQ-Specific and SWN scores, and multiple linear regression analysis was used to explore the influencing factors of medication experience in patients with schizophrenia. AMOS 24.0 was used to construct the structural equation modeling(SEM), and the mediation effect of the SEM was tested using Bootstrap method.

RESULTS

According to the sample size calculation requirements of structural equation model, a total of 300 samples were required in this study, and 400 effective questionnaires were actually collected in this study, which met the sample size requirements for constructing structural equation models. Bootstrap test showed that the mediation effect was significant. The total effect of medication burden on medication experience was significant (Z=-12.146, 95%CI (-0.577, -0.417), P < 0.001). The indirect effect of medication burden on medication experience, that is, the mediating effect of medication belief was significant (Z=-4.839, 95%CI (-0.217, -0.096), P < 0.001). The direct effect of medication burden on medication experience was significant (Z=-7.565, 95%CI (-0.437, -0.257), P < 0.001). This model belongs to partial mediation model.

CONCLUSIONS

Psychiatric nurses can enhance the patients' medication experience by reducing medication burden and strengthening medication beliefs. Therefore, the results also provide theoretical references and decision-making foundations for psychiatric nursing professionals to develop appropriate management strategies for individuals with schizophrenia.

Treatment burden and regimen fatigue among patients with HIV and diabetes attending clinics of Tikur Anbessa specialized hospital

Nascent studies showed that patients with chronic medical illnesses such as diabetes mellitus (DM) and HIV/AIDS are highly vulnerable to face both treatment burden and regimen fatigue. However, an attempt made so far in this sphere in sub-Saharan African health care context is dearth. Thus, this study aimed to determine the level of treatment burden and regimen fatigue of diabetic and HIV patients attending adult diabetic and ART clinics of TASH and explore patients' and health care workers' propositions to reduce treatment burden and regimen fatigue. An explanatory sequential mixed methods study was conducted at the adult HIV and DM clinics of TASH, Addis Ababa, Ethiopia from February 01-March 30, 2022. Simple random and purposive sampling techniques were employed to select participants for quantitative and qualitative studies, respectively. Descriptive analysis was done to summarize the quantitative data. Logistic and linear regression analyses were performed to identify predictors of treatment burden and regimen fatigue, respectively. P value < 0.05 was considered statistically significant. Qualitative data was analyzed by using a thematic analysis. A total of 300 patients (200 diabetes and 100 HIV) were included in the quantitative study. For the qualitative study, 14 patients and 10 health care workers (six nurses and four medical doctors) were included. Participants' mean global Treatment Burden Questionnaire (TBQ) and Treatment Regimen Fatigue Scale (TRFS) score were 28.86 ± 22.13 and - 42.82 ± 17.45, respectively. Roughly, 12% of patients experienced a high treatment burden. The presence of two or more comorbidities (adjusted odds ratio [AOR] = 7.95, 95% confidence interval [CI] 1.59-39.08), daily ingestion of more than five types of prescribed medications (AOR = 6.81, 95%CI 1.59-29.14), and good knowledge about DM and/or HIV (AOR = 0.33, 95%CI 0.12-0.92) were predictors of treatment burden. Poor availability of medications (β = 0.951, p < 0.001) was the only predictor of regimen fatigue. Patients and health care workers primarily proposed to foster self-care efficacy, advance administrative services of the clinic and hospital, and improve healthcare system provision. The findings of this study unveiled that a considerable proportion of patients experienced low levels of treatment burden and regimen fatigue. This study showed that boosting the patients' self-care efficacy, upgrading administrative services of the clinic and hospital, and promoting the healthcare system provision had enormous significance in reducing treatment burden and regimen fatigue. Therefore, when designing patient-specific healthcare interventions for both HIV and diabetic patients' various factors affecting both treatment burden and regimen fatigue should be considered to achieve the desired goals of therapy.

"Coming home was a disaster, I didn't know what was going to happen": a qualitative study of survivors' and family members' experiences of navigating care post-stroke

PURPOSE

Understanding navigational barriers and facilitators has the potential to advance equitable stroke care delivery. The aim of this study was to explore, using a qualitative study, the experiences of stroke survivors and their families as they journey through the stroke care system, both before and during the COVID-19 pandemic.

METHODS

In-depth semi-structured interviews were conducted with 18 stroke survivors and 12 family members during 2021 and 2022. Participants were recruited through voluntary organisations, social media, and stroke support groups. Data analysis followed a systematic process guided by the framework method with steps including familiarisation, coding, framework development, and charting and interpretation.

RESULTS

The experiences of navigating stroke care were particularly challenging following discharge from hospital into the community. Barriers to stroke care continuity included insufficient appropriate services and information, unsatisfactory relationships with healthcare professionals and distressed mental health. There were particular navigational challenges for survivors with aphasia. Facilitators to effective navigation included having prior knowledge of the health system, harnessing support for care co-ordination, and being persistent.

CONCLUSION

Greater support for patient navigation, and person-centred referral pathways, particularly during times of increased pressure on the system, have the potential to improve access to services and wellbeing among stroke survivors.

Supporting translation of research evidence into practice-the use of Normalisation Process Theory to assess and inform implementation within randomised controlled trials: a systematic review

BACKGROUND

The status of randomised controlled trials (RCTs) as the 'gold standard' for evaluating efficacy in healthcare interventions is increasingly debated among the research community, due to often insufficient consideration for implementation. Normalisation Process Theory (NPT), which focuses on the work required to embed processes into practice, offers a potentially useful framework for addressing these concerns. While the theory has been deployed in numerous RCTs to date, more work is needed to consolidate understanding of if, and how, NPT may aid implementation planning and processes within RCTs. Therefore, this review seeks to understand how NPT contributes to understanding the dynamics of implementation processes within RCTs. Specifically, this review will identify and characterise NPT operationalisation, benefits and reported challenges and limitations in RCTs.

METHODS

A qualitative systematic review with narrative synthesis of peer-reviewed journal articles from eight databases was conducted. Studies were eligible for inclusion if they reported sufficient detail on the use of NPT within RCTs in a healthcare domain. A pre-specified data extraction template was developed based on the research questions of this review. A narrative synthesis was performed to identify recurrent findings.

RESULTS

Searches identified 48 articles reporting 42 studies eligible for inclusion. Findings suggest that NPT is primarily operationalised prospectively during the data collection stage, with limited sub-construct utilisation overall. NPT is beneficial in understanding implementation processes by aiding the identification and analysis of key factors, such as understanding intervention fidelity in real-world settings. Nearly three-quarters of studies failed to report the challenges and limitations of utilising NPT, though coding difficulties and data falling outside the NPT framework are most common.

CONCLUSIONS

NPT appears to be a consistent and generalisable framework for explaining the dynamics of implementation processes within RCTs. However, operationalisation of the theory to its full extent is necessary to improve its use in practice, as it is currently deployed in varying capacities. Recommendations for future research include investigation of NPT alongside other frameworks, as well as earlier operationalisation and greater use of NPT sub-constructs.

TRIAL REGISTRATION

The protocol for this systematic review was accepted for public registration on PROSPERO (registration number: CRD42022345427) on 26 July 2022.

Protocol for the development and validation of a patient reported measure (PRM) of treatment burden in stroke

Background

Treatment burden is the workload of healthcare for people with long-term conditions and the impact on wellbeing. A validated measure of treatment burden after stroke is needed. We aim to adapt a patient-reported measure (PRM) of treatment burden in multimorbidity, PETS (Patient Experience with Treatment and Self-Management version 2.0), to create a stroke-specific measure, PETS-stroke. We aim to examine content validity, construct validity, reliability and feasibility in a stroke survivor population.

Methods

1) Adaptation of 60-item PETS to PETS-stroke using a taxonomy of treatment burden. 2) Content validity testing through cognitive interviews that will explore the importance, relevance and clarity of each item. 3) Evaluation of scale psychometric properties through analysis of data from stroke survivors recruited via postal survey (n=340). Factor structure will be tested with confirmatory factor analysis and Cronbach's alpha will be used to index internal consistency. Construct validity will be tested against: The Stroke Southampton Self-Management Questionnaire; The Satisfaction with Stroke Care Measure; and The Shortened Stroke Impact Scale. We will explore known-groups validity by exploring the association between treatment burden, socioeconomic deprivation and multimorbidity. Test-retest reliability will be examined via re-administration after 2 weeks. Acceptability and feasibility of use will be explored via missing data rates and telephone interviews with 30 participants.

