Guideline adherence in speech and language therapy in stroke aftercare. A health insurance claims data analysis.

BACKGROUND: Impairments to comprehension and production of speech (aphasia, dysarthria) and swallowing disorders (dysphagia) are common sequelae of stroke, reducing patients' quality of life and social participation. Treatment oriented on evidence-based guidelines seems likely to improve outcomes. Currently, little is known about guideline adherence in stroke aftercare for the above-mentioned sequelae. This study aims to analyse guideline adherence in the treatment of aphasia, dysarthria and dysphagia after stroke, based on suitable test parameters, and to determine factors that influence the implementation of recommended therapies. METHODS: Six test parameters were defined, based on systematic study of guidelines for the treatment of speech impairments and swallowing disorders (e.g. comprehensive diagnostics, early initiation and continuity). Guideline adherence in treatment was tested using claims data from four statutory health insurance companies. Multivariate logistic and linear regression analyses were performed in order to test the outcomes. RESULTS: 4,486 stroke patients who were diagnosed with specific disorders or received speech therapy were included in the study. The median age was 78 years; the proportion of women was 55.9%. Within the first year after the stroke, 90.3% of patients were diagnosed with speech impairments and swallowing disorders. Overall, 44.1% of patients received outpatient speech and language therapy aftercare. Women were less frequently diagnosed with specific disorders (OR 0.70 [95%CI:0.55/0.88], p = 0.003) and less frequently received longer therapy sessions (OR 0.64 [95%CI:0.43/0.94], p = 0.022). Older age and longer hospitalization duration increased the likelihood of guideline recommendations being implemented and of earlier initiation of stroke aftercare measures. CONCLUSIONS: Our observations indicate deficits in the implementation of guideline recommendations in stroke aftercare. At the same time, they underscore the need for regular monitoring of implementation measures in stroke aftercare to address group-based disparities in care.

Experiences of Physical Therapists and Professional Leaders With Implementing a Toolkit to Advance Walking Assessment Poststroke: A Realist Evaluation.

OBJECTIVE: The iWalk study showed significant increase in use of the 10-Meter Walk Test (10MWT) and 6-Minute Walk Test (6MWT) poststroke following provision of a toolkit. This paper examined the influence of contextual circumstances on use of the toolkit and implementation strategy across acute care and inpatient and outpatient rehabilitation settings. METHODS: A theory-based toolkit and implementation strategy was designed to support guideline recommendations to use standardized tools for evaluation of walking, education, and goal-setting poststroke. The toolkit comprised a mobile app, video, and educational guide outlining instructions for 3 learning sessions. After completing learning sessions, 33 physical therapists and 7 professional leaders participated in focus groups or interviews. As part of a realist evaluation, the study compared and synthesized site-specific context-mechanism-outcome descriptions across sites to refine an initial theory of how the toolkit would influence practice. RESULTS: Analysis revealed 3 context-mechanism-outcomes: (1) No onsite facilitator? No practice change in acute care: Without an onsite facilitator, participants lacked authority to facilitate and coordinate the implementation strategy; (2) Onsite facilitation fostered integration of select practices in acute care: When onsite facilitation occurred in acute care, walk test administration and use of reference values for patient education were adopted variably with high functioning patients; (3) Onsite facilitation fostered integration of most practices in rehabilitation settings: When onsite facilitation occurred, many participants incorporated 1 or both tests to evaluate and monitor walking capacity, and reference values were applied for inpatient and outpatient education and goal setting. Participants preferentially implemented the 10MWT over the 6MWT because set-up and administration were easier and a greater proportion of patients could walk 10 m. CONCLUSION: Findings underscore contextual factors and activities essential to eliciting change in assessment practice in stroke rehabilitation across care settings. IMPACT: This study shows that to foster recommended walking assessment practices, an onsite facilitator should be present to enable learning sessions and toolkit use.

Clinical Performance Measures for Stroke Rehabilitation: Performance Measures From the American Heart Association/American Stroke Association.

