Impact of COVID-19 on the Speech and Language Therapy Profession and Their Patients.

Introduction: The UK's response to the COVID-19 pandemic presented multiple challenges to healthcare services including the suspension of non-urgent care. The impact on neurorehabilitation professions, including speech and language therapy (SLT), has been substantial. Objectives: To review the changes to SLT services triggered by the COVID-19 pandemic with respect to referral rates, service delivery and outcomes, as well as examining the contribution of SLTs to the neurorehabilitation of COVID-19 patients. Methods: Two surveys were distributed to Royal College of Speech and Language Therapists (RCSLT) members exploring experiences of service provision at 6 weeks and 22 weeks after the pandemic was declared in the UK. Responses to closed-ended questions, including questions regarding referral numbers were analyzed descriptively and compared at the two time-points. A database comprising routine clinical data from SLT services across the UK was used to compare information on patients receiving services prior to and during the pandemic. Data on COVID-19 patients was extracted, and findings are provided descriptively. Results: Referrals to SLT services during the acute COVID-19 period in the UK were substantially less than in the same period in 2019. A number of service changes were common including adopting more flexible approaches to provision (such as tele-therapy) and being unable to provide services to some patients. Database analysis suggests fewer patients have accessed SLT since the pandemic began, including a reduction in neurorehabilitation patients. For those who received SLT, the outcomes did not change. SLTs supported a range of needs of COVID-19 patients. Treatment outcomes for COVID-19 patients with dysphagia were positive. Discussion: The pandemic has affected neurorehabilitation and SLT services broadly: referral patterns are different, usual care has been disrupted and interventions have been modified affecting the impact on patient outcomes both positively and negatively. Some patients with COVID-19 require and benefit from SLT intervention.

Self-managed, computerised word finding therapy as an add-on to usual care for chronic aphasia post-stroke: An economic evaluation.

OBJECTIVE: To examine the cost-effectiveness of self-managed computerised word finding therapy as an add-on to usual care for people with aphasia post-stroke. DESIGN: Cost-effectiveness modelling over a life-time period, taking a UK National Health Service (NHS) and personal social service perspective. SETTING: Based on the Big CACTUS randomised controlled trial, conducted in 21 UK NHS speech and language therapy departments. PARTICIPANTS: Big CACTUS included 278 people with long-standing aphasia post-stroke. INTERVENTIONS: Computerised word finding therapy plus usual care; usual care alone; usual care plus attention control. MAIN MEASURES: Incremental cost-effectiveness ratios (ICER) were calculated, comparing the cost per quality adjusted life year (QALY) gained for each intervention. Credible intervals (CrI) for costs and QALYs, and probabilities of cost-effectiveness, were obtained using probabilistic sensitivity analysis. Subgroup and scenario analyses investigated cost-effectiveness in different subsets of the population, and the sensitivity of results to key model inputs. RESULTS: Adding computerised word finding therapy to usual care had an ICER of £42,686 per QALY gained compared with usual care alone (incremental QALY gain: 0.02 per patient (95% CrI: -0.05 to 0.10); incremental costs: £732.73 per patient (95% CrI: £674.23 to £798.05)). ICERs for subgroups with mild or moderate word finding difficulties were £22,371 and £21,262 per QALY gained respectively. CONCLUSION: Computerised word finding therapy represents a low cost add-on to usual care, but QALY gains and estimates of cost-effectiveness are uncertain. Computerised therapy is more likely to be cost-effective for people with mild or moderate, as opposed to severe, word finding difficulties.

Where are we now with aphasia after Stroke?

OBJECTIVE: To provide a brief review of research literature relating to the current state of knowledge regarding speech and language therapy for people with aphasia and place these research findings within the context of outcome data of non-selected patients receiving usual therapy in the UK. METHODS: Part 1 presents a literature search aimed at exploring up-to-date information related to the nature and evolution of aphasia, the impact of therapy and the changing nature of therapy. This provides the context of what may be achieved in rehabilitation. Part 2 examines of the impact of speech and language therapy on 1664 prospective patients receiving therapy for aphasia after stroke by 3 different types of service provision was collected and statistically analysed. The Therapy Outcome Measure was used to identify change in impairment, activity, participation and well-being at the beginning and end of therapy. RESULTS: The findings from the non-selected group of patients supports the conclusions of the reported randomised control trials in that speech and language therapy for post stroke aphasia is associated with gains in one or more of the domains of the International Classification of Functioning.

Computerised speech and language therapy or attention control added to usual care for people with long-term post-stroke aphasia: the Big CACTUS three-arm RCT.