Conclusions

We aim to create a validated PRM of treatment burden after stroke. PETS-stroke is designed for use as an outcome measure in clinical trials of stroke treatments and complex interventions to ascertain if treatments are workable for patients in the context of their everyday lives.

Relationship between People's Interest in Medication Adherence, Health Literacy, and Self-Care: An Infodemiological Analysis in the Pre- and Post-COVID-19 Era

The prevalence of non-communicable diseases has risen sharply in recent years, particularly among older individuals who require complex drug regimens. Patients are increasingly required to manage their health through medication adherence and self-care, but about 50% of patients struggle to adhere to prescribed treatments. This study explored the relationship between interest in medication adherence, health literacy, and self-care and how it changed during the COVID-19 pandemic. We used Google Trends to measure relative search volumes (RSVs) for these three topics from 2012 to 2022. We found that interest in self-care increased the most over time, followed by health literacy and medication adherence. Direct correlations emerged between RSVs for medication adherence and health literacy (r = 0.674, p < 0.0001), medication adherence and self-care (r = 0.466, p < 0.0001), and health literacy and self-care (r = 0.545, p < 0.0001). After the COVID-19 pandemic outbreak, interest in self-care significantly increased, and Latin countries showed a greater interest in self-care than other geographical areas. This study suggests that people are increasingly interested in managing their health, especially in the context of the recent pandemic, and that infodemiology may provide interesting information about the attitudes of the population toward chronic disease management.

EXPERTS II - How are patient and caregiver participation in health and social care shaped by experienced burden of treatment and social inequalities? Protocol for a qualitative synthesis

Background

The workload health and social care service users and caregivers take on, and their capacity to do this work is important. It may play a key part in shaping the implementation of innovations in health service delivery and organisation; the utilisation and satisfaction with services; and the outcomes of care. Previous research has often focused on experiences of a narrow range of long-term conditions, and on factors that shape adherence to self-care regimes.

Aims

With the aim of deriving policy and practice implications for service redesign, this evidence synthesis will extend our understanding of service user and caregiver workload and capacity by comparing how they are revealed in qualitative studies of lived experience of three kinds of illness trajectories: long-term conditions associated with significant disability (Parkinson's disease, schizophrenia); serious relapsing remitting disease (Inflammatory Bowel Disease, bipolar disorder); and rapidly progressing acute disease (brain cancer, early onset dementia).

Methods

We will review and synthesise qualitative studies of lived experience of participation in health and social care that are shaped by interactions between experienced treatment burdens, social inequalities and illness trajectories. The review will involve:   1.  Construction of a theory-informed coding manual; systematic search of bibliographic databases to identify, screen and quality assess full-text papers.   2.  Analysis of papers using manual coding techniques, and text mining software; construction of taxonomies of service user and caregiver work and capacity.   3.  Designing a model of core components and identifying common factors across conditions, trajectories, and contexts.   4.  Work with practitioners, and a Patient and Public Involvement (PPI) group, to explore the validity of the models produced; to develop workload reduction strategies; and to consider person-centred service design.

Dissemination

We will promote workload reduction models to support service users and caregivers and produce policy briefs and peer-reviewed publications for practitioners, policy-makers, and researchers.

Treatment burden in individuals living with and beyond cancer: A systematic review of qualitative literature

BACKGROUND

Individuals with cancer are being given increasing responsibility for the self-management of their health and illness. In other chronic diseases, individuals who experience treatment burden are at risk of poorer health outcomes. Less is known about treatment burden and its impact on individuals with cancer. This systematic review investigated perceptions of treatment burden in individuals living with and beyond cancer.

METHODS AND FINDINGS

Medline, CINAHL and EMBASE databases were searched for qualitative studies that explored treatment burden in individuals with a diagnosis of breast, prostate, colorectal, or lung cancer at any stage of their diagnostic/treatment trajectory. Descriptive and thematic analyses were conducted. Study quality was assessed using a modified CASP checklist. The review protocol was registered on PROSPERO (CRD42021145601). Forty-eight studies were included. Health management after cancer involved cognitive, practical, and relational work for patients. Individuals were motivated to perform health management work to improve life-expectancy, manage symptoms, and regain a sense of normality. Performing health care work could be empowering and gave individuals a sense of control. Treatment burden occurred when there was a mismatch between the resources needed for health management and their availability. Individuals with chronic and severe symptoms, financial challenges, language barriers, and limited social support are particularly at risk of treatment burden. For those with advanced cancer, consumption of time and energy by health care work is a significant burden.

CONCLUSION

Treatment burden could be an important mediator of inequities in cancer outcomes. Many of the factors leading to treatment burden in individuals with cancer are potentially modifiable. Clinicians should consider carefully what they are asking or expecting patients to do, and the resources required, including how much patient time will be consumed.

Associations between treatment burden, self-reported treatment qualities, antiretroviral therapy obtainment, and health-related quality of life among Ugandan PLWH

BACKGROUND

Understanding related risk factors of health-related quality of life (HRQoL) could avoid treatment failure and provide an insight of personalized treatment approach among people living with HIV/AIDS (PLWH). The objective of this study was to identify factors associated with self-reported treatment qualities and domains of health-related quality of life (HRQoL) among PLWH in Uganda.

METHOD

Data were from "Life on antiretroviral therapy: People's adaptive coping and adjustment to living with HIV as a chronic condition in Wakiso District, Uganda" in English. The World Health Organization Quality of Life Brief Version (WHOQOL-BREF) questionnaire was used to assess the HRQoL of 263 PLWH in the sample. Considering variance inflation factors, multiple regression analyses were performed to assess the associations between demographic factors, ART obtainment, treatment burden, and self-reported treatment qualities, associations between demographic factors, self-reported treatment qualities, and HRQoL, and association between ART obtainment and HRQoL. Controlling for the confounding effects, several regression anatomies were employed to explore the associations between self-reported treatment qualities and six domains of HRQoL.

RESULTS

In the sample, the geographical distribution were urban (5.70%), semi-urban (37.26%), and rural (57.03%). 67.30% of the participants were females. The mean age of the sample was 39.82 years (standard deviation = 9.76) ranging from 22 to 81 years. Multiple logistic regressions reported statistically significant associations of distance to ART facility with self-reported quality of services, advice, manners, and counseling, statistically significant association between self-reported manners quality and four domains of HRQoL, and statistically significant association between TASO membership and domains of HRQoL. Plots from regression anatomies reported that self-reported treatment qualities had statistically significant associations with six domains of HRQoL.

CONCLUSIONS

Treatment burden, self-reported treatment qualities, ART obtainment, and TASO were possible determinants of individual domains of HRQoL among PLWH in Uganda. PLWH's HRQoL might be improved by promoting medical quality and optimizing ART obtainment in the healthcare providers' practice. Findings in this study had important implications for the redesign of clinical guidelines, healthcare delivery, and health care co-ordination among PLWH globally.

Treatment burden in survivors of prostate and colorectal cancers: a qualitative interview study

OBJECTIVES

Treatment burden is the workload of healthcare and the impact this has on the individual. Treatment burden is associated with poorer patient outcomes in several chronic diseases. Illness burden has been extensively studied in cancer, but little is known about treatment burden, particularly in those who have completed primary treatment for cancer. The aim of this study was to investigate treatment burden in survivors of prostate and colorectal cancers and their caregivers.

DESIGN

Semistructured interview study. Interviews were analysed using Framework and thematic analysis.

SETTING

Participants were recruited via general practices in Northeast Scotland.

PARTICIPANTS

Eligible participants were individuals who had been diagnosed with colorectal or prostate cancer without distant metastases within the previous 5 years and their caregivers. Thirty-five patients and six caregivers participated: 22 patients had prostate and 13 had colorectal cancers (six male, seven female).

RESULTS

The term 'burden' did not resonate with most survivors, who expressed gratitude that time invested in cancer care could translate into improved survival. Cancer management was time consuming, but workload reduced over time. Cancer was usually considered as a discrete episode. Individual, disease and health system factors protected against or increased treatment burden. Some factors, such as health service configuration, were potentially modifiable. Multimorbidity contributed most to treatment burden and influenced treatment decisions and engagement with follow-up. The presence of a caregiver protected against treatment burden, but caregivers also experienced burden.

