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1.
Top Stroke Rehabil ; 31(2): 157-166, 2024 03.
Artículo en Inglés | MEDLINE | ID: mdl-37415422

RESUMEN

INTRODUCTION: There is limited evidence on the costs and outcomes of patients with aphasia after stroke. The aim of this study was to estimate costs in patients with aphasia after stroke according to the aphasia therapies provided. METHODS: A three-arm, prospective, randomized, parallel group, open-label, blinded endpoint assessment trial conducted in Australia and New Zealand. Usual ward-based care (Usual Care) was compared to additional usual ward-based therapy (Usual Care Plus) and a prescribed and structured aphasia therapy program in addition to Usual Care (the VERSE intervention). Information about healthcare utilization and productivity were collected to estimate costs in Australian dollars for 2017-18. Multivariable regression models with bootstrapping were used to estimate differences in costs and outcomes (clinically meaningful change in aphasia severity measured by the WAB-R-AQ). RESULTS: Overall, 202/246 (82%) participants completed follow-up at 26 weeks. Median costs per person were $23,322 (Q1 5,367, Q3 52,669, n = 63) for Usual Care, $26,923 (Q1 7,303, Q3 76,174, n = 70) for Usual Care Plus and $31,143 (Q1 7,001. Q3 62,390, n = 69) for VERSE. No differences in costs and outcomes were detected between groups. Usual Care Plus was inferior (i.e. more costly and less effective) in 64% of iterations, and in 18% was less costly and less effective compared to Usual Care. VERSE was inferior in 65% of samples and less costly and less effective in 12% compared to Usual Care. CONCLUSION: There was limited evidence that additional intensively delivered aphasia therapy within the context of usual acute care provided was worthwhile in terms of costs for the outcomes gained.


Asunto(s)
Afasia , Rehabilitación de Accidente Cerebrovascular , Accidente Cerebrovascular , Humanos , Accidente Cerebrovascular/complicaciones , Accidente Cerebrovascular/terapia , Análisis Costo-Beneficio , Estudios Prospectivos , Habla , Australia , Afasia/etiología , Afasia/rehabilitación
2.
Implement Sci ; 18(1): 2, 2023 01 26.
Artículo en Inglés | MEDLINE | ID: mdl-36703172

RESUMEN

BACKGROUND: Facilitated implementation of nurse-initiated protocols to manage fever, hyperglycaemia (sugar) and swallowing difficulties (FeSS Protocols) in 19 Australian stroke units resulted in reduced death and dependency for stroke patients. However, a significant gap remains in translating this evidence-based care bundle protocol into standard practice in Australia and New Zealand. Facilitation is a key component for increasing implementation. However, its contribution to evidence translation initiatives requires further investigation. We aim to evaluate two levels of intensity of external remote facilitation as part of a multifaceted intervention to improve FeSS Protocol uptake and quality of care for patients with stroke in Australian and New Zealand acute care hospitals. METHODS: A three-arm cluster randomised controlled trial with a process evaluation and economic evaluation. Australian and New Zealand hospitals with a stroke unit or service will be recruited and randomised in blocks of five to one of the three study arms-high- or low-intensity external remote facilitation or a no facilitation control group-in a 2:2:1 ratio. The multicomponent implementation strategy will incorporate implementation science frameworks (Theoretical Domains Framework, Capability, Opportunity, Motivation - Behaviour Model and the Consolidated Framework for Implementation Research) and include an online education package, audit and feedback reports, local clinical champions, barrier and enabler assessments, action plans, reminders and external remote facilitation. The primary outcome is implementation effectiveness using a composite measure comprising six monitoring and treatment elements of the FeSS Protocols. Secondary outcome measures are as follows: composite outcome of adherence to each of the combined monitoring and treatment elements for (i) fever (n=5); (ii) hyperglycaemia (n=6); and (iii) swallowing protocols (n=7); adherence to the individual elements that make up each of these protocols; comparison for composite outcomes between (i) metropolitan and rural/remote hospitals; and (ii) stroke units and stroke services. A process evaluation will examine contextual factors influencing intervention uptake. An economic evaluation will describe cost differences relative to each intervention and study outcomes. DISCUSSION: We will generate new evidence on the most effective facilitation intensity to support implementation of nurse-initiated stroke protocols nationwide, reducing geographical barriers for those in rural and remote areas. TRIAL REGISTRATION: ACTRN12622000028707. Registered 14 January, 2022.