BACKGROUND: People with aphasia may improve their communication with speech and language therapy many months/years after stroke. However, NHS speech and language therapy reduces in availability over time post stroke. OBJECTIVE: This trial evaluated the clinical effectiveness and cost-effectiveness of self-managed computerised speech and language therapy to provide additional therapy. DESIGN: A pragmatic, superiority, single-blind, parallel-group, individually randomised (stratified block randomisation, stratified by word-finding severity and site) adjunct trial. SETTING: Twenty-one UK NHS speech and language therapy departments. PARTICIPANTS: People with post-stroke aphasia (diagnosed by a speech and language therapist) with long-standing (> 4 months) word-finding difficulties. INTERVENTIONS: The groups were (1) usual care; (2) daily self-managed computerised word-finding therapy tailored by speech and language therapists and supported by volunteers/speech and language therapy assistants for 6 months plus usual care (computerised speech and language therapy); and (3) activity/attention control (completion of puzzles and receipt of telephone calls from a researcher for 6 months) plus usual care. MAIN OUTCOME MEASURES: Co-primary outcomes - change in ability to find treated words of personal relevance in a bespoke naming test (impairment) and change in functional communication in conversation rated on the activity scale of the Therapy Outcome Measures (activity) 6 months after randomisation. A key secondary outcome was participant-rated perception of communication and quality of life using the Communication Outcomes After Stroke questionnaire at 6 months. Outcomes were assessed by speech and language therapists using standardised procedures. Cost-effectiveness was estimated using treatment costs and an accessible EuroQol-5 Dimensions, five-level version, measuring quality-adjusted life-years. RESULTS: A total of 818 patients were assessed for eligibility and 278 participants were randomised between October 2014 and August 2016. A total of 240 participants (86 usual care, 83 computerised speech and language therapy, 71 attention control) contributed to modified intention-to-treat analysis at 6 months. The mean improvements in word-finding were 1.1% (standard deviation 11.2%) for usual care, 16.4% (standard deviation 15.3%) for computerised speech and language therapy and 2.4% (standard deviation 8.8%) for attention control. Computerised speech and language therapy improved word-finding 16.2% more than usual care did (95% confidence interval 12.7% to 19.6%; p < 0.0001) and 14.4% more than attention control did (95% confidence interval 10.8% to 18.1%). Most of this effect was maintained at 12 months (n = 219); the mean differences in change in word-finding score were 12.7% (95% confidence interval 8.7% to 16.7%) higher in the computerised speech and language therapy group (n = 74) than in the usual-care group (n = 84) and 9.3% (95% confidence interval 4.8% to 13.7%) higher in the computerised speech and language therapy group than in the attention control group (n = 61). Computerised speech and language therapy did not show significant improvements on the Therapy Outcome Measures or Communication Outcomes After Stroke scale compared with usual care or attention control. Primary cost-effectiveness analysis estimated an incremental cost per participant of £732.73 (95% credible interval £674.23 to £798.05). The incremental quality-adjusted life-year gain was 0.017 for computerised speech and language therapy compared with usual care, but its direction was uncertain (95% credible interval -0.05 to 0.10), resulting in an incremental cost-effectiveness ratio of £42,686 per quality-adjusted life-year gained. For mild and moderate word-finding difficulty subgroups, incremental cost-effectiveness ratios were £22,371 and £28,898 per quality-adjusted life-year gained, respectively, for computerised speech and language therapy compared with usual care. LIMITATIONS: This trial excluded non-English-language speakers, the accessible EuroQol-5 Dimensions, five-level version, was not validated and the measurement of attention control fidelity was limited. CONCLUSIONS: Computerised speech and language therapy enabled additional self-managed speech and language therapy, contributing to significant improvement in finding personally relevant words (as specifically targeted by computerised speech and language therapy) long term post stroke. Gains did not lead to improvements in conversation or quality of life. Cost-effectiveness is uncertain owing to uncertainty around the quality-adjusted life-year gain, but computerised speech and language therapy may be more cost-effective for participants with mild and moderate word-finding difficulties. Exploring ways of helping people with aphasia to use new words in functional communication contexts is a priority. TRIAL REGISTRATION: Current Controlled Trials ISRCTN68798818. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 19. See the NIHR Journals Library website for further project information. The Tavistock Trust for Aphasia provided additional support to enable people in the control groups to experience the intervention after the trial had ended.