CONCLUSIONS

Intensive cancer treatment and follow-up regimens do not necessarily lead to perceived burden. A cancer diagnosis serves as a strong motivator to engage in health management, but a careful balance exists between positive perceptions and burden. Treatment burden could lead to poorer cancer outcomes by influencing engagement with and decisions about care. Clinicians should ask about treatment burden and its impact, particularly in those with multimorbidity.

TRIAL REGISTRATION NUMBER

NCT04163068.

Designing Immersive Virtual Reality Environments for Supporting Patients at Home: Translating Input From Home Care Nurse Experts to Design Requirements

Immersive virtual reality computer programs provide new experimental and treatment interventions that hold great promise for nursing. Immersive virtual reality uses sensory cues to represent real-world environments in a way that makes participants feel as if they are in a physical space different from the one in which they currently exist. As the acceptance of immersive virtual reality as a clinical and experimental tool has grown, so has the need to ensure that the context depicted in the environment mirrors both the sensory and the task requirements of the real-world situation. Here, we describe the use of nurse expert key informant group interviews to generate requirements that must be fulfilled in immersive virtual reality environments designed to evoke and engage participants in self-management tasks. An expert panel of four home care nurses participated in three sessions designed to elicit details of common home care challenges, frequency of variation, and typical participants. More than 20 potential scenarios were identified. The design team later used this information to create design requirements for two key scenarios and subsequently develop immersive virtual reality environments for use in research studies, mapping sensory and functional expectations to immersive virtual reality implementations. Challenges in mapping from key informant group findings to requirements are addressed.

Medication self-management interventions for persons with stroke: A scoping review

The use of multiple medications is common following a stroke for secondary prevention and management of co-occurring chronic conditions. Given the use of multiple medications post-stroke, optimizing medication self-management for this population is important. The objective of this scoping review was to identify and summarize what has been reported in the literature on interventions related to medication self-management for adults (aged 18+) with stroke. Electronic databases (Ovid Medline, Ovid Embase, EBSCO CINAHL, Ovid PsycINFO, Web of Science) and grey literature were searched to identify relevant articles. For inclusion, articles were required to include an adult population with stroke undergoing an intervention aimed at modifying or improving medication management that incorporated a component of self-management. Two independent reviewers screened the articles for inclusion. Data were extracted and summarized using descriptive content analysis. Of the 56 articles that met the inclusion criteria, the focus of most interventions was on improvement of secondary stroke prevention through risk factor management and lifestyle modifications. The majority of studies included medication self-management as a component of a broader intervention. Most interventions used both face-to-face interactions and technology for delivery. Behavioural outcomes, specifically medication adherence, were the most commonly targeted outcomes across the interventions. However, the majority of interventions did not specifically or holistically target medication self-management. There is an opportunity to better support medication self-management post-stroke by ensuring interventions are delivered across sectors or in the community, developing an understanding of the optimal frequency and duration of delivery, and qualitatively exploring experiences with the interventions to ensure ongoing improvement.

Treatment burden among patients with heart failure attending cardiac clinic of Tikur Anbessa Specialized Hospital: an explanatory sequential mixed methods study

Emerging evidences hypothesized that patients with heart failure are susceptible to experience treatment burden. Despite this fact, no attempt was made so far to address this neoteric construct in the sub-Saharan African health care context. Hence, this study aimed to assess patients' and health care providers' perspectives on how to decrease treatment burden among patients with heart failure attending the adult cardiac clinic of Tikur Anbessa Specialized Hospital (TASH). An explanatory sequential mixed methods study was conducted at the adult cardiac clinic of TASH, Addis Ababa, Ethiopia from August 01 to September 30, 2021. Simple random and purposive sampling techniques were employed to select participants for quantitative and qualitative studies, respectively. Descriptive analysis was done to summarize the quantitative data. Logistic regression analysis was performed to identify predictors of treatment burden. P value < 0.05 was considered to declare statistical significance. Qualitative data were analyzed by using thematic analysis. A total of 325 patients were enrolled in the quantitative study. For the qualitative study, 14 patients and 11 health care providers (five nurses and six medical doctors) were included. Participants mean global Treatment Burden Questionnaire (TBQ-15) score was 27.22 ± 19.35. Approximately 12% (n = 38) patients indicated high treatment burden (TBQ-15 global score ≥ 59) with a median global score of 63(60-69). Higher education level (adjusted odds ratio [AOR] = 6.66, 95% confidence interval [CI]: 1.16-38.43), presence of two and more comorbidities (AOR = 2.74, 95%CI: 1.02-7.39), daily intake of more than five pills (AOR = 7.38, 95%CI: 2.23-24.41), poor medication availability (AOR = 3.33, 95%CI: 1.33-8.36), presence of medication adverse effects (AOR = 4.04, 95%CI: 1.63-10.03), and higher monthly cost of medication (AOR = 5.29, 95%CI: 1.46-19.18) were predictors of treatment burden. Patients and healthcare providers' propositions were primarily focused on improving self-care management, structural organization of the clinic and hospital, and healthcare system provision. Our findings demonstrated that a substantial proportion of patients faced low levels of treatment burden. This study unveiled that improving self-care management, structural organization of the clinic, and healthcare system provision had paramount importance to reducing treatment burden. Hence, factors affecting treatment burden should be considered when designing tailored healthcare interventions for patients with heart failure.

How do illness identity, patient workload and agentic capacity interact to shape patient and caregiver experience? Comparative analysis of lung cancer and chronic obstructive pulmonary disease

Some patients have to work hard to manage their illness. When this work outweighs capacity (the resources available to patients to undertake the illness workload and other workloads such as that of daily life), this may result in treatment burden, associated with poor health outcomes for patients. This cross-sectional, comparative qualitative analysis uses an abductive approach to identify, characterise and explain treatment burden in chronic obstructive pulmonary disease (COPD) and lung cancer. It uses complementary qualitative methods (semi-structured interviews with patients receiving specialist care n = 19, specialist clinicians n = 5; non-participant observation of specialist outpatient consultations in two English hospitals [11 h, 52 min] n = 41). The findings underline the importance of the diagnostic process in relation to treatment burden; whether diagnosis is experienced as a biographically disruptive shock (as with lung cancer) or is insidiously biographically erosive (as with COPD).

What is important in supporting self-management in community stroke rehabilitation? A Q methodology study

PURPOSE

Supported self-management (SSM) is an important part of adapting to life after stroke however it is a complex concept. It is unclear what SSM in stroke consists of or how stroke survivors, families, and clinicians can most effectively work together to support person-centred self-management. In this study, we aimed to explore what was most important in making SSM work in community stroke rehabilitation.

METHODS

We conducted a Q-methodology study with stroke survivors (n = 20), community-based stroke clinicians (n = 20), and team managers (n = 8) across four health boards in Scotland, United Kingdom. Participants ranked 32 statements according to their importance in making SSM work. Factor analysis was used to identify shared viewpoints.

RESULTS

We identified four viewpoints: (i) A person-centred approach to build self-confidence and self-worth; (ii) Feeling heard, understood, and supported by everybody; (iii) Preparation of appropriate resources; and (iv) Right thing, right place, right time for the individual. Important across all viewpoints were: a trusting supportive relationship; working in partnership; focusing on meaningful goals; and building self-confidence.

CONCLUSIONS

Differing views exist on what is most important in SSM. These views could be used to inform quality improvement strategies to support the delivery of SSM that considers the preferences of stroke survivors. IMPLICATIONS FOR REHABILITATIONClinicians should be aware of their own viewpoint of supported self-management and consider how their perspective may differ from stroke survivors' and colleagues' perspectives of what's important to support self-management.Working in partnership with stroke survivors plus developing a trusting and supportive relationship with them are core components of supporting self-management in the longer term after stroke.Building a sense of self-worth and self-confidence, a focus on meaningful goals, training and support for staff, and tailoring support to people's needs at the right time are important considerations for supporting longer-term engagement in self-management.