The American Heart Association/American Stroke Association released the adult stroke rehabilitation and recovery guidelines in 2016. A working group of stroke rehabilitation experts reviewed these guidelines and identified a subset of recommendations that were deemed suitable for creating performance measures. These 13 performance measures are reported here and contain inclusion and exclusion criteria to allow calculation of rates of compliance in a variety of settings ranging from acute hospital care to postacute care and care in the home and outpatient setting.

mHealth applications to support caregiver needs and engagement during stroke recovery: A content review.

Caregiving in stroke results in severe physical, psychological, and social impacts on the caregiver. Over the past few years, researchers have explored the use of mHealth technologies to support healthcare-related activities due to their ability to provide real-time care at any given place or time. The purpose of this content review is to investigate mHealth apps in supporting stroke caregiving engagement based on three aspects: motivation, value, and satisfaction. We searched app stores and repositories for apps related to stroke caregiving published up to September 2020. Extracted apps were reviewed and filtered using inclusion criteria, and then downloaded onto compatible devices to determine eligibility. Results were compared with evidence-based frameworks to identify the ability of these apps in engaging and supporting the caregiver. Forty-seven apps were included in this review that enabled caregivers to support their needs, such as adjustment to new roles and relationships, involvement in care and caring for oneself using several different functionalities. These functionalities include information resources, risk assessment, remote monitoring, data sharing, reminders and so on. However, no single app was identified that focuses on all aspects of stroke caregiving. We also identified several challenges faced by users through their reviews and the factors associated with value and satisfaction. Our findings can add to the knowledge of existing mHealth technologies and their functionalities to support stroke caregiving needs, and the importance of considering user engagement in the design. They can be used by developers and researchers looking to design better mHealth apps for stroke caregiving.

Documenting the impact of stroke in a middle-income country: a Malaysian case study.

Purpose: Stroke is an abrupt event that often leaves survivors with long term disabilities, causing role changes, and financial strains on households. The profound impact of stroke on survivors may lead to a decline in quality of life due to the physical, psychological, and social difficulties they experience. Taking Malaysia as an example, this study aimed to explore the impact of stroke on survivors and how health services influence their recovery in low and middle-income countries (LMIC).Method: An ethnographic approach with data obtained primarily through in-depth interviews was used. Twenty-seven participants identified as having suffered a stroke were drawn from a health and demographic surveillance system in Malaysia.Results: The physical and social disruption of the lives of stroke survivors was intensified by the resultant financial constraints placed upon individuals, families and households, compounded by inadequate support from the health, and welfare systems. Despite the disruption to their lives, most participants were, at least in part, able to reestablish their lives through various factors that include a strong family support and active coping strategies.Conclusion: In LMIC, recovery can be shaped by the family unit and through active coping strategies especially those in relation to spirituality.Implications for rehabilitationThe impact of stroke on survivors and lack of specialized stroke care compromise the recovery process and quality of life for stroke survivors in low and middle-income countries.Support from the family and reinforcement of religious coping were judged to successfully aid recovery.Physical and emotional impairments as well as psychosocial wellbeing of survivors in the context of environmental factors need to be addressed.

Studying the correlation between balance assessment by Biodex Stability System and Berg Scale in stroke individuals.

INTRODUCTION: Balance disorders are considered to be a serious clinical manifestation after stroke. Therefore, to assess stroke patients' balance performance, use of a quantitative method appears essential. A fundamental step would be the approval of the efficiency of the measurement instruments. The current study aimed to investigate correlations between balance assessment as examined by Biodex Stability System (BSS) and the clinical Berg Balance Scale (BBS) in post-stroke hemiparesis. METHODS: Twenty-five stroke survivors and 25 healthy age-sex matched subjects were recruited. The subjects were assessed using BSS during 3 days, with a 24-h interval. The high interclass correlation coefficient (ICC) values showed that the system was reliable enough to continue the study. The clinical evaluation was performed by the standard BBS. RESULTS: There was a significant moderate negative correlation between the Biodex overall indices and BBS scores in the stroke groups (ravg = -0.68) and in the healthy cohort (ravg = -0.55). Also, a significant moderate negative correlation was found between the Biodex antero-posterior stability indices and BBS scores in the stroke groups (ravg = -0.67) and in healthy cohort (ravg = -0.55). The correlation between the Biodex mediolateral stability indices and BBS scores was moderate to low in the stroke and healthy groups (ravg = -0.67 and -0.39 respectively). DISCUSSION AND CONCLUSION: Moderate negative correlation between the stability indices of the Biodex Stability System and BBS scores indicates that dynamic balance status of the participants partially reflects their functional balance status.

