Factors associated with mental health service access among Australian community-dwelling survivors of stroke.

PURPOSE: To describe types of mental health treatment accessed by community-based stroke survivors and factors associated with access. METHODS: A sub-group of registrants from the Australian Stroke Clinical Registry completed a supplementary survey 2.5 years post-stroke. Self-reported information about depression/anxiety and treatment access were collected. Demographic and clinical data were obtained through linkages with registry and government data. Staged multivariable logistic regression was conducted to examine factors associated with treatment access. RESULTS: Among 623 registrants surveyed (37% female, median age 69 years), 26% self-reported a medical diagnosis of depression/anxiety at 2.5 years post-stroke. Of these, only 30% reported having accessed mental health services, mostly through government-funded Medicare schemes. Younger age (odds ratio (OR) 0.95, 95% CI 0.93, 0.98), history of mental health treatment (OR 3.38, 95% CI 1.35, 8.48), feeling socially isolated (OR 2.32, 95% CI 1.16, 4.66), self-reported medical diagnosis of depression/anxiety (OR 4.85, 95% CI 2.32, 10.14), and government-subsidised team care plan arrangement (OR 4.05, 95% CI 1.96, 8.37) were associated with receiving treatment. CONCLUSIONS: Many stroke survivors have untreated depression/anxiety. Primary care practitioners should be supported in undertaking effective detection and management. Older and newly diagnosed individuals should be educated about depression/anxiety and available supports.Implications for rehabilitationPrimary care providers play a pivotal role in the pathway to mental health care, and therefore should always screen for depression/anxiety and provide comprehensive assessment and referral to specialist services where necessary.Targeted psychoeducation should be provided to survivors of stroke who are older and newly diagnosed with depression/anxiety, to increase awareness about mood problems following stroke.Primary care providers should collaborate with other health professionals (e.g., through coordinating a team care arrangement plan), to address patients' multiple and complex rehabilitation needs.Rehabilitation professionals should remain informed about current evidence-based treatments for post-stroke depression/anxiety and pathways that enable their patients to access these services.

Treatment with Multiple Therapeutic Classes of Medication Is Associated with Survival after Stroke.

INTRODUCTION: Treatment with several therapeutic classes of medication is recommended for secondary prevention of stroke. We analyzed the associations between the number of classes of prevention medications supplied within 90 days after discharge for ischemic stroke (IS)/transient ischemic attack (TIA) and survival. METHODS: This is a retrospective cohort study of adults with first-ever IS/TIA (2010-2014) from the Australian Stroke Clinical Registry individually linked with data from national pharmaceutical and Medicare claims. Exposure was the number of classes of recommended medications, i.e., blood pressure-lowering, antithrombotic, or lipid-lowering agents, supplied to patients within 90 days after discharge for IS/TIA. The longitudinal association between the number of classes of medications and survival was evaluated with Cox proportional hazards regression models using the landmark approach. A landmark date of 90 days after hospital discharge was used to separate exposure and outcome periods, and only patients who survived until this date were included. RESULTS: Of 8,429 patients (43% female, median age 74 years, 80% IS), 607 (7%) died in the year following 90 days after discharge. Overall, 56% of patients were supplied all 3 classes of medications, 28% 2 classes of medications, 11% 1 class of medications, and 5% no class of medications. Compared to patients supplied all 3 medication classes, adjusted hazard ratios for all-cause mortality ranged from 1.43 (95% confidence interval [CI]: 1.18-1.72) in those supplied 2 medication classes to 2.04 (95% CI: 1.44-2.88) in those supplied with no medication class. DISCUSSION/CONCLUSION: Treatment with all 3 classes of guideline-recommended medications within 90 days after discharge was associated with better survival. Ongoing efforts are required to ensure optimal pharmacological intervention for secondary prevention of stroke.

Optimal Measures for Primary Care Physician Encounters after Stroke and Association with Survival: A Data Linkage Study.

BACKGROUND AND PURPOSE: Primary care physicians (PCPs) provide ongoing management after stroke. However, little is known about how best to measure physician encounters with reference to longer term outcomes. We aimed to compare methods for measuring regularity and continuity of PCP encounters, based on survival following stroke using linked healthcare data. METHODS: Data from the Australian Stroke Clinical Registry (2010-2014) were linked with Australian Medicare claims from 2009 to 2016. Physician encounters were ascertained within 18 months of discharge for stroke. We calculated three separate measures of continuity of encounters (consistency of visits with primary physician) and three for regularity of encounters (distribution of service utilization over time). Indices were compared based on 1-year survival using multivariable Cox regression models. The best performing measures of regularity and continuity, based on model fit, were combined into a composite "optimal care" variable. RESULTS: Among 10,728 registrants (43% female, 69% aged ≥65 years), the median number of encounters was 17. The measures most associated with survival (hazard ratio [95% confidence interval], Akaike information criterion [AIC], and Bayesian information criterion [BIC]) were the Continuity of Care Index (COCI, as a measure of continuity; 0.88 [0.76-1.02], p = 0.099, AIC = 13,746, BIC = 13,855) and our persistence measure of regularity (encounter at least every 6 months; 0.80 [0.67-0.95], p = 0.011, AIC = 13,742, BIC = 13,852). Our composite measure, persistent plus COCI ≥80% (24% of registrants; 0.80 [0.68-0.94], p = 0.008, AIC = 13,742, BIC = 13,851), performed marginally better than our persistence measure alone. CONCLUSIONS: Our persistence measure of regularity or composite measure may be useful when measuring physician encounters following stroke.

Co-Designing a New Yoga-Based Mindfulness Intervention for Survivors of Stroke: A Formative Evaluation.

Movement-based mindfulness interventions (MBI) are complex, multi-component interventions for which the design process is rarely reported. For people with stroke, emerging evidence suggests benefits, but mainstream programs are generally unsuitable. We aimed to describe the processes involved and to conduct a formative evaluation of the development of a novel yoga-based MBI designed for survivors of stroke. We used the Medical Research Council complex interventions framework and principles of co-design. We purposefully approached health professionals and consumers to establish an advisory committee for developing the intervention. Members collaborated and iteratively reviewed the design and content of the program, formatted into a training manual. Four external yoga teachers independently reviewed the program. Formative evaluation included review of multiple data sources and documentation (e.g., formal meeting minutes, focus group discussions, researcher observations). The data were synthesized using inductive thematic analysis. Three broad themes emerged: (a) MBI content and terminology; (b) manual design and readability; and (c) barriers and enablers to deliver the intervention. Various perspectives and feedback on essential components guided finalizing the program. The design phase of a novel yoga-based MBI was strengthened by interdisciplinary, consumer contributions and peer review. The 12-week intervention is ready for testing among survivors of stroke.