Comprehensive quality assessment for aphasia rehabilitation after stroke: protocol for a multicentre, mixed-methods study.

INTRODUCTION: People with aphasia following stroke experience disproportionally poor outcomes, yet there is no comprehensive approach to measuring the quality of aphasia services. The Meaningful Evaluation of Aphasia SeRvicES (MEASuRES) minimum dataset was developed in partnership with people with lived experience of aphasia, clinicians and researchers to address this gap. It comprises sociodemographic characteristics, quality indicators, treatment descriptors and outcome measurement instruments. We present a protocol to pilot the MEASuRES minimum dataset in clinical practice, describe the factors that hinder or support implementation and determine meaningful thresholds of clinical change for core outcome measurement instruments. METHODS AND ANALYSIS: This research aims to deliver a comprehensive quality assessment toolkit for poststroke aphasia services in four studies. A multicentre pilot study (study 1) will test the administration of the MEASuRES minimum dataset within five Australian health services. An embedded mixed-methods process evaluation (study 2) will evaluate the performance of the minimum dataset and explore its clinical applicability. A consensus study (study 3) will establish consumer-informed thresholds of meaningful change on core aphasia outcome constructs, which will then be used to establish minimal important change values for corresponding core outcome measurement instruments (study 4). ETHICS AND DISSEMINATION: Studies 1 and 2 have been registered with the Australian and New Zealand Clinical Trial Registry (ACTRN12623001313628). Ethics approval has been obtained from the Royal Brisbane and Women's Hospital (HREC/2023/MNHB/95293) and The University of Queensland (2022/HE001946 and 2023/HE001175). Study findings will be disseminated through peer-reviewed publications, conference presentations and engagement with relevant stakeholders including healthcare providers, policy-makers, stroke and rehabilitation audit and clinical quality registry custodians, consumer support organisations, and individuals with aphasia and their families.

High-Intensity Aphasia Therapy Is Cost-Effective in People With Poststroke Aphasia: Evidence From the COMPARE Trial.

BACKGROUND: Evidence from systematic reviews confirms that speech and language interventions for people with aphasia during the chronic phase after stroke (>6 months) improve word retrieval, functional communication, and communication-related quality of life. However, there is limited evidence of their cost-effectiveness. We aimed to estimate the cost per quality-adjusted life year gained from 2 speech and language therapies compared with usual care in people with aphasia during the chronic phase (median, 2.9 years) after stroke. METHODS: A 3-arm, randomized controlled trial compared constraint-induced aphasia therapy plus (CIAT-Plus) and multimodality aphasia therapy (M-MAT) with usual care in 216 people with chronic aphasia. Participants were administered a standardized questionnaire before intervention and at 12 weeks after the 2-week intervention/control period to ascertain health service utilization, employment changes, and informal caregiver burden. Unit prices from Australian sources were used to estimate costs in 2020. Quality-adjusted life years were estimated using responses to the EuroQol-5 Dimension-3 Level questionnaire. To test uncertainty around the differences in costs and outcomes between groups, bootstrapping was used with the cohorts resampled 1000 times. RESULTS: Overall 201/216 participants were included (mean age, 63 years, 29% moderate or severe aphasia, 61 usual care, 70 CIAT-Plus, 70 M-MAT). There were no statistically significant differences in mean total costs ($13 797 usual care, $17 478 CIAT-Plus, $11 113 M-MAT) and quality-adjusted life years (0.19 usual care, 0.20 CIAT-Plus, 0.20 M-MAT) between groups. In bootstrapped analysis of CIAT-Plus, 21.5% of iterations were likely to result in better outcomes and be cost saving (dominant) compared with usual care. In contrast, 72.4% of iterations were more favorable for M-MAT than usual care. CONCLUSIONS: We observed that both treatments, but especially M-MAT, may result in better outcomes at an acceptable additional cost, or potentially with cost savings. These findings are relevant in advocating for the use of these therapies for chronic aphasia after stroke.