Assessment of the quality and content of clinical practice guidelines for post-stroke rehabilitation of aphasia.

OBJECTIVES: The purpose of this study was to evaluate the quality of guidelines for rehabilitation of post-stroke aphasia using the Appraisal of Guidelines for Research and Evaluation (AGREE-II) instrument and identify consistency of different guidelines. METHODS: A systematic search was undertaken from inception to October 2018. Two reviewers independently screened all titles and abstracts, and assessed eligible guidelines using the AGREE-II. Agreement among reviewers was measured by using intra-class correlation coefficient (ICC). RESULTS: From 5008 records screened, 8 guidelines met the inclusion criteria. The quality of guidelines was heterogeneous. Three guidelines were rated high (6.5) across; the highest rated domain was "scope and purpose' (median score 95.8%); the lowest rated domain was "rigor of development' (median score 67.2%). An overall high degree of agreement among reviewers to each domain was observed (ICC ranged from 0.60 to 0.99). The speech language therapy was recommended in 3 guidelines. Four guidelines described group treatment was beneficial for the continuum of care. However, other therapies for aphasia varied in the level of detail across guidelines. CONCLUSIONS: Our study indicated the quality of guidelines for post-stroke aphasia needed to be improved. Moreover, the treatment recommendations of aphasia existed discrepancy among the included guidelines. Therefore, it is suggested to pay more attention on the rigor of methodology and applicability during the process of the formulation of guideline. Future research should focus on the effectiveness, intensity, and duration of treatment measures.

The Effect of a Low-Cost Body Weight-Supported Treadmill Trainer on Walking Speed and Joint Motion.

Background and Objectives: Gait training with body weight-support has been shown to improve the walking speed of individuals with movement disorders. The AccesSportAmerica Gait Trainer is a low-cost, pre-market gait rehabilitation device that alters the stride characteristics of participants walking on a standard treadmill. The purpose of this study was to examine the biomechanical outcomes that training on this device has for people with brain injuries that affect motor functioning. It was hypothesized that there would be an increase in walking speed post-intervention, and that there would be an increase in step length and joint range-of-motion. Materials and Methods: An intervention study was conducted with 11 people with ambulatory difficulty caused by post-stroke hemiparesis (n = 7), traumatic brain injury (n = 3), and cerebral palsy (n = 1). The average time using the AccesSportAmerica Gait Trainer was 34.5 (SD = 6.0) minutes per session for 36.9 (SD = 21.8) sessions. Gait speed, step length and time, and joint flexion were measured during the 10 Meter Walk Test. Results: From pre- to post-intervention, there was a mean increase in walking speed of 0.19 m/s (SD = 0.06, p = 0.016, d = 0.40) and a decrease in step time of both affected and unaffected legs (affected: p = 0.011, d = 0.37; unaffected: p = 0.004, d = 0.67). There was no significant change in stride length or joint angles. Conclusions: The AccesSportAmerica Gait Trainer has the potential to improve the walking speed of people with ambulatory difficulty.

Test-retest reliability of the Mini Nutritional Assessment and its relationship with quality of life in patients with stroke.