Asunto(s)
Trastornos de Deglución , Hiperglucemia , Accidente Cerebrovascular , Humanos , Australia , Accidente Cerebrovascular/terapia , Australasia , Trastornos de Deglución/terapia , Hiperglucemia/terapia , Fiebre/terapia , Ensayos Clínicos Controlados Aleatorios como Asunto
3.
Top Stroke Rehabil ; 30(6): 603-609, 2023 09.
Artículo en Inglés | MEDLINE | ID: mdl-35786371

RESUMEN

BACKGROUND: People with communication disabilities post-stroke have poor quality-of-life. OBJECTIVES: We aimed to explore the association of self-reported communication disabilities with different dimensions of quality-of-life between 90 and 180 days post-stroke. METHODS: Cross-sectional survey data were obtained between 90 and 180 days post-stroke from registrants in the Australian Stroke Clinical Registry recruited from three hospitals in Queensland. The usual follow-up survey included the EQ5D-3L. Responses to the Hospital Anxiety and Depression Scale, and extra questions (e.g. communication disabilities) were also collected. We used χ2 statistics to determine differences. RESULTS: Overall, 244/647 survivors completed the survey. Respondents with communication disabilities (n = 72) more often reported moderate to extreme problems in all EQ5D-3L dimensions, than those without communication disabilities (n = 172): anxiety or depression (74% vs 40%, p < .001), pain or discomfort (58% vs 39%, p = .006), self-care (46% vs 18%, p < .001), usual activities (77% vs 49%, p < .001), and mobility (68% vs 35%, p < .001). Respondents with communication disabilities reported less fatigue (66% vs 89%, p < .001), poorer cognitive skills (thinking) (16% vs 1%, p < .001) and lower social participation (31% vs 6%, p < .001) than those without communication disabilities. CONCLUSIONS: Survivors of stroke with communication disabilities are more negatively impacted across different dimensions of quality-of-life (as reported between 90 and 180 days post-stroke) compared to those without communication disabilities. This highlights the need for timely and on-going comprehensive multidisciplinary person-centered support.


Asunto(s)
Accidente Cerebrovascular , Humanos , Accidente Cerebrovascular/complicaciones , Accidente Cerebrovascular/psicología , Estudios Transversales , Australia , Calidad de Vida/psicología , Sobrevivientes/psicología
4.
Eur J Neurol ; 28(2): 469-478, 2021 02.
Artículo en Inglés | MEDLINE | ID: mdl-32920917

RESUMEN

BACKGROUND AND PURPOSE: Women may receive stroke care less often than men. We examined the contribution of clinical care on sex differences and health-related quality of life (HRQoL) after stroke. METHODS: We included first-ever strokes registered in the Australian Stroke Clinical Registry (2010-2014) with HRQoL assessed between 90 and 180 days after onset (EQ-5D-3L instrument) that were linked to hospital administrative data (up to 2013). Study factors included sociodemographics, comorbidities, walking ability on admission (stroke severity proxy) and clinical care (e.g. stroke unit care). Responses to the EQ-5D-3L were transformed into a total utility value (-0.516 'worse than death' to 1 'best' health). Quantile regression models, adjusted for confounding factors, were used to determine median differences (MD) in utility scores by sex. RESULTS: Approximately 60% (6852/11 418) of stroke survivors had an EQ-5D-3L assessment (median 139 days; 44% female). Compared with men, women were older (median age 77.1 years vs. men 71.2 years) and fewer could walk on admission (37.9% vs. men 46.1%, P < 0.001). Women had lower utility values than men, and the difference was explained by age and stroke severity, but not clinical care [MDadjusted = -0.039, 95% confidence interval: -0.056, -0.021]. Poorer HRQoL was observed in younger men (aged <65 years), particularly those with more comorbidities, and in older women (aged ≥75 years). CONCLUSIONS: Stroke severity and comorbidities contribute to the poorer HRQoL in young men and older women. Further studies are needed to understand age-sex interaction to better inform treatments for different subgroups and ensure evidence-based treatments to reduce the severity of stroke are prioritized.


Asunto(s)
Calidad de Vida , Accidente Cerebrovascular , Anciano , Australia/epidemiología , Femenino , Humanos , Masculino , Sistema de Registros , Caracteres Sexuales , Accidente Cerebrovascular/epidemiología , Accidente Cerebrovascular/terapia , Encuestas y Cuestionarios
5.
Public Health ; 185: 102-109, 2020 Aug.
Artículo en Inglés | MEDLINE | ID: mdl-32603874