Aphasia is a communication disorder that can be caused by a stroke. It affects a person's understanding of spoken words and their talking, reading and writing abilities. Communication may improve months, or years, after a stroke with speech and language therapy. Many patients want more speech and language therapy than the NHS can provide. The Big CACTUS (clinical and cost-effectiveness of aphasia computer treatment versus usual stimulation or attention control long term post-stroke) trial evaluated the use of speech and language therapy software for people with aphasia to practise finding words independently at home on their own computer or one loaned by the NHS. People with aphasia who had had a stroke at least 4 months previously were randomly allocated to one of three groups: usual speech and language therapy caredaily use of computerised speech and language therapy for 6 months, tailored by a speech and language therapist and supported by a volunteer or speech and language therapy assistantdaily completion of puzzles and supportive telephone calls from a researcher to mimic the activity/attention the computerised speech and language therapy group received. All groups received usual speech and language therapy. A total of 278 people with aphasia took part in this trial, from 21 UK NHS speech and language therapy departments. They had their strokes between 4 months and 36 years previously. Computerised speech and language therapy enabled more practice (28 hours on average) than usual speech and language therapy (3.8 hours). The computerised speech and language therapy group significantly improved their ability to say words they chose to practise compared with those in the usual speech and language therapy or puzzle book groups. Although computerised speech and language therapy can help people with aphasia to learn new words for years after stroke, no improvements in conversation or quality of life were seen. The cost-effectiveness for the NHS is still uncertain. However, our best estimate is that it is unlikely to be cost-effective for everyone with aphasia, but it may be cost-effective for people with mild and moderate word-finding difficulties. Next steps will focus on how to encourage use of new words in conversation to have an impact on quality of life.

Towards a theoretical framework for Integrated Team Leadership (IgTL).

This study presents a framework for the leadership of integrated, interprofessional health, and social-care teams (IgTs) based on a previous literature review and a qualitative study. The theoretical framework for Integrated Team Leadership (IgTL) is based on contributions from 15 professional and nonprofessional staff, in 8 community teams in the United Kingdom. Participants shared their perceptions of IgT's good practice in relation to patient outcomes. There were two clear elements, Person-focused and Task-focused leadership behaviors with particular emphasis on the facilitation of shared professional practices. Person-focused leadership skills include: inspiring and motivating; walking the talk; change and innovation; consideration; empowerment, teambuilding and team maintenance; and emotional intelligence. Task-focused leadership behaviors included: setting team direction; managing performance; and managing external relationships. Team members felt that the IgTL should be: a Health or Social Care (HSC) professional; engaged in professional practice; and have worked in an IgT before leading one. Technical and cultural issues were identified that differentiate IgTL from usual leadership practice; in particular the ability to facilitate or create barriers to effective integrated teamworking within the organizational context. In common with other OECD countries, there are policy imperatives in England for further integration of health and social care, needed to improve the quality and effectiveness of care for older people with multiple conditions. Further attention is needed to support the development of effective IgTs and leadership will be a pre-requisite to achieve this vision. The research advances the understanding of the need for skilled interprofessional leadership practice.

Self-managed, computerised speech and language therapy for patients with chronic aphasia post-stroke compared with usual care or attention control (Big CACTUS): a multicentre, single-blinded, randomised controlled trial.

BACKGROUND: Post-stroke aphasia might improve over many years with speech and language therapy; however speech and language therapy is often less readily available beyond a few months after stroke. We assessed self-managed computerised speech and language therapy (CSLT) as a means of providing more therapy than patients can access through usual care alone. METHODS: In this pragmatic, superiority, three-arm, individually randomised, single-blind, parallel group trial, patients were recruited from 21 speech and language therapy departments in the UK. Participants were aged 18 years or older and had been diagnosed with aphasia post-stroke at least 4 months before randomisation; they were excluded if they had another premorbid speech and language disorder caused by a neurological deficit other than stroke, required treatment in a language other than English, or if they were currently using computer-based word-finding speech therapy. Participants were randomly assigned (1:1:1) to either 6 months of usual care (usual care group), daily self-managed CSLT plus usual care (CSLT group), or attention control plus usual care (attention control group) with the use of computer-generated stratified blocked randomisation (randomly ordered blocks of sizes three and six, stratified by site and severity of word finding at baseline based on CAT Naming Objects test scores). Only the outcome assessors and trial statistician were masked to the treatment allocation. The speech and language therapists who were doing the outcome assessments were different from those informing participants about which group they were assigned to and from those delivering all interventions. The statistician responsible for generating the randomisation schedule was separate from those doing the analysis. Co-primary outcomes were the change in ability to retrieve personally relevant words in a picture naming test (with 10% mean difference in change considered a priori as clinically meaningful) and the change in functional communication ability measured by masked ratings of video-recorded conversations, with the use of Therapy Outcome Measures (TOMs), between baseline and 6 months after randomisation (with a standardised mean difference in change of 0·45 considered a priori as clinically meaningful). Primary analysis was based on the modified intention-to-treat (mITT) population, which included randomly assigned patients who gave informed consent and excluded those without 6-month outcome measures. Safety analysis included all participants. This trial has been completed and was registered with the ISRCTN, number ISRCTN68798818. FINDINGS: From Oct 20, 2014, to Aug 18, 2016, 818 patients were assessed for eligibility, of which 278 (34%) participants were randomly assigned (101 [36%] to the usual care group; 97 [35%] to the CSLT group; 80 [29%] to the attention control group). 86 patients in the usual care group, 83 in the CSLT group, and 71 in the attention control group contributed to the mITT. Mean word finding improvements were 1·1% (SD 11·2) in the usual care group, 16·4% (15·3) in the CSLT group, and 2·4% (8·8) in the attention control group. Word finding improvement was 16·2% (95% CI 12·7 to 19·6; p<0·0001) higher in the CSLT group than in the usual care group and was 14·4% (10·8 to 18·1) higher than in the attention control group. Mean changes in TOMs were 0·05 (SD 0·59) in the usual care group (n=84), 0·04 (0·58) in the CSLT group (n=81), and 0·10 (0·61) in the attention control group (n=68); the mean difference in change between the CSLT and usual care groups was -0·03 (-0·21 to 0·14; p=0·709) and between the CSLT and attention control groups was -0·01 (-0·20 to 0·18). The incidence of serious adverse events per year were rare with 0·23 events in the usual care group, 0·11 in the CSLT group, and 0·16 in the attention control group. 40 (89%) of 45 serious adverse events were unrelated to trial activity and the remaining five (11%) of 45 serious adverse events were classified as unlikely to be related to trial activity. INTERPRETATION: CSLT plus usual care resulted in a clinically significant improvement in personally relevant word finding but did not result in an improvement in conversation. Future studies should explore ways to generalise new vocabulary to conversation for patients with chronic aphasia post-stroke. FUNDING: National Institute for Health Research, Tavistock Trust for Aphasia.