Experiences of multimorbidity in urban and rural Malawi: An interview study of burdens of treatment and lack of treatment

Multimorbidity (presence of ≥2 long term conditions (LTCs)) is a growing global health challenge, yet we know little about the experiences of those living with multimorbidity in low- and middle-income countries (LMICs). We therefore explore: 1) experiences of men and women living with multimorbidity in urban and rural Malawi including their experiences of burden of treatment and 2) examine the utility of Normalization Process Theory (NPT) and Burden of Treatment Theory (BOTT) for structuring analytical accounts of these experiences. We conducted in depth, semi-structured interviews with 32 people in rural (n = 16) and urban settings (n = 16); 16 males, 16 females; 15 under 50 years; and 17 over 50 years. Data were analysed thematically and then conceptualised through the lens of NPT and BOTT. Key elements of burden of treatment identified included: coming to terms with and gaining an understanding of life with multimorbidity; dealing with resulting disruptions to family life; the work of seeking family and community support; navigating healthcare systems; coping with lack of continuity of care; enacting self-management advice; negotiating medical advice; appraising treatments; and importantly, dealing with the burden of lack of treatments/services. Poverty and inadequate healthcare provision constrained capacity to deal with treatment burden while supportive social and community networks were important enabling features. Greater access to health information/education would lessen treatment burden as would better resourced healthcare systems and improved standards of living. Our work demonstrates the utility of NPT and BOTT for aiding conceptualisation of treatment burden issues in LMICs but our findings highlight that 'lack' of access to treatments or services is an important additional burden which must be integrated in accounts of treatment burden in LMICs.

Supported self-management in community stroke rehabilitation: what is it and how does it work? A protocol for a realist evaluation study

INTRODUCTION

A growing evidence base demonstrates the effectiveness of supported self-management in stroke for stroke survivors and their families. However, there is significant variation in its implementation in community stroke care and little understanding about how supported self-management works and is delivered across different settings, models used and contexts of community stroke rehabilitation.

METHODS AND ANALYSIS

Using a mixed method, realist approach across two phases, this protocol describes a study on community-based supported self-management. The aim is to identify the mechanisms and outcomes of supported self-management in stroke and to understand how supported self-management is implemented in different contexts of community stroke rehabilitation. Phase 1 involves (1) a realist synthesis, (2) a scoping and mapping of current community rehabilitation settings and (3) a Q-methodology study to develop initial programme theories about how community-based supported self-management works, for whom and in what contexts. Phase 2 involves realist informed interviews/focus groups with stroke survivors, community rehabilitation practitioners and team managers from across Scotland to test and refine programme theories and an explanatory model for how supported self-management works across different contexts of community-based stroke rehabilitation.

ETHICS AND DISSEMINATION

Ethical approval and R&D approvals have been granted from East of Scotland Research Ethics Committee (REC reference number: 19/ES/0055) and participating NHS boards. An understanding of how, for whom and in what contexts community-based supported self-management works will help to strengthen its delivery in practice. Such an understanding will enable the design of context-specific recommendations for policy and practice that genuinely reflect the challenges in implementing supported self-management in community stroke care. Results will be disseminated to clinical partners working in community stroke rehabilitation, stroke survivors and families and to policymakers and third sector partners involved in the provision of long-term support for people affected by stroke.

PROSPERO REGISTRATION NUMBER

CRD42020166208.

Correlates of Treatment and Disease Burden in People Living with HIV (PLHIV) in Italy

Treatment burden is a multidimensional concept, including several aspects of life of patients affected by chronic conditions. It has been poorly explored in people living with HIV (PLHIV). An online anonymous survey of PLHIV taking antiretroviral therapy (ART) was conducted, in order to investigate the self-reported correlates of disease burden. HIV Treatment and Diseases Burden (TDB) was investigated with a questionnaire containing 31 items in 7 domains. Respondents were stratified in high burden (H-TDB)/low burden (L-TDB) according to overall HIV TDB mean + 1 standard deviation. Factors associated with H-TDB has been evaluated with a logistic regression model. In total, 531 PLHIV completed the questionnaire. 99 PLHIV had a H-TDB (18.6%). PLHIV with H-TDB were younger (p < 0.001), less frequently on current two drug antiretroviral (ARV) regimens (p = 0.01) and more frequently with plasma HIV-RNA >50 copies/mL (p = 0.04). At multivariable regression analysis, younger age (aOR 1.43, 95%CI 1.14–1.80; p = 0.002), not fully treatment satisfaction (aOR 2.19, 95%CI 1.28–3.74; p = 0.004), the need of a more accurate dialogue with treating physician (aOR 2.29, 95%CI 1.21–4.36, p = 0.01) and a self-declared lower overall Health Status (aOR 1.75, 95%CI 1.33–2.32; p = 0.002) were all associated with a H-TDB. One out of five PLHIV showed a high level of treatment and disease burden. Younger age, not fully satisfaction with ART and need of interaction with a tailored health system should be taken into consideration as correlates of treatment and disease burden in a patient-centered approach, to reduce the negative impact that it can produce on the overall perceived health status of the person.

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.

An analysis of the diagnostic accuracy and peer-to-peer health information provided on online health forums for heart failure

AIMS

To examine the accuracy of diagnostic responses and types of information provided on online health forums.

DESIGN

Qualitative descriptive study.

METHODS

This paper reports the findings of a thematic analysis of peer responses to posts included on heart failure online health forums, to understand the quality and types of information provided. Responses posted between March 2016 and March 2019 were screened, collected and analysed thematically using Braun & Clarke. Themes were conceptually underpinned by Normalization Process Theory. Responses were assessed for quality against the NICE and SIGN guidelines to determine whether they were evidence based or not.

RESULTS

The total number of responses collected for analysis was 639. Five main themes were identified: diagnostic, experiential, informational, peer relations and relationships with healthcare professionals. Out of 298 diagnostic responses, 5% were guideline evidence-based and 6% had information that were partly evidence-based. Non-evidence based and potentially dangerous responses were 10%. Experiential responses were 10%; 23% included advice that was not supported with any clinical evidence; and 46% signposted users to other online references/healthcare professionals.

CONCLUSION

Online health communication largely focuses on provision of experiential responses to assist those in need of pre- or post-diagnosis advice and support. However, there is evidence of inaccurate information provision which suggests the use of a moderator would be beneficial.

IMPACT

This study suggests heart failure online health forums are a source of support, however, there are potential risks. Increasing nurses and other health care professional's awareness of online health forums will be important. Additional training is needed to help them learn more about patient's use of online health forums, to gain a better understanding about the types of information sought, and how best to address such knowledge deficits. Healthcare systems must ensure sufficient time and resources are available to meet information needs for people with heart failure.

Do chronic heart failure symptoms interact with burden of treatment? Qualitative literature systematic review

OBJECTIVE

Explore the interaction between patient experienced symptoms and burden of treatment (BoT) theory in chronic heart failure (CHF). BoT explains how dynamic patient workload (self-care) and their capacity (elements influencing capability), impacts on patients' experience of illness.

DESIGN

Review of qualitative research studies.

DATA SOURCES

CINAHL, EMBASE, MEDLINE, PsycINFO, Scopus and Web of Science were searched between January 2007 and 2020.

ELIGIBILITY CRITERIA

Journal articles in English, reporting qualitative studies on lived experience of CHF.

RESULTS

35 articles identified related to the lived experience of 720 patients with CHF. Symptoms with physical and emotional characteristics were identified with breathlessness, weakness, despair and anxiety most prevalent. Identifying symptoms' interaction with BoT framework identified three themes: (1) Symptoms appear to infrequently drive patients to engage in self-care (9.2% of codes), (2) symptoms appear to impede (70.5% of codes) and (3) symptoms form barriers to self-care engagement (20.3% of codes). Symptoms increase illness workload, making completing tasks more difficult; simultaneously, symptoms alter a patient's capacity, through a reduction in their individual capabilities and willingness to access external resources (ie, hospitals) often with devasting impact on patients' lives.

CONCLUSIONS

Symptoms appear to be integral in the patient experience of CHF and BoT, predominately acting to impede patients' efforts to engage in self-care. Symptoms alter illness workload, increasing complexity and hardship. Patients' capacity is reduced by symptoms, in what they can do and their willingness to ask for help. Symptoms can lower their perceived self-value and roles within society. Symptoms appear to erode a patient's agency, decreasing self-value and generalised physical deconditioning leading to affective paralysis towards self-care regimens. Together describing a state of overwhelming BoT which is thought to be a contributor to poor engagement in self-care and may provide new insights into the perceived poor adherence to self-care in the CHF population.