RESUMEN

OBJECTIVES: Chinese adults are the biggest users of healthcare services, and understanding current trends in disability profiles is relevant to planning healthcare workforce infrastructure. We investigated the trends over time for disability and physical functional limitations from 2011 to 2015 among Chinese adults and identified the factors associated with these limitations. STUDY DESIGN: We used nationally representative data from the China Health and Retirement Longitudinal Study (CHARLS); the CHARLS participants were followed up every 2 years as they moved from work to retirement with an emphasis on their health status and functional abilities. METHODS: Participants aged ≥50 years from three waves of the CHARLS were included. Data were collected on physical functioning limitations, disabilities in activities of daily living (ADLs) and disabilities in instrumental activities of daily living (IADLs). Multilevel logistic regression models were used to test for changes and factors associated with limitations and disabilities between 2011 and 2015 adjusting for sociodemographic, medical history and health measures. RESULTS: There were 44,447 eligible participants (mean age: 63 years; standard deviation [SD], 9 years; 51% female). After adjustment, there was no significant increase in reporting of ADLs or IADLs in the 2015 survey compared with the 2011 survey. After adjustment, there was a 26% significant increase in reporting of physical functioning limitations in the 2015 survey compared with the 2011 survey (odds ratio: 1.26; 95% confidence interval, 1.17 to 1.35). Factors associated with ADL disability were being female, being older, minimal education, no alcohol intake in the previous year, falls, fractured hip, feeling depressed and being obese. Factors associated with IADL disabilities were being female, being older, minimal education and feeling depressed. CONCLUSIONS: Chinese health agencies should consider the growing need for sufficient community services infrastructure to maximise independence, particularly in the context of ageing populations.


Asunto(s)
Actividades Cotidianas , Personas con Discapacidad/estadística & datos numéricos , Estado de Salud , Anciano , Anciano de 80 o más Años , Envejecimiento , China/epidemiología , Enfermedad Crónica/epidemiología , Femenino , Humanos , Modelos Logísticos , Estudios Longitudinales , Masculino , Persona de Mediana Edad , Oportunidad Relativa , Prevalencia , Jubilación , Encuestas y Cuestionarios
7.
Int J Popul Data Sci ; 4(1): 1097, 2019 Aug 05.
Artículo en Inglés | MEDLINE | ID: mdl-34095531

RESUMEN

INTRODUCTION: The growing burden of chronic diseases means some governments have been providing financial incentives for multidisciplinary care and self-management support delivered within primary care. Currently, population-based evaluations of the effectiveness of these policies are lacking. AIM: To outline the methodological approach for our study that is designed to evaluate the effectiveness (including cost) of primary care policies for chronic diseases in Australia using stroke as a case study. METHODS: Person-level linkages will be undertaken between registrants from the Australian Stroke Clinical Registry (AuSCR) and (i) Government-held Medicare Australia claims data, to identify receipt or not of chronic disease management and care coordination primary care items; (ii) state government-held hospital data, to define outcomes; and (iii) government-held pharmaceutical and aged care claims data, to define covariates. N=1500 randomly selected AuSCR registrants will be sent surveys to obtain patient experience information. In Australia, unique identifiers are unavailable. Therefore, personal-identifiers will be submitted to government data linkage units. Researchers will merge the de-identified datasets for analysis using a project identifier. An economic evaluation will also be undertaken. ANALYSIS: The index event will be the first stroke recorded in the AuSCR. Multivariable competing risks Poisson regression for multiple events, adjusted by a propensity score, will be used to test for differences in the rates of hospital presentations and medication adherence for different care (policy) types. Our estimated sample size of 25,000 patients will provide 80% estimated power (ɑ>0.05) to detect a 6-8% difference in rates. The incremental costs per Quality-adjusted life years gained of community-based care following the acute event will be estimated from a health sector perspective. CONCLUSION: Completion of this study will provide a novel and comprehensive evaluation of the effectiveness and cost-effectiveness of Australian primary care policies. Its success will enable us to highlight the value of data-linkage for this type of research.

8.
Eur J Neurol ; 24(7): 920-928, 2017 07.
Artículo en Inglés | MEDLINE | ID: mdl-28488353

RESUMEN

BACKGROUND AND PURPOSE: Limited evidence exists on the benefits of organized care for improving risk factor control in patients with stroke or transient ischaemic attack. The effectiveness of an individualized management programme in reducing absolute cardiovascular disease risk in this high-risk population was determined. METHODS: This was a prospective, multicentre, cluster-randomized controlled trial with blinded assessment of outcomes and intention-to-treat analysis. Patients hospitalized for stroke/transient ischaemic attack and aged ≥18 years were recruited from four hospitals. General practices treating recruited patients were randomized to provide either usual care or an individualized management programme comprising nurse-led education and review of care plans by stroke specialists in addition to usual care. The primary outcome was a change in cardiovascular Framingham Risk Score between baseline and 12 months. RESULTS: From January 2010 to November 2013, 156 general practices (280 patients) were randomly assigned to usual care (control) and 159 (283 patients) to the intervention. The median age was 70.1 years; 65% were male. Overall, >80% of participants were prescribed recommended secondary prevention therapies at baseline. The primary efficacy analysis comprised 533 participants, with 30 either dying or lost to follow-up. In adjusted analyses, no significant between-group difference was found in the cardiovascular risk score at 12 months (0.04, 95% confidence interval -1.7, 1.8). CONCLUSIONS: The effectiveness of an organized secondary prevention programme for stroke may be limited in patients from high-performing hospitals with regular post-discharge follow-up and communication with general practices.