BACKGROUND & OBJECTIVE: Malnutrition is one of commonly issues in patients with stroke. The Mini Nutritional Assessment (MNA) is a widely used measure for assessing nutritional status in patients with stroke. A nutritional measure with acceptable test-retest reliability allows clinicians to consistently assess patients' nutritional status. Knowledge of the relationship between nutritional status and quality of life (QOL) could guide clinicians to improve QOL in patients with stroke more effectively. This study aimed to examine test-retest reliability of the MNA and its relationship with QOL in patients with stroke. METHODS: Fifty-nine patients participated in the test-retest reliability study and the correlation between the MNA and WHO Quality of Life-BREF (WHOQOL-BREF) study. A repeated-assessments design (1 week apart) was used to examine the test-retest reliability of the MNA. RESULTS: The intraclass correlation coefficient for the MNA was 0.91. The minimal detectable change and percentage of minimal detectable change for the MNA were 2.1 and 8.2%, respectively. The MNA was positively associated with the QOL (r = 0.32; p = 0.013). The result of linear regression analysis shows that after controlling for age, sex and activities of daily living functions, only the MNA was significantly associated with the WHOQOL-BREF (r2 = 0.104; p = 0.008). CONCLUSIONS: The MNA has satisfactory test-retest reliability that is useful for repeatedly assessing the nutritional status of patients with stroke. The MDC of the MNA has acceptable random measurement error which is useful for determining whether the change score of a patient is outside the range of random measurement error. Future studies that recruit stroke patients in the acute stage is needed to further examine the relationship between the nutritional status and QOL.

Association Between Performance on an Interdisciplinary Stroke Assessment Battery and Falls in Patients With Acute Stroke in an Inpatient Rehabilitation Facility: A Retrospective Cohort Study.

OBJECTIVE: To explore the association between demographic factors and functional performance measures of patients with acute stroke in an inpatient rehabilitation facility (IRF) and falls during the IRF stay and to quantify the diagnostic accuracy of functional outcome measures in identifying fallers. DESIGN: Retrospective cohort study. SETTING: Inpatient rehabilitation facility. PARTICIPANTS: Individuals with acute stroke admitted to hospital-based IRF (N=139). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Odds ratios were used to examine the relationship between fall frequency and functional outcome measures (National Institute of Stroke Scale, neglect [Item #11], Berg Balance Scale, Stroke Rehabilitation Assessment of Movement mobility and Stroke Rehabilitation Assessment of Movement lower extremity subscales [STREAM-LE], Montreal Cognitive Assessment, Dynamic Gait Index, and Stroke Impact Scale). Receiver operator characteristic analysis with area under the curve, sensitivity, specificity, and diagnostic odds ratio were used to assess the diagnostic accuracy of each functional outcome measure to distinguish patients who fell vs those who did not fall in the IRF. RESULTS: A total of 23 patients (16.2%) fell during the IRF hospitalization. Patients who did and did not fall did not differ in terms of age, sex, stroke type, or stroke location. Only the STREAM-LE was associated with falls (odds ratio, 0.93; 95% CI, 0.86-0.99). Area under the curve was 0.67 (95% CI, 0.51-0.82). With a positivity cutoff point of 12, sensitivity and specificity were 73.3% (95% CI, 54.6%-92.2%) and 50.0% (95% CI, 39.9%-59.2%), respectively. The diagnostic odds ratio was 3.4. CONCLUSIONS: The STREAM-LE score at admission to IRF may identify patients with acute stroke who are more likely to fall during their stay. However, the search for measures with greater diagnostic accuracy should continue.

Sexual health policies in stroke rehabilitation: A multi national study.

OBJECTIVE: To identify and explore sexual health policies at specialized stroke rehabilitation centres in relation to the perspectives of healthcare personnel concerning sexual health. DESIGN: Cross-sectional study. SUBJECTS: Nine specialized rehabilitation centres representing 7 countries, and healthcare personnel (n = 323) working with stroke rehabilitation at the 9 centres were included in the study. METHODS: Two structured questionnaires were used: (i) an organizational-audit on sexual health policies; (ii) an anonymous web-questionnaire assessing the perspectives of healthcare personnel concerning sexual health. RESULTS: Of the 9 centres, 5 scored high on having sexual health policy in stroke rehabilitation and 4 scored low. Healthcare personnel working at centres with high scores reported higher levels of knowledge and comfort in working with sexual health, and looked more positively on the workplace sexual health policies, than personnel working at centres scoring low on these factors. Most personnel expressed a need for knowledge on the topic. Being comfortable about addressing sexuality was significantly associated with higher levels of knowledge about sexuality and working at centres having sexual health policies. CONCLUSION: A lack of sexual health policy represents a barrier to evidence-based practice in stroke rehabilitation. Such protocols need to be implemented in standard care in order to meet the sexual rehabilitation needs of stroke patients and partners.