PROSPERO REGISTRATION NUMBER

CRD42017077487.

The Experiences of Treatment Burden in People with Parkinson's Disease and Their Caregivers: A Systematic Review of Qualitative Studies

BackgroundHigh treatment burden is associated with poor adherence, wasted resources, poor quality of life and poor health outcomes. Identifying factors that impact treatment burden in Parkinson's disease can offer insights into strategies to mitigate them.ObjectiveTo explore the experiences of treatment burden among people with Parkinson's disease (PwP) and their caregivers.MethodsA systematic review of studies published from year 2006 was conducted. Qualitative and mixed-method studies with a qualitative component that relate to usual care in Parkinson's disease were included. Quantitative studies and grey literature were excluded. Data synthesis was conducted using framework synthesis.Results1757 articles were screened, and 39 articles included. Understanding treatment burden in PwP and caregivers was not the primary aim in any of the included studies. The main issues of treatment burden in Parkinson's disease are: 1) work and challenges of taking medication; 2) healthcare provider obstacles including lack of patient-centered care, poor patient-provider relationships, lack of care coordination, inflexible organizational structures, lack of access to services and issues in care home or hospital settings; and 3) learning about health and challenges with information provision. The treatment burden led to physical and mental exhaustion of self-care and limitations on the role and social activities of PwP and caregivers.Conclusion:There are potential strategies to improve the treatment burden in Parkinson's disease at an individual level such as patient-centered approach to care, and at system level by improving access and care coordination between services. Future research is needed to determine the modifiable factors of treatment burden in Parkinson's disease.

Validity and reliability of the Mandarin version of the Treatment Burden Questionnaire among stroke patients in Mainland China

OBJECTIVES

To examine the validity and reliability of the Mandarin version of the Treatment Burden Questionnaire (TBQ) among stroke patients.

BACKGROUND

Stroke patients need long-term management of symptoms and life situation, and treatment burden has recently emerged as a new concept that can influence the health outcomes during the rehabilitation process.

METHODS

The convenience sampling method was used to recruit 187 cases of stroke patients in a tertiary grade hospital in Tianjin for a formal investigation. Item analysis, reliability and validity tests were carried out. The reliability test included internal consistency and test-retest reliability. And as well as content, structure and convergent validity were performed for the validity test.

RESULTS

Of the 187 completed questionnaires, only 180 (96.3%) were suitable for analysis. According to the experts' evaluation, the I-CVI of each item was from 0.833 to 1.000, and the S-CVI was 0.967. The exploratory factor analysis yielded three-factor components with a cumulative variation of 53.054%. Convergent validity was demonstrated using measures of Morisky's Medication Adherence Scale 8 (r = -0.450, P < 0.01). All correlations between items and global scores ranged from 0.403 to 0.638. Internal consistency reliability and test-retest reliability were found to be acceptable, as indicated by a Cronbach's α of 0.824 and an intraclass correlation coefficient of 0.846, respectively.

CONCLUSIONS

The Mandarin TBQ had acceptable validity and reliability. The use of TBQ in the assessment of treatment burden of stroke survivor may benefit health resources allocation and provide tailor therapeutic interventions to construct minimally disruptive care.

Utilization of Advanced Practice Providers in Advanced Practice Provider-Led Stroke Clinic to Expand Outpatient Stroke Follow-up Care

Stroke follow-up care with neurology specialty advanced practice providers is critical to focus on stroke prevention. The need for which is underscored by results of a recent study noting that many stroke survivors of first-ever strokes were not receiving stroke standard-of-care prevention measures including consistent antiplatelet therapies and regular exercise. Study findings further note the rates of usage for stroke prevention interventions (daily anti-platelet therapy, smoking cessation, regular exercise, hypertension control) were between 50% and 70%. Clinical nurse specialists along with nurse practitioner and physician assistant advanced practice providers are uniquely suited to manage outpatient ischemic stroke care to reduce the recurrence of stroke and improve patient outcomes.

Discussing treatment burden

Treatment burden is defined as “the workload of healthcare and its effect on patient functioning and well-being” [1, 2]. It has also been defined as “the self-care practices that patients with chronic illness must perform to respond to the requirements of their healthcare providers, as well as the impact that these practices have on patient functioning and well-being” [3]. In this issue of Breathe, there are several articles addressing treatment burden from different perspectives. This Viewpoint article focusses on the discussions between the patient and their healthcare professional (HCP). What are the important topics to cover in discussions about treatment burden? What are the barriers to these discussions? What facilitates a productive conversation about treatment burden? The authors of this article include three patients (with asthma, COPD and idiopathic pulmonary fibrosis (IPF), four HCPs representing different specialties (primary care, secondary and tertiary care, nursing and pharmacy) and a representative of the European Lung Foundation (ELF). This article is based on a video discussion between the authors; it was then refined via e-mail by all the authors.

Healthcare professionals should help patients to reach informed decisions about treatments in order to maximise benefits while minimising treatment burdenhttps://bit.ly/2XRtRPK

The Unmet Needs of Community-Dwelling Stroke Survivors: A Systematic Review of Qualitative Studies

The unmet needs perceived by community-dwelling stroke survivors may truly reflect the needs of patients, which is crucial for pleasant emotional experiences and a better quality of life for community-dwelling survivors not living in institutionalized organizations. The purpose of the study is to identify the scope of unmet needs from the perspectives of stroke patients in the community. A qualitative meta-synthesis was performed according to the Joanna Briggs Institute method. Six electronic databases were searched from inception to February 2020. A total of 24 articles were involved, providing data on 378 stroke survivors. Eight categories were derived from 63 findings, and then summarized into four synthesized findings based on the framework of ICF: (1) unmet needs regarding with the disease-related information; (2) unmet physical recovery and activity/participation needs; (3) unmet needs for social environmental resources; (4) unmet psycho-emotional support needs. We found the framework of ICF mostly complete, but unmet information needs still remain. The needs that are mainly unsatisfied include physical, psychosocial and informational, as well as the practical support from professional or environment resources. The ever-present unmet needs perceived by community-dwelling stroke survivors who do not live in institutions are discoverable and mitigable. Future studies should focus on quantifying unmet needs comprehensively derived from experiential domains, assessing the rationality of the unmet needs expressed by patients' perspectives and developing flexible strategies for long-term and changing needs.

Minimally disruptive medicine (MDM) in clinical practice: a qualitative case study of the human immunodeficiency virus (HIV) clinic care model

Background

Recent evidence suggests the need to reframe healthcare delivery for patients with chronic conditions, with emphasis on minimizing healthcare footprint/workload on patients, caregivers, clinicians and health systems through the proposed Minimally Disruptive Medicine (MDM) care model named. HIV care models have evolved to further focus on understanding barriers and facilitators to care delivery while improving patient-centered outcomes (e.g., disease progression, adherence, access, quality of life). It is hypothesized that these models may provide an example of MDM care model in clinic practice. Therefore, this study aimed to observe and ascertain MDM-concordant and discordant elements that may exist within a tertiary-setting HIV clinic care model for patients living with HIV or AIDS (PLWHA). We also aimed to identify lessons learned from this setting to inform improving the feasibility and usefulness of MDM care model.

Methods

This qualitative case study occurred in multidisciplinary HIV comprehensive-care clinic within an urban tertiary-medical center. Participants included Adult PLWHA and informal caregivers (e.g. family/friends) attending the clinic for regular appointments were recruited. All clinic staff were eligible for recruitment. Measurements included; semi-guided interviews with patients, caregivers, or both; semi-guided interviews with varied clinicians (individually); and direct observations of clinical encounters (patient-clinicians), as well as staff daily operations in 2015–2017. The qualitative-data synthesis used iterative, mainly inductive thematic coding.

Results

Researcher interviews and observations data included 28 patients, 5 caregivers, and 14 care-team members. With few exceptions, the clinic care model elements aligned closely to the MDM model of care through supporting patient capacity/abilities (with some patients receiving minimal social support and limited assistance with reframing their biography) and minimizing workload/demands (with some patients challenged by the clinic hours of operation).