Towards efficient, ecological assessment of interaction: A scoping review of co-constructed communication.

BACKGROUND: The complexity of communication presents challenges for clinical assessment, outcome measurement and intervention for people with acquired brain injury. For the purposes of assessment or treatment, this complexity is usually managed by isolating specific linguistic functions or speech acts from the interactional context. Separating linguistic functions from their interactional context can lead to discourse being viewed as a static entity comprised of discrete features, rather than as a dynamic process of co-constructing meaning. The ecological validity of discourse assessments which rely on the deconstruction of linguistic functions is unclear. Previous studies have reported assessment tasks that preserve some of the dialogic features of communication, but as yet, these tasks have not been identified as a distinct genre of assessment. We suggest the term 'co-constructed communication' to describe tasks which are specifically designed to capture the dynamic, jointly produced nature of communication within a replicable assessment task. AIMS: To identify and summarize how co-constructed communication has been assessed with individuals with non-progressive acquired communication disability regarding task design, measures and psychometric robustness. METHODS: A scoping review methodology was used to identity relevant studies. Systematic database searches were conducted on studies published before July 2021. Studies in the yield were assessed against eligibility criteria, with 37 studies identified as eligible for inclusion. MAIN CONTRIBUTION: This is the first time that co-constructed communication has been defined as a genre of discourse assessment for stroke and traumatic brain injury populations. Co-constructed communication has been assessed for 144 individuals with aphasia and 111 with cognitive-communication disability. Five categories of co-constructed communication tasks were identified, ranging in complexity. Variability exists in how these assessment tasks are labelled and measured. Assessment measures require further psychometric profiling, specifically regarding test-retest reliability and validity. CONCLUSIONS: Co-constructed communication is a discourse genre which offers researchers and clinicians a replicable method to assess language and communication in an experimentally rigorous way, within an ecologically valid context, bridging the gap between experimental and ecological assessment approaches. WHAT THIS PAPER ADDS: What is already known on this subject Standardized assessments of language skills and monologue offer reliable, replicable ways to measure language. However, isolating language from an interactional context fundamentally changes the behaviour under study. This raises questions about the ecological validity of the measures we routinely use to determine diagnoses, guide treatment planning and measure the success of treatment. What this study adds to the existing knowledge This review highlights studies that conceptualize, and often quantify, interaction by combining experimental rigour and aspects of everyday dialogue. This is the first time this genre of discourse assessment has been identified. We propose the term 'co-constructed communication' to describe this genre and provide an operational definition for the term. What are the practical and clinical implications of this study? Co-constructed communication assessment tasks require refinement, particularly regarding aspects of psychometric robustness. In the future, these tasks offer pragmatic, meaningful ways to capture the effect and impact of aphasia and cognitive-communication disability within interaction.

The Excess Costs of Hospitalization for Acute Stroke in People With Communication Impairment: A Stroke123 Data Linkage Substudy.

OBJECTIVE: To describe the costs of hospital care for acute stroke for patients with aphasia or dysarthria. DESIGN: Observational study from the Stroke123 project. SETTING: Data from patients admitted with stroke (2009-2013) from 22 hospitals in Queensland participating in the Australian Stroke Clinical Registry (AuSCR) were linked to administrative datasets. PARTICIPANTS: Communication impairments were identified using International Classification of Diseases, 10th Revision, Australian Modification codes. Overall, 1043 of 4195 (25%) patients were identified with aphasia (49% were women; median age 78 years; 83% with ischemic stroke), and 1005 (24%) with dysarthria (42% were women; median age 76 years; 85% with ischemic stroke). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Linked patient-level, hospital clinical costing related to the stroke, were adjusted to 2013/2014 Australian dollars (AU$, US$ conversion x 0.691) using recommended national price indices and multivariable regression analysis with clustering by hospital performed. RESULTS: Compared with patients without aphasia, the median hospital costs/patient were greater for those with aphasia for medical (aphasia AU$2273 vs AU$1727, P<.001), nursing (aphasia AU$3829 vs AU$2748, P<.001) and allied health services (aphasia AU$1138 vs AU$720, P<.001). Similarly, costs were greater for patients with dysarthria compared with those without dysarthria. Adjusted median total costs were AU$2882 greater for patients with aphasia compared with patients without aphasia (95% confidence interval, AU$1880-3884), and AU$843 greater for patients with dysarthria compared with those without dysarthria (95% confidence interval, AU$-301 to 1987). CONCLUSIONS: People with communication impairment after stroke incur greater hospital costs, in particular for medical, allied health, and nursing resources.