A core outcome set for aphasia treatment research: The ROMA consensus statement.

BACKGROUND: A core outcome set (COS; an agreed, minimum set of outcomes) was needed to address the heterogeneous measurement of outcomes in aphasia treatment research and to facilitate the production of transparent, meaningful, and efficient outcome data. OBJECTIVE: The Research Outcome Measurement in Aphasia (ROMA) consensus statement provides evidence-based recommendations for the measurement of outcomes for adults with post-stroke aphasia within phases I-IV aphasia treatment studies. METHODS: This statement was informed by a four-year program of research, which comprised investigation of stakeholder-important outcomes using consensus processes, a scoping review of aphasia outcome measurement instruments, and an international consensus meeting. This paper provides an overview of this process and presents the results and recommendations arising from the international consensus meeting. RESULTS: Five essential outcome constructs were identified: Language, communication, patient-reported satisfaction with treatment and impact of treatment, emotional wellbeing, and quality of life. Consensus was reached for the following measurement instruments: Language: The Western Aphasia Battery Revised (WAB-R) (74% consensus); emotional wellbeing: General Health Questionnaire (GHQ)-12 (83% consensus); quality of life: Stroke and Aphasia Quality of Life Scale (SAQOL-39) (96% consensus). Consensus was unable to be reached for measures of communication (where multiple measures exist) or patient-reported satisfaction with treatment or impact of treatment (where no measures exist). DISCUSSION: Harmonization of the ROMA COS with other core outcome initiatives in stroke rehabilitation is discussed. Ongoing research and consensus processes are outlined. CONCLUSION: The WAB-R, GHQ-12, and SAQOL-39 are recommended to be routinely included within phases I-IV aphasia treatment studies. This consensus statement has been endorsed by the Collaboration of Aphasia Trialists, the British Aphasiology Society, the German Society for Aphasia Research and Therapy, and the Royal College of Speech Language Therapists.

Leadership in interprofessional health and social care teams: a literature review.

Purpose The purpose of this study is to review evidence on the nature of effective leadership in interprofessional health and social care teams. Design/methodology/approach A critical review and thematic synthesis of research literature conducted using systematic methods to identify and construct a framework to explain the available evidence about leadership in interprofessional health and social care teams. Findings Twenty-eight papers were reviewed and contributed to the framework for interprofessional leadership. Twelve themes emerged from the literature, the themes were: facilitate shared leadership; transformation and change; personal qualities; goal alignment; creativity and innovation; communication; team-building; leadership clarity; direction setting; external liaison; skill mix and diversity; clinical and contextual expertise. The discussion includes some comparative analysis with theories and themes in team management and team leadership. Originality/value This research identifies some of the characteristics of effective leadership of interprofessional health and social care teams. By capturing and synthesising the literature, it is clear that effective interprofessional health and social care team leadership requires a unique blend of knowledge and skills that support innovation and improvement. Further research is required to deepen the understanding of the degree to which team leadership results in better outcomes for both patients and teams.

Attention control comparisons with SLT for people with aphasia following stroke: methodological concerns raised following a systematic review.