The significant gap between international standards and stroke management practices at Queen Elizabeth Central Hospital (Malawi): An audit report.

Background: The Queen Elizabeth Central Hospital (QECH) is preparing to set up the first stroke unit in Blantyre, Malawi. We conducted this audit to assess current stroke management practices and outcomes at QECH and identify priority areas for intervention. Methods: From April to June 2018, we prospectively enrolled patients with acute stroke and collected data on clinical presentation, cardiovascular risk factors, investigations and interventions, in-hospital outcomes, and follow-up plans after discharge. The American Heart Association/American Stroke Association (AHA/ASA) guidelines were used as the standard of care for comparison. Results: Fifty patients with acute stroke were enrolled (46% women, 54% men). The mean age was 63.1 years (95% CI: 59.7-66.6). The diagnosis of stroke was based on the World Health Organization criteria. The diagnosis was made within 24 hours of admission in 19 patients (38%). Acute revascularisation therapy was not available. Forty-eight patients (96%) had their vital signs checked at baseline and <10% had their vital signs checked more than three times within the first 24 hours. Essential blood tests including random blood sugar (RBS), full blood count (FBC), urea/creatinine, and lipid profiles were performed in 72%, 68%, 48%, and 4%, respectively. An electrocardiogram was performed on 34 patients (68%). Blood pressure on admission was >140/90 mmHg in 34 patients (68%), including 4 with values >220/120 mmHg. Nine patients had an RBS >10 mmol/L and four received insulin. Prophylaxis for deep venous thrombosis was offered to 12 patients (24%). Aspiration pneumonia was reported in 16 patients (32%) and was the most common hospital complication. The mean duration of hospitalisation was 10.4 days (95% CI: 5.6-15.2), and case fatality was 18%. The modified Rankin scale at discharge was ≤2 in 32% of patients. Only four patients (8%) were transferred to a rehabilitation centre. At the time of discharge, only 32% of patients received education on stroke. Conclusion: Acute stroke care is less than optimal in this setting. Simple interventions such as reducing the delay in making a stroke diagnosis, early swallow assessments, and closer monitoring of vital signs could make a significant difference in stroke outcome. Furthermore, treating cardiovascular risk factors and setting up health education programmes to improve secondary prevention represent key priorities.

Supporting the implementation of stroke quality-based procedures (QBPs): a mixed methods evaluation to identify knowledge translation activities, knowledge translation interventions, and determinants of implementation across Ontario.