Conclusions

The studied HIV clinic incorporated many of the MDM tenants, contributing to its validation, and informing gaps in knowledge. While these findings may support the design and implementation of care that is both minimally disruptive and maximally supportive, the impact of MDM on patient-important outcomes and different care settings require further studying.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-020-06010-x.

Community care coordination for stroke survivors: results of a complex intervention study

BACKGROUND

Outpatient follow-up care for stroke survivors is often inadequate and mostly self-organized by the patients themselves. In the German health care system, there are no standard care programs for patients after they are discharged from the hospital to support them with their multifaceted and heterogeneous health care needs. The objective of this complex intervention study was to evaluate the effectiveness of a post-stroke care coordination program in comparison to standard care in the first year after a stroke.

METHODS

Patients aged 55 and older who had survived a stroke or a transient ischemic attack (TIA) within the last 6 months before enrollment were included. Participants received care coordination either by telephone or face-to-face for up to 1 year. Patients' health insurance claims data were used to measure outcomes. The control group consisted of stroke survivors receiving standard care and was constructed by exact matching based on six criteria. Outcome measures were health services utilization, rate of recurrent events, readmissions and accompanying costs, and mortality. Outcomes were tested using different multiple models.

RESULTS

In total, N = 361 patients were included in the analyses. Intervention participants had seen an outpatient neurologist more often (OR = 4.75; 95% CI: 2.71-8.31) and were readmitted to a hospital less frequently (IRR = 0.42; 95% CI: 0.29-0.61), resulting in lower hospital costs (IQR = €0-1910 in the intervention group, IQR = €0-4375 in the control group). There were no substantial group differences in the rate of recurrent events and mortality.

CONCLUSION

This study showed the beneficial potential of care coordination for a vulnerable patient population: the utilization rate of important health services was increased, and the rate of hospital readmissions decreased as a result. Future research should focus on the risk of recurrent strokes and the long-term effects of improved care.

TRIAL REGISTRATION

DRKS00017526 on DRKS - German Clinical Trials Register (retrospectively registered: 21 June 2019).

Barriers and facilitators to patient uptake and utilisation of digital interventions for the self-management of low back pain: a systematic review of qualitative studies

OBJECTIVES

Low back pain (LBP) is a leading contributor to disability globally. Self-management is a core component of LBP management. We aimed to synthesise published qualitative literature concerning digital health interventions (DHIs) to support LBP self-management to: (1) determine engagement strategies, (2) identify barriers and facilitators affecting patient uptake/utilisation and (3) develop a preliminary conceptual model of barriers and facilitators to uptake/utilisation.

DESIGN

Systematic review following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines.

DATA SOURCES

MEDLINE, Embase, CINAHL, PsycINFO, Cochrane Library, DoPHER, TRoPHI, Web of Science and OT Seeker, from January 2000 to December 2018, using the concepts: LBP, DHI and self-management.

ELIGIBILITY CRITERIA

Peer-reviewed qualitative study (or component) examining engagement with, or barriers and/or facilitators to the uptake/utilisation of an interactive DHI for self-management of LBP in adults (community, primary or secondary care settings).

DATA EXTRACTION AND SYNTHESIS

Standardised data extraction form was completed. COREQ (Consolidated criteria for Reporting Qualitative research) checklist was used to assess methodology. Data was synthesised narratively for engagement strategies, thematically for barriers/facilitators to uptake/utilisation and normalisation process theory was applied to produce a conceptual model.

RESULTS

We identified 14 191 citations, of which 105 full-text articles were screened, and five full-text articles from four studies included. These were from community and primary care contexts in Europe and the USA, and involved 56 adults with LBP and 19 healthcare professionals. There was a lack of consideration on how to sustain engagement with DHIs. Examination of barriers and facilitators for uptake/utilisation identified four major themes: IT (information technology) usability-accessibility; quality-quantity of content; tailoring-personalisation; and motivation-support. These themes informed the development of a preliminary conceptual model for uptake/utilisation of a DHI for LBP self-management.

CONCLUSIONS

We highlight key barriers and facilitators that should be considered when designing DHIs for LBP self-management. Our findings are in keeping with reviews of DHIs for other long-term conditions, implying these findings may not be condition specific.

SYSTEMATIC REVIEW REGISTRATION

A protocol for this systematic review was registered with https://www.crd.york.ac.uk/PROSPERO/ (CRD42016051182) on 10 November 2016. https://www.crd.york.ac.uk/PROSPERO/display_record.php?ID=CRD42016051182.

Patient and health-care worker perspectives on the short-course regimen for treatment of drug-resistant tuberculosis in Karakalpakstan, Uzbekistan

Introduction

Standard multidrug-resistant tuberculosis (MDR-TB) treatment is lengthy, toxic, and insufficiently effective. New drugs and a shorter treatment regimen (SCR) are now recommended. However, patient and health-care worker (HCW) perspectives regarding the SCR are unknown. We aimed to determine the views and experiences of patients with MDR-TB and HCW regarding the SCR in Karakalpakstan, Uzbekistan.

Methods

In a qualitative study, we conducted 48 in-depth interviews with 24 people with MDR-TB and 20 HCW, purposively recruited to include those with a range of treatment-taking experiences and employment positions. Data were analysed thematically using Nvivo 12, to identify emergent patterns, concepts, and categories. Principles of grounded theory were drawn upon to generate findings inductively from participants’ accounts.

Results

All patients viewed the SCR favourably. The SCR was seen as enabling an expedited return to work, studies, and “normality”. This reduced the burden of treatment and difficulties with treatment fatigue. The SCR appeared to improve mental health, ease difficulties with TB-related stigma, and foster improved adherence. While patients wanted shorter treatment, it was also important that treatment be tolerable and effective. However, HCW doubted the appropriateness and effectiveness of the SCR, which influenced their confidence in prescribing the regimen.

Conclusion

The SCR was said to benefit treatment completion and patients’ lives. HCW concerns about SCR appropriateness and effectiveness may influence who receives the regimen. These are important considerations for SCR implementation and MDR-TB treatment developments, and dissonance between patient and HCW perspectives must be addressed for successful implementation of shorter regimens in the future.

App-Delivered Self-Management Intervention Trial selfBACK for People With Low Back Pain: Protocol for Implementation and Process Evaluation

Background

Implementation and process evaluation is vital for understanding how interventions function in different settings, including if and why interventions have different effects or do not work at all.

Objective

This paper presents the protocol for an implementation and process evaluation embedded in a multicenter randomized controlled trial conducted in Denmark and Norway (the selfBACK project). selfBACK is a data-driven decision support system that provides participants with weekly self-management plans for low back pain. These plans are delivered through a smartphone app and tailored to individual participants by using case-based reasoning methodology. In the trial, we compare selfBACK in addition to usual care with usual care alone.

Methods

The aim of this study is to conduct a convergent mixed-methods implementation and process evaluation of the selfBACK app by following the reach, effectiveness, adoption, implementation, and maintenance framework. We will evaluate the process of implementing selfBACK and investigate how participants use the intervention in daily life. The evaluation will also cover the reach of the intervention, health care provider willingness to adopt it, and participant satisfaction with the intervention. We will gather quantitative measures by questionnaires and measures of data analytics on app use and perform a qualitative exploration of the implementation using semistructured interviews theoretically informed by normalization process theory. Data collection will be conducted between March 2019 and October 2020.

Results

The trial opened for recruitment in February 2019. This mixed-methods implementation and evaluation study is embedded in the randomized controlled trial and will be collecting data from March 2019 to October 2020; dissemination of trial results is planned thereafter. The results from the process evaluation are expected 2021-2022.

Conclusions

This study will provide a detailed understanding of how self-management of low back pain can be improved and how a digital health intervention can be used as an add-on to usual care to support patients to self-manage their low back pain. We will provide knowledge that can be used to explore the possibilities of extending the generic components of the selfBACK system and key drivers that could be of use in other conditions and diseases where self-management is an essential prevention or treatment strategy.

Trial Registration

ClinicalTrials.gov NCT03798288; https://www.clinicaltrials.gov/ct2/show/NCT03798288

International Registered Report Identifier (IRRID)

DERR1-10.2196/20308

The effect of transition care interventions incorporating health coaching strategies for stroke survivors: A systematic review and meta-analysis

OBJECTIVE

To systematically analyse health coaching strategies in transition care and synthesise the effect of these strategies on health care outcomes for stroke survivors.