OBJECTIVE: Attention control comparisons in trials of stroke rehabilitation require care to minimize the risk of comparison choice bias. We compared the similarities and differences in SLT and social support control interventions for people with aphasia. DATA SOURCES: Trial data from the 2016 Cochrane systematic review of SLT for aphasia after stroke Methods: Direct and indirect comparisons between SLT, social support and no therapy controls. We double-data extracted intervention details using the template for intervention description and replication. Standardized mean differences and risk ratios (95% confidence intervals (CIs)) were calculated. RESULTS: Seven trials compared SLT with social support ( n = 447). Interventions were matched in format, frequency, intensity, duration and dose. Procedures and materials were often shared across interventions. Social support providers received specialist training and support. Targeted language rehabilitation was only described in therapy interventions. Higher drop-out ( P = 0.005, odds ratio (OR) 0.51, 95% CI 0.32-0.81) and non-adherence to social support interventions ( P < 0.00001, OR 0.18, 95% CI 0.09-0.37) indicated an imbalance in completion rates increasing the risk of control comparison bias. CONCLUSION: Distinctions between social support and therapy interventions were eroded. Theoretically based language rehabilitation was the remaining difference in therapy interventions. Social support is an important adjunct to formal language rehabilitation. Therapists should continue to enable those close to the person with aphasia to provide tailored communication support, functional language stimulation and opportunities to apply rehabilitation gains. Systematic group differences in completion rates is a design-related risk of bias in outcomes observed.

Combined electrical stimulation and exercise for swallow rehabilitation post-stroke: a pilot randomized control trial.

BACKGROUND: Dysphagia is common after stroke, affecting up to 50% of patients initially. It can lead to post-stroke pneumonia, which causes 30% of stroke-related deaths, a longer hospital stay and poorer health outcomes. Dysphagia care post-stroke generally focuses on the management of symptoms, via modified oral intake textures and adapted posture, rather than direct physical rehabilitation of the swallowing function. Transcutaneous neuromuscular electrical stimulation (NMES) is a promising rehabilitation technology that can be used to stimulate swallowing; however, findings regarding efficacy have been conflicting. AIMS: This pilot randomized controlled study involving three UK sites compared the efficacy of the Ampcare Effective Swallowing Protocol (ESP), combining NMES with swallow-strengthening exercises, with usual care in order to clarify evidence on NMES in the treatment of dysphagia post-stroke. A further objective was to pilot recruitment procedures and outcome measures in order to inform the design of a full-scale trial. METHODS & PROCEDURES: Thirty patients were recruited and randomized into either (1) usual speech and language therapy dysphagia care; or (2) Ampcare ESP, receiving treatment 5 days/week for 4 weeks. Outcome measures included: the Functional Oral Intake Scale (FOIS), the Rosenbek Penetration-Aspiration Scale (PAS) and patient-reported outcomes (Swallow Related Quality of Life-SWAL-QOL). OUTCOMES & RESULTS: Thirty patients were recruited; 15 were randomized to the Ampcare ESP intervention arm and 15 to usual care. A greater proportion (75%, or 9/12) of patients receiving Ampcare ESP improved compared with 57% (or 8/14) of the usual-care group. Patients receiving Ampcare ESP also made clinically meaningful change (a comparative benefit of 1.5 on the FOIS, and on the PAS: 1.35 for diet and 0.3 for fluids) compared with usual care. The intervention group also reported much better outcome satisfaction. CONCLUSIONS & IMPLICATIONS: The pilot demonstrated successful recruitment, treatment safety and tolerability and clinically meaningful outcome improvements, justifying progression to a fully powered study. It also showed clinically meaningful treatment trends for the Ampcare ESP intervention.

Provision of powered communication aids in the United Kingdom.

AAC service provision in the United Kingdom (UK) has evolved since the first service dedicated to the provision of communication aids opened in 1986. Within the UK, many health and care services are provided via government funding; however, the assessment and provision of AAC and specifically of speech-generating devices (SGDs) is inconsistent and inequitable. The study reported in this paper aimed to collect information on levels of current provision of powered communication aids (the term used in the study to refer to SGDs) by UK service providers in 2013 with the intention of improving future estimates for need of services. A questionnaire survey was designed and data were obtained from 98 AAC services across the UK. Service providers reported the number of individuals known to be using powered communication aids and the mean value reported was 0.0155% of the services' catchment populations. However levels of service provision reported were highly variable. Although the data reported must be treated with caution, it adds to the sparse literature on the topic, informs AAC service design and delivery in the UK, and acts as an indicative baseline measure for future service development.

Speech pathology as the MasterChef: Getting the right ingredients and stirring the pot.