BACKGROUND: In 2013, Health Quality Ontario introduced stroke quality-based procedures (QBPs) to promote use of evidence-based practices for patients with stroke in Ontario hospitals. The study purpose was to: (a) describe the knowledge translation (KT) interventions used to support stroke QBP implementation, (b) assess differences in the planned and reported KT interventions by region, and (c) explore determinants perceived to have affected outcomes. METHODS: A mixed methods approach was used to evaluate: activities, KT interventions, and determinants of stroke QBP implementation. In Phase 1, a document review of regional stroke network work plans was conducted to capture the types of KT activities planned at a regional level; these were mapped to the knowledge to action framework. In Phase 2, we surveyed Ontario hospital staff to identify the KT interventions used to support QBP implementation at an organizational level. Phase 3 involved qualitative interviews with staff to elucidate deeper understanding of survey findings. RESULTS: Of the 446 activities identified in the document review, the most common were 'dissemination' (24.2%; n = 108), 'implementation' (22.6%; n = 101), 'implementation planning' (15.0%; n = 67), and 'knowledge tools' (10.5%; n = 47). Based on survey data (n = 489), commonly reported KT interventions included: staff educational meetings (43.1%; n = 154), champions (41.5%; n = 148), and staff educational materials (40.6%; n = 145). Survey participants perceived stroke QBP implementation to be successful (median = 5/7; interquartile range = 4-6; range = 1-7; n = 335). Forty-four people (e.g., managers, senior leaders, regional stroke network representatives, and frontline staff) participated in interviews/focus groups. Perceived facilitators to QBP implementation included networks and collaborations with external organizations, leadership engagement, and hospital prioritization of stroke QBP. Perceived barriers included lack of funding, size of the hospital (i.e., too small), lack of resources (i.e., staff and time), and simultaneous implementation of other QBPs. CONCLUSIONS: Information on the types of activities and KT interventions used to support stroke QBP implementation and the key determinants influencing uptake of stroke QBPs can be used to inform future activities including the development and evaluation of interventions to address barriers and leverage facilitators.

Dealing with stroke: Perspectives from stroke survivors and stroke caregivers from an underserved Hispanic community.

Globally, stroke is the leading cause of death and disease burden. While post-stroke studies have been conducted, they excluded survivors and caregivers from underserved communities. It can be argued that the impact of stroke on survivors and caregivers from underserved communities may be greater. Using qualitative exploratory research design, the purpose of this study was to examine the lived experiences of post-stroke recovery and readjustment among stroke survivors and stroke caregivers from an underserved community. Two separate focus groups were conducted, one each for stroke survivors and caregivers. Thematic analysis was used to analyze the data. Finding meaning in life is the general theme of stroke survivors' and stroke caregivers' journey of post-stroke recovery and readjustment. For stroke survivors, the transition to stroke recovery required time, life goal reconfiguration, willpower, humor, and network support. Post-stroke caregiving is a daily navigation and negotiation influenced by internal and external processes. Personal, economic, and socio-cultural nuances play a role in how post-stroke recovery is lived and experienced. Study findings highlight the importance of policies to support family-centered and system-level advocacy in post-stroke care.

Timely access to inpatient rehabilitation after stroke: a qualitative study of perceived barriers and potential solutions in Ontario, Canada.

PURPOSE: Stroke units have been established as best practice care, in part because they offer timely initiation of rehabilitation. Experts in Ontario, Canada recommend that eligible patients be transferred to inpatient rehabilitation (on average) by day 5 after ischemic stroke and day 7 after a hemorrhagic stroke. This study explores perceived barriers to implementation of these recommendations and potential solutions. METHOD: Exploratory focus groups were held with stakeholders from five geographically diverse regions across Ontario between September 2011 and January 2012. Participants were asked to consider the recommendations, list perceived barriers and to collectively discuss potential solutions. Data analysis included coding of transcribed data, sorting material to identify themes and confronting themes with a formalized body of knowledge. RESULTS: Barriers identified by participants fell into three categories: patient-centered, clinician-focused and resource or system based, within these, specific challenges included managing patients' medical and emotional readiness for rehabilitation, timely completion of medical tests, staff comfort in discharging patients, dedicated transportation and funding-related concerns. CONCLUSIONS: The structure of Ontario's health care system presents challenges to early transfer of stroke patients to inpatient rehabilitation, yet the stakeholders consulted in this study felt that these could be addressed with proper planning, improved coordination and targeted investment. Implications for rehabilitation Stroke units are a well-established best practice in stroke care and timely access to rehabilitation is a key component of their effectiveness. Stroke experts in Ontario, Canada recommend transfer of suitable patients to inpatient rehabilitation on day 5 and day 7, on average, after ischemic and hemorrhagic stroke, respectively. Stakeholders report that meeting these targets may require some adjustments to local processes of care, many of which can be achieved with little to no financial investment.

Addressing the Evidence Gap in Stroke Rehabilitation for Complex Patients: A Preliminary Research Agenda.