METHODS

A systematic search of nine databases in two languages was conducted. Meta-analysis was conducted when data were available.

RESULTS

Twenty-five randomised controlled trials met the inclusion criteria. The meta-analysis revealed that health coaching strategies in transition care interventions significantly improve quality of life (QoL) (p < 0.001), activities of daily living (ADL) (p = 0.002) and reduce depression (p = 0.001) for stroke survivors at 3 months. Further subgroup analysis demonstrated that transition care interventions with a greater number of health coaching strategies are associated with a larger effect size on QoL (SMD=1.15) and ADL (SMD=1.177) at 3 months, and a medium effect size (SMD=0.674) on depression reduction. However, the effects of health coaching strategies on readmission, mortality and falls in stroke survivors remain inconclusive.

CONCLUSIONS

This review provides evidence that incorporating health coaching strategies in transitional care improves health outcomes of stroke survivors.

PRACTICE IMPLICATION

More trials of health coaching interventions to improve transition care with a rigorous study design are much needed to address the lack of support for stroke survivors and their caregivers in this crucial care period.

Experiences of augmented arm rehabilitation including supported self-management after stroke: a qualitative investigation

OBJECTIVE

To explore the experiences of stroke survivors and their carers of augmented arm rehabilitation including supported self-management in terms of its acceptability, appropriateness and relevance.

DESIGN

A qualitative design, nested within a larger, multi-centre randomized controlled feasibility trial that compared augmented arm rehabilitation starting at three or nine weeks after stroke, with usual care. Semi-structured interviews were conducted with participants in both augmented arm rehabilitation groups. Normalization Process Theory was used to inform the topic guide and map the findings. Framework analysis was applied.

SETTING

Interviews were conducted in stroke survivors' homes, at Glasgow Caledonian University and in hospital.

PARTICIPANTS

17 stroke survivors and five carers were interviewed after completion of augmented arm rehabilitation.

INTERVENTION

Evidence-based augmented arm rehabilitation (27 additional hours over six weeks), including therapist-led sessions and supported self-management.

RESULTS

Three main themes were identified: (1) acceptability of the intervention (2) supported self-management and (3) coping with the intervention. All stroke survivors coped well with the intensity of the augmented arm rehabilitation programme. The majority of stroke survivors engaged in supported self-management and implemented activities into their daily routine. However, the findings suggest that some stroke survivors (male >70 years) had difficulties with self-management, needing a higher level of support.

CONCLUSION

Augmented arm rehabilitation commencing within nine weeks post stroke was reported to be well tolerated. The findings suggested that supported self-management seemed acceptable and appropriate to those who saw the relevance of the rehabilitation activities for their daily lives, and embedded them into their daily routines.

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.

Impact of Memory Problems Post-stroke on Patients and Their Family Carers: A Qualitative Study

Background: Memory problems post-stroke are common and for some, these problems could then progress to a dementia illness. Once in the community, stroke-survivors are looked after by their family doctors although there is evidence that these patients may struggle to access appropriate help in the community for these problems. Although a stroke-survivor may be physically capable of performing daily tasks, they and their families may have to learn to manage and adapt to their new memory deficits. There is often less focus on cognitive recovery post-stroke from clinical services perhaps because of the lack of awareness and evidence of these adaptations. There is also good evidence that organized stroke care improves physical recovery but no equivalent evidence for the effectiveness of cognitive rehabilitation. The aim of this qualitative study was to report the impact of memory problems on the stroke-survivor and their family once they are living in the community.

Methods: Semi-structured interviews were conducted with patients and family carers to gain an in-depth understanding of their experiences. Participants were invited to take part in an interview at around six and 12-months post-stroke. A topic guide was developed to explore participant's care experiences post-stroke when they have also presented with memory difficulties. Data collection and analysis were iterative; all transcripts were anonymized. The data were thematically analyzed.

Results: Twenty-two interviews were conducted. Five family carers and ten stroke-survivors were interviewed at six-months post-stroke, of these eight stroke-survivors and four family carers agreed to a 12-month follow-up interview. They identified several areas of impact: (1) impact on daily life; (2) emotional impact; and (3) compensating strategies implemented in response to impact.

Conclusion: Living with stroke combined with memory impairment can have negative effects on the stroke-survivor and their family once in the community. Health professionals and services in the community need to recognize the burden of managing symptoms post-stroke for these individuals and their families. Understanding the impact can enable more effective community and specialist support to be provided particularly if we were to also identify those who may then be at risk of a future dementia illness.

Innovations in framework synthesis as a systematic review method

Framework synthesis is one systematic review method employed to address health care practice and policy. Adapted from framework analysis methods, it has been used increasingly, using both qualitative and mixed-method systematic review methods. This article demonstrates a spectrum of approaches to framework synthesis that are dependent on the extent to which theory is tentative, emergent, refined, or established; and that stakeholder involvement may help to understand the topic's complexity where theory is more nascent. The choice of approach depends on the degree of match with existing theories and, in the absence of existing theory, the scale and heterogeneity of the literature to be managed.

Capacity Coaching: A Focused Ethnographic Evaluation in Clinical Practice

Objective

To qualitatively evaluate the implementation of Capacity Coaching, an intervention to address the work patients must undertake to manage their conditions, implemented as a quality improvement pilot in 1 of 2 implementing US Department of Veterans Affairs medical centers.

Participants and Methods

Two Veterans Affairs medical centers in the Midwest sought to implement Capacity Coaching as a quality improvement pilot in their Patient-Aligned Care Teams for 6 months (April 1, 2017, through October 31, 2017). Following the pilot, we conducted a focused ethnographic evaluation (on-site data collection, January 2-4, 2018), including interviews, a focus group, and observations with staff at one site to assess the implementation of capacity coaching. Data were analyzed inductively and findings were cross-referenced with implementation theory.

Results

We found that implementation was feasible and achieved changes that were aligned with reducing patient work and increasing capacity. We found that the key facilitators for the implementation of this program were in participants making sense of the intervention (coherence) and working collectively to enact the program (collective action). The main challenges for the program were in planning the work of implementation and enrolling a diverse coalition of staff to expand referrals to the program (cognitive participation) and in evaluating the impact of the program on outcomes that upper leadership was interested in (reflexive monitoring).

Conclusion

Implementation of Capacity Coaching is feasible in clinical practice and may be a promising intervention for the care of chronic conditions. Further research should focus on testing capacity coaching using these lessons learned.

Implementing Supported Self-Management in Community-Based Stroke Care: A Secondary Analysis of Nurses' Perspectives

The provision of supported self-management (SSM) is recommended in contemporary guidelines to address the longer-term needs and outcomes of stroke survivors and their families, yet its implementation across stroke pathways has been inconsistent. This paper presents a secondary analysis of qualitative data, which aims to identify and offer insight into the challenges of implementing SSM from the perspectives of community stroke nurses (n = 14). The findings revealed that the implementation of SSM in stroke is influenced by factors operating at multiple levels of the healthcare system. Contextual challenges arise because of different understandings and interpretations of what SSM is, what it comprises and professionals' perceptions of their roles in its implementation in practice. A professionally controlled, one-size-fits-all model of SSM continues to be reinforced within organizations, offering few opportunities for nurses to deliver contextually tailored and person-centred SSM. In conclusion, there are many professional concerns and organizational tensions that need to be addressed across multiple layers of the healthcare system to achieve the consistent implementation of contextually tailored and person-centred SSM following a stroke. Attempts to address these challenges will help to narrow the gap between policy and practice of implementing SSM, ensuring that stroke survivors and families benefit from SSM in the longer-term.

A systematic literature review looking for the definition of treatment burden

BACKGROUND

Treatment burden is an emerging concept in health care literature. It can complicate the patients' condition and perhaps result in poor adherence to treatment, which is linked to worse clinical outcomes. However, until now there is no definition for treatment burden recognized by all stakeholders. This review was prepared in order to find what available definitions for treatment burden are present in the literature.

METHODS

A systematic review of the literature was prepared looking for definitions of treatment burden in adult patients. Articles about adults aged 18 years or older from both genders with one or more medical conditions that contained a (new) definition of treatment burden were included. The search approach consisted of conventional systematic review database searching of multiple resources including Embase, Medline, PsycINFO, and CINAHL. Two independent reviewers screened the titles and abstracts, and full papers.