Asunto(s)
Manejo de la Enfermedad , Accidente Cerebrovascular/terapia , Anciano , Anciano de 80 o más Años , Evaluación de la Discapacidad , Femenino , Humanos , Ataque Isquémico Transitorio/terapia , Masculino , Persona de Mediana Edad , Enfermeras y Enfermeros , Grupo de Atención al Paciente , Educación del Paciente como Asunto , Médicos , Medicina de Precisión , Estudios Prospectivos , Factores de Riesgo , Accidente Cerebrovascular/mortalidad , Resultado del Tratamiento
9.
Qual Life Res ; 25(8): 2053-62, 2016 08.
Artículo en Inglés | MEDLINE | ID: mdl-26847339

RESUMEN

PURPOSE: Understanding the relationship between health-related quality of life (HRQoL) and long-term unmet needs is important for guiding services to optimise life following stroke. We investigated whether HRQoL between 90 and 180 days following stroke was associated with long-term unmet needs. METHODS: Data from Australian Stroke Clinical Registry (AuSCR) registrants who participated in the Australian Stroke Survivor Needs Survey were used. Outcome data, including the EQ-5D, are routinely collected in AuSCR between 90 and 180 days post-stroke. Unmet needs were assessed at a median of 2 years and categorised into: health; everyday living; work/leisure; and support domains. Multivariable regression was used to determine associations between the EQ-5D dimensions and the likelihood of experiencing unmet needs and the visual analogue scale (VAS) (rating 0-100) and number of reported unmet needs. RESULTS: In total, 173 AuSCR registrants completed the Needs Survey (median age 69 years, 67 % male; 77 % ischaemic stroke). VAS scores were negatively associated with the number of reported long-term unmet needs [irr 0.98, (95 % CI 0.97, 0 99) p < 0.001]. Having EQ-5D activity limitations was associated with unmet living needs (aOR 4.5, 95 % CI 1.1, 18.8). Requiring living supports at 90-180 days was associated with unmet health needs (aOR 4.9, 95 % CI 1.5, 16.1). Those with pain at 90-180 days were less likely to report unmet health (aOR 0.09, 95 % CI 0.02, 0.4) and support needs (aOR 0.2, 95 % CI 0.06, 0.6). CONCLUSION: Routinely collected HRQoL data can identify survivors at risk of experiencing long-term unmet needs. This information is important for targeting service delivery to optimise outcomes following stroke.


Asunto(s)
Cuidados a Largo Plazo/métodos , Perfil de Impacto de Enfermedad , Accidente Cerebrovascular/psicología , Anciano , Femenino , Humanos , Masculino , Persona de Mediana Edad , Accidente Cerebrovascular/mortalidad , Accidente Cerebrovascular/fisiopatología , Factores de Tiempo
10.
Intern Med J ; 45(9): 951-6, 2015 09.
Artículo en Inglés | MEDLINE | ID: mdl-26011155

RESUMEN

BACKGROUND: Stroke telemedicine is widely used to treat patients with acute stroke in Europe and North America but is seldom used in Australia. The Victorian Stroke Telemedicine (VST) programme aims to enhance acute stroke care in regional Australia. METHODS: Twelve-month pilot prospective, historical-controlled, implementation cohort study. Emergency Department (ED) at a large regional hospital in Victoria. Patients ≥ 18 years of age arriving < 4.5 h in the ED with a possible diagnosis of acute stroke. Telemedicine consultation by a Melbourne-based stroke specialist. Stroke thrombolysis rate, timelines for clinical processes, discharge outcomes. RESULTS: In the initial 12 month VST implementation, 62 patients arrived < 4.5 h of stroke onset (60% male; median age 75 years). Compared to pre-VST data (n = 58; 52% male; median age 77 years), stroke thrombolysis use increased from 17% to 26% (P = 0.26). Clinical process timelines improved including door to computed tomography time (reduced by 29 min, P = 0.006), and door to needle time (reduced by 21 min, P = 0.21). There was no significant increase in deaths (pre-VST 7% vs VST 10%), or symptomatic intracerebral haemorrhage (n = 1 tPA patient). More patients who received tPA were discharged to home or rehabilitation (pre-VST 33% vs VST 80%, P = 0.02), with significantly fewer transfers to other acute care services. CONCLUSIONS: The VST pilot implementation provides evidence that telemedicine can enhance the quality of acute stroke care in a regional hospital. Expanding VST to 16 regional hospitals, Australia's largest telestroke programme, will allow for a more comprehensive clinical and economic analysis.