Evidence suggests that a stroke occurs in isolation (no comorbid conditions) in less than 6% of patients. Multimorbidity, compounded by psychosocial issues, makes treatment and recovery for stroke increasingly complex. Recent research and health policy documents called for a better understanding of the needs of this patient population, and for the development and testing of models of care that meet their needs. A research agenda specific to complexity is required. The primary objective of the think tank was to identify and prioritize research questions that meet the information needs of stakeholders, and to develop a research agenda specific to stroke rehabilitation and patient complexity. A modified Delphi and World Café approach underpinned the think tank meeting, approaches well recognized to foster interaction, dialogue, and collaboration between stakeholders. Forty-three researchers, clinicians, and policymakers attended a 2-day meeting. Initial question-generating activities resulted in 120 potential research questions. Sixteen high-priority research questions were identified, focusing on predetermined complexity characteristics-multimorbidity, social determinants, patient characteristics, social supports, and system factors. The final questions are presented as a prioritized research framework. An emergent result of this activity is the development of a complexity and stroke rehabilitation research network. The research agenda reflects topics of importance to stakeholders working with stroke patients with increasingly complex care needs. This robust process resulted in a preliminary research agenda that could provide policymakers with the evidence needed to make improvements toward better-organized services, better coordination between settings, improved patient outcomes, and lower system costs.

The Quality of Discharge Care Planning in Acute Stroke Care: Influencing Factors and Association with Postdischarge Outcomes.

BACKGROUND: Comprehensive discharge planning is important for successful transitions from hospital to home after stroke. The aim of this study was to describe the quality of discharge planning received by patients discharged home from acute care, identify factors associated with a positive discharge experience, and assess the influence of discharge quality on outcomes. METHOD: Patients discharged to the community and registered in the Australian Stroke Clinical Registry in 2014 were invited to participate. Patient-perceived discharge quality was evaluated using the Prescriptions, Ready to re-enter community, Education, Placement, Assurance of safety, Realistic expectations, Empowerment, Directed to appropriate services questionnaire (recall at 3-9 months). Factors associated with higher discharge quality scores were identified and associations between quality scores of more than 80% and outcomes were investigated using multivariable, multilevel regression analyses. RESULTS: There were 200 of 434 eligible registrants who responded; responders and nonresponders were similar with respect to age, sex, and type of stroke. The average overall quality score was 73% (standard deviation: 21). However, only 18% received all aspects of discharge care planning. Quality scores of more than 80% were independently associated with receiving hospital specific information (odds ratio: 5.7, 95% confidence interval [CI]: 2.7, 12.4), and referral to a local support group (odds ratio: 2.5, 95% CI: 1.1, 5.9). Discharge quality scores of more than 80% were associated with higher European Quality of Life-5 Dimensions EQ-5D scores (coefficient: .1, 95% CI: .04, .2) and a reduction in the rate of unmet needs reported at 3-9 months postdischarge (incidence rate ratio: .5, 95% CI: .3, .7). CONCLUSION: We provide new information on the quality of discharge planning from acute care after stroke. Aspects of discharge planning that correlate with quality of care may reduce unmet needs and improve quality of life outcomes.

Development of elbow spasticity model for objective training of spasticity assessment of patients post stroke.

Reliable assessment is essential for the management of spasticity, one of the most frequent complication of various neurological diseases. For the spasticity assessment, several clinical tools have been developed and widely used in clinics. The most popular one is modified Ashworth scale (MAS). It has a simple protocol, but is subjective and qualitative. To improve its reliability, quantitative measurement and consistent training would be needed. This study presents an elbow spasticity simulator which mimics spastic response of adult post stroke survivors. First, spastic responses (i.e. resistance and joint motion) from patients with a stroke were measured during conventional MAS assessment. Each grade of MAS was quantified by using three parameters representing three characteristics of the spasticity. Based on the parameters, haptic models of MAS were developed for implementing repeatable and consistent haptic training of novice clinicians. Two experienced clinicians participated in preliminary evaluation of the models.