RESULTS

The searches resulted in 8045 records, of which 16 articles were included. Based on quality appraisal criteria, we decided that two definitions had better evaluations than the rest of the definitions, the first one defining it as the impact of the 'work of being a patient' on functioning and well-being, the second as the actions and resources they devote to their healthcare.

CONCLUSION

We consider the definition concentrating on actions and resources patients devote to their healthcare, including difficulty, time, and out-of-pocket costs dedicated to the healthcare tasks such as adhering to medications, dietary recommendations, and self-monitoring as the one probably comprising most domains of Treatment Burden that we have found in our search in the existing literature. However, adding even more domains to this definition and differentiating explicitly between patient's perception and caregiver's perception in the definition could in our opinion result in an improved definition. Also patients' evaluation of this definition is commendable.

What helps and hinders the provision of healthcare that minimises treatment burden and maximises patient capacity? A qualitative study of stroke health professional perspectives

OBJECTIVES

Treatment burden is the healthcare workload experienced by individuals with long-term conditions and the impact on well-being. Excessive treatment burden can negatively affect quality-of-life and adherence to treatments. Patient capacity is the ability of an individual to manage their life and health problems and is dependent on a variety of physical, psychological and social factors. Previous work has suggested that stroke survivors experience considerable treatment burden and limitations on their capacity to manage their health. We aimed to examine the potential barriers and enablers to minimising treatment burden and maximising patient capacity faced by health professionals and managers providing care to those affected by stroke.

SETTING

Primary and secondary care stroke services in a single health board area in Scotland.

PARTICIPANTS

Face-to-face qualitative interviews with 21 participants including stroke consultants, nurses, physiotherapists, occupational therapists, speech and language therapists, psychologists, general practitioners and health-service managers.

OUTCOME MEASURES

Data were analysed using thematic analysis to ascertain any factors that influence the provision of low-burden healthcare.

RESULTS

Barriers and facilitators to the provision of healthcare that minimises treatment burden and maximises patient capacity were reported under five themes: healthcare system structure (e.g. care coordination and autonomous working); resources (e.g. availability of ward nurses and community psychologists); knowledge and awareness (e.g. adequate time and materials for optimal information delivery); availability of social care (e.g. waiting times for home adaptations or extra social support) and patient complexity (e.g. multimorbidity).

CONCLUSIONS

Our findings have important implications for the design and implementation of stroke care pathways, emphasising the importance of removing barriers to health professional provision of person-centred care. This work can inform the design of interventions aimed at nurturing autonomous working by health professionals, improving communication and care coordination or ensuring availability of a named person throughout the patient journey.

From recovery to regaining control of life - the perspectives of people with stroke, their carers and health professionals

Aim: To understand how people with stroke and carers adapt over time, and how health professionals support transition to home.Method: A multi-perspective, prospective, qualitative, longitudinal study was conducted using in-depth semi-structured interviews one and six months after inpatient discharge. Twenty-four participants (eight triads, including people with stroke, carers and health professionals) were included. Thematic and narrative analysis facilitated identification of cross-cutting themes according to individual trajectories post-stroke.Findings: A major theme: "regaining control of life" suggested a shift in perspective after six months at home. Four sub-themes help to understand the triads' perspectives over time: i) importance of team involvement; ii) differences in perceived roles within the triad; iii) differences in expectations and collaboration within the triad and iv) planning a different future. People who were involved in supporting adaptation and rehabilitation processes were reported differently between triads and over time, showing the complexity of interrelations. A reduction in professional involvement was matched by changes in participants' goals and expectations.Conclusion: Findings suggest the importance of a dyadic perspective and a gradual increase in people with stroke and carers' active engagement. Professionals' approach throughout rehabilitation should be modified according to people with stroke and carers' changing needs and expectations.IMPLICATIONS FOR REHABILITATIONDivergence in perspectives about priorities and goals between the person with stroke their carers and healthcare professionals can lead to the creation of different agendas within rehabilitation.An open dialogue and decision-making process that involves both the person with stroke and carers is highly recommended for the identification of shared rehabilitation goals and to support ongoing recovery post discharge.A tailored approach to rehabilitation is required which focusses on shared priorities and includes individual or collective support for the person with stroke and their carers.Ongoing consultation about the desires of the person with stroke about rehabilitation, priorities and goals is important in order to tailor the professional approach to the stage individuals are at with their coping and adjustment post stroke.

Blood pressure control and burden of treatment in South African primary healthcare: A cross-sectional study

Background

Poor blood pressure (BP) control has been associated with high burden of treatment (BOT) in several settings. It is not known whether this relationship holds true for South African primary care.

Aim

The aim of this study was to assess BOT and determine its relationship with BP control amongst patients with hypertension in a large community health centre, south of Johannesburg.

Setting

The setting of this study was carried out in the OPD of Johan Heyns Community Health Center.

Methods

A cross-sectional study involving 239 patients with hypertension was carried out. Information on sociodemography and BP readings in the last 3 months were extracted from patient medical records. A researcher-administered treatment burden questionnaire was also used to collect information on participants’ perceptions of BOT relating to medication regimen, navigating the healthcare system and life style changes and/or social and/or financial issues. Total BOT (TBOT) was determined as the sum of the scores in the three components and categorised as 1–45 = low, 46–90 = moderate and 91–140 = high. Analysis included descriptive statistics and test of association.

Results

Most participants were white (54.2%), > 55 years (52.9%), female (60.1%), married (56.3%), had grade 12 or more education (71.9%) and had no comorbidity (56.7%). The mean duration of hypertension treatment was 113.8 months and most participants were uncontrolled (60.1%). Most participants (75%) reported a low TBOT score, with a mean of 19.7. Amongst participants with clinical comorbidities, most (66.3%) did not consider hypertension to be more burdensome than other comorbid illnesses. There was no significant association between TBOT and BP control (p = 0.53). However, participants with a high BOT relating to medication regimen were significantly more likely to be uncontrolled (p = 0.04).

Conclusion

Total BOT is low amongst study participants and has no significant influence on BP control. However, improvements in BP control in South African primary healthcare may be hinged on interventions that address problems associated with hypertension medication regimen.

Implementation of a billable transitional care model for stroke patients: the COMPASS study

Background

The COMprehensive Post-Acute Stroke Services (COMPASS) pragmatic trial compared the effectiveness of comprehensive transitional care (COMPASS-TC) versus usual care among stroke and transient ischemic attack (TIA) patients discharged home from North Carolina hospitals. We evaluated implementation of COMPASS-TC in 20 hospitals randomized to the intervention using the RE-AIM framework.

Methods

We evaluated hospital-level Adoption of COMPASS-TC; patient Reach (meeting transitional care management requirements of timely telephone and face-to-face follow-up); Implementation using hospital quality measures (concurrent enrollment, two-day telephone follow-up, 14-day clinic visit scheduling); and hospital-level sustainability (Maintenance). Effectiveness compared 90-day physical function (Stroke Impact Scale-16), between patients receiving COMPASS-TC versus not. Associations between hospital and patient characteristics with Implementation and Reach measures were estimated with mixed logistic regression models.

Results

Adoption: Of 95 eligible hospitals, 41 (43%) participated in the trial. Of the 20 hospitals randomized to the intervention, 19 (95%) initiated COMPASS-TC.

Reach: A total of 24% (656/2751) of patients enrolled received a billable TC intervention, ranging from 6 to 66% across hospitals.

Implementation: Of eligible patients enrolled, 75.9% received two-day calls (or two attempts) and 77.5% were scheduled/offered clinic visits. Most completed visits (78% of 975) occurred within 14 days.

Effectiveness: Physical function was better among patients who attended a 14-day visit versus those who did not (adjusted mean difference: 3.84, 95% CI 1.42–6.27, p = 0.002).

Maintenance: Of the 19 adopting hospitals, 14 (74%) sustained COMPASS-TC.

Conclusions

COMPASS-TC implementation varied widely. The greatest challenge was reaching patients because of system difficulties maintaining consistent delivery of follow-up visits and patient preferences to pursue alternate post-acute care. Receiving COMPASS-TC was associated with better functional status.

Trial registration

ClinicalTrials.gov number: NCT02588664. Registered 28 October 2015.