Asunto(s)
Accesibilidad a los Servicios de Salud/organización & administración , Accidente Cerebrovascular/terapia , Telemedicina/organización & administración , Investigación Biomédica Traslacional/tendencias , Anciano , Australia/epidemiología , Femenino , Humanos , Masculino , Proyectos Piloto , Desarrollo de Programa , Evaluación de Programas y Proyectos de Salud , Estudios Prospectivos , Accidente Cerebrovascular/epidemiología , Terapia Trombolítica/métodos , Resultado del Tratamiento , Victoria/epidemiología
11.
Intern Med J ; 45(9): 957-64, 2015 Sep.
Artículo en Inglés | MEDLINE | ID: mdl-25904209

RESUMEN

BACKGROUND: Fast diagnosis and delivery of treatment to patients experiencing acute stroke can reduce subsequent disability. While telemedicine can improve rural community access to specialists and facilitate timely diagnosis and treatment decisions, it is not widely used for stroke in Australia. AIM: Identifying the barriers and facilitators to clinician engagement with, and utilisation of, telemedicine consultations could expedite implementation in rural and remote locations. METHODS: Purposive sampling was used to identify and recruit medical and nursing staff varying in telemedicine experience across one hospital department. Twenty-four in-depth, face-to-face interviews were conducted examining aspects surrounding stroke telemedicine uptake. Inductive qualitative thematic analysis was undertaken, and two further researchers verified coding. RESULTS: The main barriers identified were contrasting opinions about the utility of thrombolysis for treating acute stroke, lack of confidence in the telemedicine system, perceived limited need for specialist advice and concerns about receiving advice from an unfamiliar doctor. Facilitators included assistance with diagnosis and treatment, the need for a user-friendly system and access to specialists for complex cases. CONCLUSIONS: Acceptability of telemedicine for acute stroke was multifaceted and closely aligned with regional clinician beliefs about the value of thrombolysis for stroke, highlighting an important area for education. Addressing beliefs about treatment efficacy and other perceived barriers is important for establishing a stroke telemedicine programme.


Asunto(s)
Atención a la Salud/organización & administración , Diagnóstico Precoz , Población Rural , Accidente Cerebrovascular/diagnóstico , Telemedicina , Terapia Trombolítica/métodos , Adulto , Australia/epidemiología , Femenino , Conocimientos, Actitudes y Práctica en Salud , Humanos , Masculino , Persona de Mediana Edad , Datos de Secuencia Molecular , Investigación Cualitativa , Autocuidado , Accidente Cerebrovascular/terapia , Terapia Trombolítica/normas , Resultado del Tratamiento
13.
Intern Med J ; 41(4): 321-6, 2011 Apr.
Artículo en Inglés | MEDLINE | ID: mdl-20546059

RESUMEN

BACKGROUND: Stroke care across Australian hospitals is variable. The impact on health outcomes, in particular levels of disability for patients in rural areas, is unclear. The aim of this study was to determine whether geographic location and access to stroke units are associated with differences in health outcomes in patients with acute stroke. METHODS: Retrospective cohort study of consecutive eligible admissions from 32 hospitals (12 rural) in New South Wales between 2003 and 2007. Health status measured at discharge included level of independence (modified Rankin score: mRS) and frequency of severe complications during hospitalization. Multivariable analyses included adjustment for patient casemix and clustering. RESULTS: Among 2254 eligible patients, 55% were treated in metropolitan hospitals. Stroke unit treatment varied significantly (rural 3%; metropolitan 77%). Age, gender and stroke type did not differ by location (mean age 74, 50% female). After adjusting for age, gender, ethnicity, important risk factors and validated stroke prognostic variables, patients treated in rural hospitals had a greater odds of dying during hospitalization compared with those treated in metropolitan hospitals (adjusted odds ratio (aOR) 1.46, 95% confidence interval (CI) 1.03-2.05). There were no differences in mortality or frequency of severe complications between patients treated in rural and metropolitan hospitals when we adjusted for access to stroke units (aOR 1.00, 95% CI 0.62-1.61). Nevertheless, patients treated in rural hospitals were more dependent (mRS 3-5) at discharge (aOR 1.82, 95% CI 1.23-2.70) despite adjusting for stroke unit status. CONCLUSION: Patients with stroke treated in rural hospitals have poorer health outcomes, especially if not managed in stroke units.