The purpose of this paper is to consider the many influences that have an impact on appropriate speech-language pathology service delivery. The competitive cooking and entertainment television program, MasterChef, is used as an analogy to consider the ingredients, blend and approach required to improve speech-language pathology services. Speech-language pathologists (SLPs) enter the profession with the aim of assisting those with communication and swallowing disorders to have a better quality of life. Thus, we should be restless to continue to improve our services in order to achieve the best influence and outcomes by changing our recipes and ingredients. However, having good technical skills as a SLP is not sufficient in ensuring that the services are the best they can be. We have to consider available resources, customers and service users, who it is that judges our services, whether we are as good as we could or should be, what can help us improve our services, what the appetite is for our services, and how we incorporate evidence-based practice. This paper considers the value of understanding and using information on incidence and prevalence, evidence-based practice and outcome measurement. Blending technical, clinical and academic abilities with personal skills will result in an award-winning menu.

Understanding the Models of Community Hospital rehabilitation Activity (MoCHA): a mixed-methods study.

INTRODUCTION: To understand the variation in performance between community hospitals, our objectives are: to measure the relative performance (cost efficiency) of rehabilitation services in community hospitals; to identify the characteristics of community hospital rehabilitation that optimise performance; to investigate the current impact of community hospital inpatient rehabilitation for older people on secondary care and the potential impact if community hospital rehabilitation was optimised to best practice nationally; to examine the relationship between the configuration of intermediate care and secondary care bed use; and to develop toolkits for commissioners and community hospital providers to optimise performance. METHODS AND ANALYSIS: 4 linked studies will be performed. Study 1: cost efficiency modelling will apply econometric techniques to data sets from the National Health Service (NHS) Benchmarking Network surveys of community hospital and intermediate care. This will identify community hospitals' performance and estimate the gap between high and low performers. Analyses will determine the potential impact if the performance of all community hospitals nationally was optimised to best performance, and examine the association between community hospital configuration and secondary care bed use. Study 2: a national community hospital survey gathering detailed cost data and efficiency variables will be performed. Study 3: in-depth case studies of 3 community hospitals, 2 high and 1 low performing, will be undertaken. Case studies will gather routine hospital and local health economy data. Ward culture will be surveyed. Content and delivery of treatment will be observed. Patients and staff will be interviewed. Study 4: co-designed web-based quality improvement toolkits for commissioners and providers will be developed, including indicators of performance and the gap between local and best community hospitals performance. ETHICS AND DISSEMINATION: Publications will be in peer-reviewed journals, reports will be distributed through stakeholder organisations. Ethical approval was obtained from the Bradford Research Ethics Committee (reference: 15/YH/0062).

The association between delays in screening for and assessing dysphagia after acute stroke, and the risk of stroke-associated pneumonia.

BACKGROUND: There is no robust evidence that screening patients with acute stroke for dysphagia reduces the risk of stroke-associated pneumonia (SAP), or of how quickly it should be done after admission. We aimed to identify if delays in bedside dysphagia screening and comprehensive dysphagia assessments by a speech and language therapist (SALT) were associated with patients' risk of SAP. METHODS: Nationwide, registry-based, prospective cohort study of patients admitted with acute stroke in England and Wales. Multilevel multivariable logistic regression models were fitted, adjusting for patient variables and stroke severity. The exposures were time from (1) admission to bedside dysphagia screen, and (2) admission to comprehensive dysphagia assessment. RESULTS: Of 63 650 patients admitted with acute stroke, 55 838 (88%) had a dysphagia screen, and 24 542 (39%) a comprehensive dysphagia assessment. Patients with the longest delays in dysphagia screening (4th quartile adjusted OR 1.14, 1.03 to 1.24) and SALT dysphagia assessment (4th quartile adjusted OR 2.01, 1.76 to 2.30) had a higher risk of SAP. The risk of SAP increased in a dose-response manner with delays in SALT dysphagia assessment, with an absolute increase of pneumonia incidence of 1% per day of delay. CONCLUSIONS: Delays in screening for and assessing dysphagia after stroke, are associated with higher risk of SAP. Since SAP is one of the main causes of mortality after acute stroke, early dysphagia assessment may contribute to preventing deaths from acute stroke and could be implemented even in settings without access to high-technology specialist stroke care.

Accessing rehabilitation after stroke - a guessing game?

AIM: To explore the use, meaning and value of the term "rehabilitation potential". METHOD: The authors of this commentary met to discuss concerns relating to the pressure on health service staff created by reduced length of stay in acute settings of those who have suffered a stroke and the need to determine the potential of a patient for rehabilitation in order to inform discharge arrangements. Points raised at this meeting were shared with an email group who over a 12-month period contributed to this paper. RESULTS: The group agreed that: (a) Given that there is very limited evidence to guide judgements regarding rehabilitation potential following stroke at an early stage the need for rehabilitation needs to be reviewed on a regular basis over a long period and that this needs to be reflected in clinical guidelines. (b) Rehabilitation needs to be available in a broad range of care settings, in order that discharge from hospital is not equated with a lack of rehabilitation potential. (c) Research related to rehabilitation potential needs to be conducted. This should examine influences of decision-making and the algorithms associated with recovery and local policy on rehabilitation potential. (d) The economic benefits of rehabilitation needs further exploration. (e) Assessment of rehabilitation potential should be made more explicit and supported by appropriate evidence. CONCLUSION: Whilst further research is required to assist in determining the right time for people to benefit from formal rehabilitation this gives the impression that one dose of rehabilitation at a specific time will meet all needs. It is likely that a rehabilitation pathway identifying features required in the early stages following stroke as well as that required over many years in order to prevent readmission, maintain fitness and prevent secondary sequelae such as depression and social isolation would be beneficial. Implications for Rehabilitation The potential of a patient to benefit from rehabilitation may be overlooked due to other pressures. Some patients following a stroke will demonstrate potential to benefit from rehabilitation later than the majority and this is not always easy to predict. Regular reassessment is required in order to identify whether an individual will benefit from rehabilitation at a particular time.