Constraint-induced or multi-modal personalized aphasia rehabilitation (COMPARE): A randomized controlled trial for stroke-related chronic aphasia.

RATIONALE: The comparative efficacy and cost-effectiveness of constraint-induced and multi-modality aphasia therapy in chronic stroke are unknown. AIMS AND HYPOTHESES: In the COMPARE trial, we aim to determine whether Multi-Modal Aphasia Treatment (M-MAT) and Constraint-Induced Aphasia Therapy Plus (CIAT-Plus) are superior to usual care (UC) for chronic post-stroke aphasia. Primary hypothesis: CIAT-Plus and M-MAT will reduce aphasia severity (Western Aphasia Battery-Revised Aphasia Quotient (WAB-R-AQ)) compared with UC: CIAT-Plus superior for moderate aphasia; M-MAT superior for mild and severe aphasia. SAMPLE SIZE ESTIMATES: A total of 216 participants (72 per arm) will provide 90% power to detect a 5-point difference on the WAB-R-AQ between CIAT-Plus or M-MAT and UC at α = 0.05. METHODS AND DESIGN: Prospective, randomized, parallel group, open-label, assessor blinded trial. Participants: Stroke >6 months; aphasia severity categorized using WAB-R-AQ. Computer-generated blocked and stratified randomization by aphasia severity (mild, moderate, and severe), to 3 arms: CIAT-Plus, M-MAT (both 30 h therapy over two weeks); UC (self-reported usual community care). STUDY OUTCOMES: WAB-R-AQ immediately post-intervention. Secondary outcomes: WAB-R-AQ at 12-week follow-up; naming scores, discourse measures, Communicative Effectiveness Index, Scenario Test, and Stroke and Aphasia Quality of Life Scale-39 g immediately and at 12 weeks post-intervention; incremental cost-effectiveness ratios compared with UC at 12 weeks. DISCUSSION: This trial will determine whether CIAT-Plus and M-MAT are superior and more cost-effective than UC in chronic aphasia. Participant subgroups with the greatest response to CIAT-Plus and M-MAT will be described.

Statistical analysis plan (SAP) for the Very Early Rehabilitation in Speech (VERSE) after stroke trial: an international 3-arm clinical trial to determine the effectiveness of early, intensive, prescribed, direct aphasia therapy.

Background Limited evidence exists to support very early intensive aphasia rehabilitation after stroke. VERSE is a PROBE trial designed to determine whether two types of intensive aphasia therapy, beginning within 14 days of acute stroke, provide greater therapeutic and cost-effectiveness than usual care. Objective To publish the detailed statistical analysis plan for the VERSE trial prior to unblinding. This statistical analysis plan was based on the published and registered VERSE trial protocol and was developed by the blinded steering committee and management team, led by the trial statistician. This plan was developed using outcome measures and trial data collection forms. Results The VERSE statistical analysis plan is consistent with reporting standards for clinical trials and provides for clear and open reporting. Conclusions Publication of a statistical analysis plan serves to reduce potential trial reporting bias and outlines transparent pre-specified analyses. Australian New Zealand Clinical Trials Registry (ANZCTR) Registration number: ACTRN12613000776707; Universal Trial Number (UTN) is U1111-1145-4130.

Current Australian speech-language pathology practice in addressing psychological well-being in people with aphasia after stroke.