Asunto(s)
Hospitalización , Hospitales Rurales/normas , Hospitales Urbanos/normas , Accidente Cerebrovascular/terapia , Anciano , Anciano de 80 o más Años , Estudios de Cohortes , Femenino , Mortalidad Hospitalaria/tendencias , Hospitalización/tendencias , Hospitales Rurales/tendencias , Hospitales Urbanos/tendencias , Humanos , Masculino , Persona de Mediana Edad , Nueva Gales del Sur/epidemiología , Alta del Paciente/normas , Alta del Paciente/tendencias , Estudios Retrospectivos , Factores de Riesgo , Accidente Cerebrovascular/diagnóstico , Accidente Cerebrovascular/mortalidad , Resultado del Tratamiento
14.
Intern Med J ; 41(10): 736-43, 2011 Oct.
Artículo en Inglés | MEDLINE | ID: mdl-20681960

RESUMEN

BACKGROUND: Stroke is an Australian health priority area causing considerable levels of disability. We report 90-day outcomes for a cohort of acute stroke patients in New South Wales (NSW), Australia prior to randomization to a large cluster randomized controlled trial (CRCT), the Quality in Acute Stroke Care (QASC) trial. AIMS: This paper describes prospectively collected, 90-day outcome data for a cohort of NSW stroke patients, providing pre-intervention data for the QASC trial. METHODS: A consecutive sample of patients from acute stroke units in NSW was recruited. We measured patient death, disability (modified Rankin Score (mRS)), dependency (Barthel Index (BI)) and Health Status (Medical Outcomes Short-Form Health Survey (SF-36)) 90 days post-hospital admission. We also collected self-reported healthcare utilization and patient satisfaction with health professionals' advice and management to reduce risk of subsequent stroke. RESULTS: Ninety-day outcome data were obtained for 687 patients, of which, 335 (49%) had an mRS ≥2; 44 patients (6.4%) had died. For the 643 surviving patients, the mean BI was 87.2 (SD 21.9) and the mean scores for SF-36 Physical Component Summary score and Mental Component Summary score were 46.2 (SD 10.1) and 46.3 (SD 12.6) respectively. CONCLUSIONS: In this pre-intervention cohort of selected acute stroke inpatients, stroke severity was mild to moderate and subsequent clinical outcomes were favourable in the majority. The findings from this study provide a comprehensive description of 90-day health outcomes of patients who have experienced a mild-moderate stroke managed in stroke care units across metropolitan NSW and provide valuable data to inform the subsequent cluster trial.


Asunto(s)
Hospitalización , Accidente Cerebrovascular/epidemiología , Actividades Cotidianas , Enfermedad Aguda , Anciano , Anciano de 80 o más Años , Daño Encefálico Crónico/epidemiología , Daño Encefálico Crónico/etiología , Femenino , Estado de Salud , Unidades Hospitalarias/estadística & datos numéricos , Humanos , Masculino , Persona de Mediana Edad , Nueva Gales del Sur/epidemiología , Admisión del Paciente , Satisfacción del Paciente , Selección de Paciente , Estudios Prospectivos , Ensayos Clínicos Controlados Aleatorios como Asunto , Recuperación de la Función , Conducta de Reducción del Riesgo , Prevención Secundaria , Índice de Severidad de la Enfermedad , Accidente Cerebrovascular/complicaciones , Accidente Cerebrovascular/mortalidad , Accidente Cerebrovascular/prevención & control , Accidente Cerebrovascular/terapia , Análisis de Supervivencia , Resultado del Tratamiento
15.
Int J Stroke ; 4(3): 206-14, 2009 Jun.
Artículo en Inglés | MEDLINE | ID: mdl-19659823

RESUMEN

Transient ischemic attack is a medical emergency because early stroke risk after transient ischemic attack is high. Hypertension is the most important modifiable risk factor for stroke and transient ischemic attack. The aims of this review are to provide a summary of the current knowledge concerning the relationship between blood pressure and transient ischemic attack, as well as outline issues regarding diurnal variation and the potential of chronotherapy (timing medications to accord with diurnal patterns of blood pressure). There is a strong relationship between hypertension and the incidence of transient ischemic attack and the subsequent short-term risk for stroke. Ambulatory blood pressure monitoring is a reliable diagnostic and monitoring tool for hypertension and provides additional information about diurnal variation in blood pressure. Different diurnal blood pressure patterns may confer variable stroke risk. Patients with stroke commonly have abnormal diurnal blood pressure patterns and this may relate, in part, to autonomic nervous system dysfunction. However, blood pressure patterns have not been systematically studied in patients with transient ischemic attack. Blood pressure remains poorly controlled in a large proportion of patients after transient ischemic attack and under-treatment and poor adherence are important factors. Chronotherapy for blood pressure may result in more effective blood pressure control. More research is needed in this area. Hypertension is strongly associated with transient ischemic attack. Diurnal blood pressure patterns may influence subsequent stroke risk after transient ischemic attack and more evidence is needed to inform clinical practice to improve blood pressure management for transient ischemic attack patients.