Speech and language therapy for aphasia following stroke.

BACKGROUND: Aphasia is an acquired language impairment following brain damage that affects some or all language modalities: expression and understanding of speech, reading, and writing. Approximately one third of people who have a stroke experience aphasia. OBJECTIVES: To assess the effects of speech and language therapy (SLT) for aphasia following stroke. SEARCH METHODS: We searched the Cochrane Stroke Group Trials Register (last searched 9 September 2015), CENTRAL (2015, Issue 5) and other Cochrane Library Databases (CDSR, DARE, HTA, to 22 September 2015), MEDLINE (1946 to September 2015), EMBASE (1980 to September 2015), CINAHL (1982 to September 2015), AMED (1985 to September 2015), LLBA (1973 to September 2015), and SpeechBITE (2008 to September 2015). We also searched major trials registers for ongoing trials including ClinicalTrials.gov (to 21 September 2015), the Stroke Trials Registry (to 21 September 2015), Current Controlled Trials (to 22 September 2015), and WHO ICTRP (to 22 September 2015). In an effort to identify further published, unpublished, and ongoing trials we also handsearched the International Journal of Language and Communication Disorders (1969 to 2005) and reference lists of relevant articles, and we contacted academic institutions and other researchers. There were no language restrictions. SELECTION CRITERIA: Randomised controlled trials (RCTs) comparing SLT (a formal intervention that aims to improve language and communication abilities, activity and participation) versus no SLT; social support or stimulation (an intervention that provides social support and communication stimulation but does not include targeted therapeutic interventions); or another SLT intervention (differing in duration, intensity, frequency, intervention methodology or theoretical approach). DATA COLLECTION AND ANALYSIS: We independently extracted the data and assessed the quality of included trials. We sought missing data from investigators. MAIN RESULTS: We included 57 RCTs (74 randomised comparisons) involving 3002 participants in this review (some appearing in more than one comparison). Twenty-seven randomised comparisons (1620 participants) assessed SLT versus no SLT; SLT resulted in clinically and statistically significant benefits to patients' functional communication (standardised mean difference (SMD) 0.28, 95% confidence interval (CI) 0.06 to 0.49, P = 0.01), reading, writing, and expressive language, but (based on smaller numbers) benefits were not evident at follow-up. Nine randomised comparisons (447 participants) assessed SLT with social support and stimulation; meta-analyses found no evidence of a difference in functional communication, but more participants withdrew from social support interventions than SLT. Thirty-eight randomised comparisons (1242 participants) assessed two approaches to SLT. Functional communication was significantly better in people with aphasia that received therapy at a high intensity, high dose, or over a long duration compared to those that received therapy at a lower intensity, lower dose, or over a shorter period of time. The benefits of a high intensity or a high dose of SLT were confounded by a significantly higher dropout rate in these intervention groups. Generally, trials randomised small numbers of participants across a range of characteristics (age, time since stroke, and severity profiles), interventions, and outcomes. AUTHORS' CONCLUSIONS: Our review provides evidence of the effectiveness of SLT for people with aphasia following stroke in terms of improved functional communication, reading, writing, and expressive language compared with no therapy. There is some indication that therapy at high intensity, high dose or over a longer period may be beneficial. HIgh-intensity and high dose interventions may not be acceptable to all.

Volunteer involvement in the support of self-managed computerised aphasia treatment: The volunteer perspective.

PURPOSE: The speech-language pathology profession has explored a number of approaches to support efficient delivery of interventions for people with stroke-induced aphasia. This study aimed to explore the role of volunteers in supporting self-managed practice of computerised language exercises. METHOD: A qualitative interview study of the volunteer support role was carried out alongside a pilot randomised controlled trial of computer aphasia therapy. Patients with aphasia practised computer exercises tailored for them by a speech-language pathologist at home regularly for 5 months. Eight of the volunteers who supported the intervention took part in semi-structured interviews. Interviews were audio recorded, transcribed verbatim and analysed thematically. RESULT: Emergent themes included: training and support requirements; perception of the volunteer role; challenges facing the volunteer, in general and specifically related to supporting computer therapy exercises. CONCLUSION: The authors concluded that volunteers helped to motivate patients to practise their computer therapy exercises and also provided support to the carers. Training and ongoing structured support of therapy activity and conduct is required from a trained speech-language pathologist to ensure the successful involvement of volunteers supporting impairment-based computer exercises in patients' own homes.