PURPOSE: Psychological well-being is essential to overall health; however, there is a paucity of research on how to address psychological well-being in stroke survivors with aphasia. This study describes the current beliefs, attitudes and practices of Australian speech-language pathologists in addressing psychological well-being in people with aphasia after stroke. METHOD: A 26-item web-based survey consisting of open and closed questions was distributed to Australian speech-language pathologists through four electronic databases. RESULT: Australian speech-language pathologists (n = 111) utilized counselling and clinical approaches to address psychological well-being in people with post-stroke aphasia. The majority of speech-language pathologists did not feel comfortable with addressing psychological well-being in people with aphasia and sought support from other health professionals in this practice. Self-perception of being under-skilled was the main barrier identified to adequate practice in this domain, followed by inadequate time, inadequate staffing and people with aphasia declining referral to counselling. The main facilitators reported by speech-language pathologists to address psychological well-being included personal interest, personal and professional experience and availability of counselling health professionals for people with aphasia. There were small-to-medium statistically significant correlations between speech-language pathologists reporting additional training in counselling and perceived knowledge of, confidence in and satisfaction with managing psychological well-being in people with aphasia. CONCLUSION: This study identifies factors requiring attention in order to enable speech-language pathologists to facilitate improved psychological well-being in people with aphasia.

Practices and challenges in community aphasia groups in Australia: Results of a national survey.

PURPOSE: This study reports on practices and challenges in developing community aphasia groups in Australia. METHOD: A 24-item web-based survey addressed the structure of existing community aphasia groups, funding models, group activities, facilitator satisfaction, challenges to group development and maintenance and suggestions for improvement. A total of 156 surveys were completed, mostly by speech-language pathologists (SLPs), with 66% urban and 34% regional/rural/remote participants representing all Australian states/territories consistent with their populations. RESULT: Seventy respondents indicated running a total of 86 groups, reflecting a substantial under-representation of service in proportion to the population of people with aphasia. Further, 23.6% of respondents reported dissatisfaction with aspects of their groups. The primary barriers to achieving satisfaction relate to limited resources and staffing, inability to run sufficient numbers of groups and to tailor them effectively, dispersed populations beyond major cities, group dynamics and a lack of group promotion and referral to groups. Respondents suggested means for improvement including changes to group structure, improved SLP training, dedicated funding and staffing, development of specific resources and better liaison and promotion. CONCLUSION: The major features differentiating the community aphasia groups run in Australia from those running overseas are discussed and practical ways to achieve service improvement are suggested.

Intensive comprehensive aphasia programs: an international survey of practice.

BACKGROUND: In response to the need to simultaneously address multiple domains of the International Classification of Functioning, Disability and Health (ICF) in aphasia therapy and to incorporate intensive treatment doses consistent with principles of neuroplasticity, a potentially potent treatment option termed intensive comprehensive aphasia programs (ICAPs) has been developed. OBJECTIVE: To conduct an international survey of ICAPs to determine the extent of their use and to explore current ICAP practices. METHODS: A 32-item online survey was distributed internationally through Survey Monkey between May and August 2012. The survey addressed ICAP staffing, philosophy, values, funding, admission criteria, activities, family involvement, outcome measures, and factors considered important to success. RESULTS: Twelve ICAPs responded: 8 from the United States, 2 from Canada, and 1 each from Australia and the United Kingdom. The majority of ICAPs are affiliated with university programs and are funded through participant self-pay. ICAPs emphasize individualized treatment goals and evidence-based practices, with a focus on applying the principles of neuroplasticity related to repetition and intensity of treatment. On average, 6 people with aphasia attend each ICAP, for 4 days per week for 4 weeks, receiving about 100 hours of individual, group, and computer-based treatment. Speech-language pathologists, students, and volunteers staff the majority of ICAPs. CONCLUSIONS: ICAPs are increasing in number but remain a rare service delivery option. They address the needs of individuals who want access to intensive treatment and are interested in making significant changes to their communication skills and psychosocial well-being in a short period of time. Their efficacy and cost-effectiveness require future investigation.