Asunto(s)
Hipertensión/epidemiología , Ataque Isquémico Transitorio/epidemiología , Sistema Nervioso Autónomo/fisiopatología , Presión Sanguínea/fisiología , Diabetes Mellitus/epidemiología , Humanos , Hipertensión/complicaciones , Hipertensión/fisiopatología , Ataque Isquémico Transitorio/etiología , Factores de Riesgo , Accidente Cerebrovascular/epidemiología , Accidente Cerebrovascular/etiología
16.
Int J Stroke ; 4(2): 72-80, 2009 Apr.
Artículo en Inglés | MEDLINE | ID: mdl-19383046

RESUMEN

BACKGROUND: Stroke is a leading cause of disease burden. The quality of care provided in hospitals can affect outcome. Therefore, examining adherence to clinically important processes of care can help improve care delivery and patient outcomes. However, knowing which process indicators to measure is essential. AIM: Systematically review process indicators used to evaluate acute stroke services, including early rehabilitation interventions, and assess whether published indicators conform to clinical guidelines. METHODS: Publications (1985-2006) were identified by systematically searching databases (e.g. Medline and Cochrane Library), and the internet using free text terms: 'stroke unit', 'process', 'quality', 'mobilisation', 'acute', and 'early rehabilitation'. Publications describing process indicators relating to the first 2 weeks of in-patient stroke care were included. Process indicators were categorised according to six clinical process domains covering the acute stroke admission. Commonly cited indicators (>or=6 publications) were then mapped to the 2003 Australian clinical guidelines. RESULTS: Sixty potential studies were found from title and abstract. Following full text review, 32 publications were retained. Of the 161 process indicators identified, 43 were commonly cited. Seventy-nine per cent of commonly cited indicators were found in the guidelines. The level of evidence underpinning each indicator ranged from low 'expert opinion' (59%), to high, 'level 1' (12%) evidence. Indicators related to rehabilitation were rare. CONCLUSION: Many acute stroke process indicators have been published. However, a quarter did not align with current clinical guidelines. Developing an 'ideal set' of process indicators to reflect the evidence base seems sensible and should include rehabilitation interventions.


Asunto(s)
Evaluación de Procesos y Resultados en Atención de Salud/métodos , Garantía de la Calidad de Atención de Salud/métodos , Rehabilitación de Accidente Cerebrovascular , Humanos , Guías de Práctica Clínica como Asunto
17.
Int J Stroke ; 4(2): 137-44, 2009 Apr.
Artículo en Inglés | MEDLINE | ID: mdl-19383056

RESUMEN

BACKGROUND: Self-management is seen as a primary mechanism to support the optimization of care for people with chronic diseases such as symptomatic vascular disease. There are no established and evidence-based stroke-specific chronic disease self-management programs. Our aim is to evaluate whether a stroke-specific program is safe and feasible as part of a Phase II randomized-controlled clinical trial. METHODS: Stroke survivors are recruited from a variety of sources including: hospital stroke services, local paper advertisements, Stroke South Australia newsletter (volunteer peer support organization), Divisions of General Practice, and community service providers across Adelaide, South Australia. Subjects are invited to participate in a multi-center, single-blind, randomized, controlled trial. Eligible participants are randomized to either; * standard care, * standard care plus a six week generic chronic condition self-management group education program, or, * standard care plus an eight week stroke specific self-management education group program. Interventions are conducted after discharge from hospital. Participants are assessed at baseline, immediate post intervention and six months. STUDY OUTCOMES: The primary outcome measures determine study feasibility and safety, measuring, recruitment, participation, compliance and adverse events. Secondary outcomes include: * positive and active engagement in life measured by the Health Education Impact Questionnaire, * improvements in quality of life measured by the Assessment of Quality of Life instrument, * improvements in mood measured by the Irritability, Depression and Anxiety Scale, * health resource utilization measured by a participant held diary and safety. CONCLUSION: The results of this study will determine whether a definitive Phase III efficacy trial is justified.