Negotiating excess treatment costs in a clinical research trial: the good, the bad and the innovative.

UNLABELLED: Barriers to recovering the excess treatment costs associated with health research from local organisations in the United Kingdom can increase research costs, delay completion of high- quality studies and risk disenfranchising health trusts and patients from participation. The authors demonstrate how the process for recovering excess treatment costs at a local National Health Service (NHS) trust level in a multicentre study was inconsistent and resulted in excess effort and cost to the research budget. An innovative example of how an organisation acting as a broker between commissioners and researchers facilitated a more timely excess treatment cost agreement is highlighted. TRIAL REGISTRATION: Current Controlled Trials ISRCTN68798818, registered on 18 February 2014.

The state of the art in non-pharmacological interventions for developmental stuttering. Part 2: qualitative evidence synthesis of views and experiences.

BACKGROUND: A range of interventions have been developed to treat stuttering in recent years. The effectiveness of these interventions has largely been assessed in studies focusing on the impact of specific types of therapy on patient outcomes. Relatively little is known about the factors that influence how the delivery and impact of different types of intervention may be experienced from the perspective of both people who deliver as well as those who receive interventions. AIMS: To synthesize the available evidence in relation to factors that might enhance or mitigate against successful outcomes following interventions for stuttering by identifying and synthesizing relevant qualitative research that explored the experiences of people delivering and receiving interventions that aim to improve fluency. METHODS & PROCEDURES: We carried out a systematic review including research that had used in-depth interviews and focus groups and conducted a substantive qualitative analysis of the data collected. Included study populations were either adults or children affected by a diagnosed stutter and/or providers of therapy for stuttering. An iterative approach was used to search for published qualitative evidence in relevant databases from 1990 to 2014. Retrieved citations were sifted for relevance and the data from articles that met the inclusion criteria were extracted. Each included paper was assessed for quality and a thematic analysis and synthesis of findings was carried out. MAIN CONTRIBUTION: Synthesized qualitative evidence highlights the changing experiences for people who stutter both historically and, for individuals, over the life course. Barriers and facilitators to the implementation of interventions for stuttering are encountered at the individual, intervention, interpersonal and social levels. Interventions may be particularly pertinent at certain transition points in the life course. Attention to emotional as well as practical aspects of stuttering is valued by people receiving therapy. The client-therapist relationship and support from others are also key factors in achieving successful outcomes. CONCLUSIONS & IMPLICATIONS: A synthesis of qualitative findings from published papers has added to the effectiveness data reported in an accompanying paper in understanding how stuttering impacts on people across the life course. Evidence suggests that a client-centred and individually tailored approach enhances the likelihood of successful intervention outcomes through attention to emotional, situational and practical needs.

The state of the art in non-pharmacological interventions for developmental stuttering. Part 1: a systematic review of effectiveness.

BACKGROUND: The growing range of available treatment options for people who stutter presents a challenge for clinicians, service managers and commissioners, who need to have access to the best available treatment evidence to guide them in providing the most appropriate interventions. While a number of reviews of interventions for specific populations or a specific type of intervention have been carried out, a broad-based systematic review across all forms of intervention for adults and children was needed to provide evidence to underpin future guidelines, inform the implementation of effective treatments and identify future research priorities. AIMS: To identify and synthesize the published research evidence on the clinical effectiveness of the broad range of non-pharmacological interventions for the management of developmental stuttering. METHODS & PROCEDURES: A systematic review of the literature reporting interventions for developmental stuttering was carried out between August 2013 and April 2014. Searches were not limited by language or location, but were restricted by date to studies published from 1990 onwards. Methods for the identification of relevant studies included electronic database searching, reference list checking, citation searching and hand searching of key journals. Appraisal of study quality was performed using a tool based on established criteria for considering risk of bias. Due to heterogeneity in intervention content and outcomes, a narrative synthesis was completed. MAIN CONTRIBUTION: The review included all available types of intervention and found that most may be of benefit to at least some people who stutter. There was evidence, however, of considerable individual variation in response to these interventions. The review indicated that effects could be maintained following all types of interventions (although this was weakest with regard to feedback and technology interventions). CONCLUSIONS: This review highlights a need for greater consensus with regard to the key outcomes used to evaluate stuttering interventions, and also a need for enhanced understanding of the process whereby interventions effect change. Further analysis of the variation in effectiveness for different individuals or groups is needed in order to identify who may benefit most from which intervention.