Asunto(s)
Educación del Paciente como Asunto/métodos , Autocuidado/métodos , Rehabilitación de Accidente Cerebrovascular , Enfermedad Crónica , Femenino , Humanos , Masculino , Calidad de Vida , Accidente Cerebrovascular/psicología
18.
Qual Saf Health Care ; 17(5): 329-33, 2008 Oct.
Artículo en Inglés | MEDLINE | ID: mdl-18842970

RESUMEN

BACKGROUND AND OBJECTIVES: Provision of evidence-based hospital stroke care is limited worldwide. In Australia, about a fifth of public hospitals provide stroke care units (SCUs). In 2001, the New South Wales (NSW) state government funded a clinician-led, health system redesign programme that included inpatient stroke services. Our objective was to determine the effects of this initiative for improving: (i) access to SCUs and care quality and (ii) health outcomes. DESIGN, SETTING AND PARTICIPANTS: Preintervention-postintervention design (12 months prior and a minimum 6-12 months following SCU implementation). Retrospective, public hospital audit of 50 consecutive medical records per time period of stroke admissions (using International Classification of Diseases (ICD)-10 codes). Combined analyses for 15 hospitals presented. OUTCOMES: Process of care indicators and patient independence (proportional odds modelling using modified Rankin scale). RESULTS: Pre-programme cases (n = 703) (mean (SD) age 74 (14) years; female: 51%) and post-programme cases (n = 884) (mean age 74 (14) years; female: 49%) were comparable. Significant post-programme improvements for most process indicators were found, such as more brain imaging within 24 hours. Post-programme, access to SCUs increased 22-fold (95% CI 16.8 to 28.3). Improvement in inpatient independence at post-programme discharge was significant compared with pre-programme outcomes (proportional odds ratio 0.73, 95% CI 0.57 to 0.94; p = 0.013) when adjusted for patient clustering and case mix. CONCLUSIONS: This distinctive SCU initiative was shown as effective for improving clinical practice and significantly reducing disability following stroke.


Asunto(s)
Implementación de Plan de Salud , Unidades Hospitalarias/normas , Calidad de la Atención de Salud , Accidente Cerebrovascular/terapia , Anciano , Anciano de 80 o más Años , Femenino , Accesibilidad a los Servicios de Salud/economía , Humanos , Masculino , Auditoría Médica , Registros Médicos , Nueva Gales del Sur , Evaluación de Procesos y Resultados en Atención de Salud , Admisión del Paciente , Evaluación de Programas y Proyectos de Salud , Indicadores de Calidad de la Atención de Salud , Estudios Retrospectivos , Accidente Cerebrovascular/complicaciones
19.
Intern Med J ; 36(11): 700-4, 2006 Nov.
Artículo en Inglés | MEDLINE | ID: mdl-17040355

RESUMEN

BACKGROUND: There is level I evidence that management of stroke patients in stroke units (SU) improves outcomes (death and institutionalization) by approximately 20%. In Australia, there is uncertainty as to the proportion of incident cases that have access to SU. Recent national and State-based policy initiatives to increase access to SU have been taken. However, objective evidence related to SU implementation progress is lacking. The aims of the study were (i) to determine the number of SU in Australian acute public hospitals in 2004, (ii) to describe hospitals according to national SU policy criteria and (iii) to compare results to the 1999 survey to track progress. METHODS: The method used in the study was a cross-sectional, postal survey technique. The participants were clinical representatives considered appropriate to describe stroke care within survey hospitals. RESULTS: The outcome of the study was presence of a SU according to an accepted definition. Response rate was 261/301 (87%). Sixty-one sites (23%) had either a SU and/or a dedicated stroke team. Fifty sites claimed to have a SU (19%). New South Wales with 23 had the most number of SU. Based on policy criteria, up to 64 sites could have a SU. In 1999, there were 35 public hospitals with a SU. CONCLUSION: Access to SU in Australian public hospitals remains low compared with other countries (Sweden, 70%). Implementation strategies supported by appropriate health policy to improve access are needed.


Asunto(s)
Accesibilidad a los Servicios de Salud/tendencias , Unidades Hospitalarias/provisión & distribución , Hospitales Públicos/organización & administración , Accidente Cerebrovascular/terapia , Australia/epidemiología , Humanos , Accidente Cerebrovascular/epidemiología
20.
Aust Nurs J ; 5(11): 18-21, 1998 Jun.
Artículo en Inglés | MEDLINE | ID: mdl-10639958

RESUMEN

Stroke, the leading cause of adult disability in our society and third most common cause of death, costs our community around $1.2 billion per year. As a medical condition, stroke conjures negative images in the minds of health care providers and the general public as a condition for which little or nothing can be done.


Asunto(s)
Tratamiento de Urgencia/métodos , Fibrinolíticos/uso terapéutico , Fármacos Neuroprotectores/uso terapéutico , Inhibidores de Agregación Plaquetaria/uso terapéutico , Accidente Cerebrovascular/tratamiento farmacológico , Enfermedad Aguda , Australia/epidemiología , Tratamiento de Urgencia/enfermería , Tratamiento de Urgencia/tendencias , Humanos , Accidente Cerebrovascular/epidemiología , Accidente Cerebrovascular/enfermería , Rehabilitación de Accidente Cerebrovascular
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