Balance, Capacity, and the Contingencies of Everyday Life: Narrative Etiologies of Health Among Women in Street-Based Sex Work.

There is an abundance of health research with women in street-based sex work, but few studies examine what health means and how it is practiced by participants. We embrace these tasks by exploring how a convenience sample of sex workers (n = 33) think about and enact health in their lives. Findings reveal pluralistic notions of health that include neoliberal, biomedical, and lay knowledge. Health is operationalized through clinic/hospital visits and self-care practices, which emerge as pragmatic behaviors and ways to resist or compensate for exclusionary treatment in health care systems. Participants also use symbols of biomedical authority to substantiate their lay interpretations of certain conditions, revealing complex forms of moral reasoning in their health etiologies. We conclude that doing health and constructing rich narratives about it are constituent elements of the women's everyday praxis and subjectivities in relation to the broader socioeconomic and political worlds of which they are a part.

Indicators to guide health equity work in local public health agencies: a locally driven collaborative project in Ontario. / Indicateurs pour orienter l'action visant l'équité en matière de santé dans les organismes locaux de santé publique : le programme Projets locaux en Ontario.

INTRODUCTION: Funded by a Public Health Ontario 'Locally Driven Collaborative Project' grant, a team led by public health practitioners set out to develop and test a comprehensive set of indicators to guide health equity work in local public health agencies (LPHAs). METHODS: The project began with a scoping review, consultation with content experts, and development of a face-validated set of indicators aligned with the four public health roles to address health inequities (NCCDH, 2014), plus a fifth set of indicators related to an organizational and system development role. We report here on the field testing of the indicators for feasibility, face validity (clarity, relevance), reliability, and comparability in four Ontario LPHAs. Data were collected by two separate individuals or groups at each site, during two consecutive periods. These individuals participated in separate focus groups at the end of each test period, which further examined indicator clarity, data source availability and relevance. A third focus group explored anticipated indicator uses. RESULTS: Field testing showed that indicators addressed important issues in all public health roles. Although the capacity for indicator use varied, all test sites found the indicators useful. Suggestions for improved clarity were used to refine the final set of indicators, and to develop a Health Equity Indicator User Guide with background information and recommended resources. CONCLUSION: The process of evaluating health equity-related activity within LPHAs is still in its early stages. This project provides Ontario LPHAs with a tool to guide health equity work that may be adaptable to other Canadian jurisdictions.

INTRODUCTION: Grâce au programme Projet locaux financé par Santé publique Ontario, une équipe de professionnels de la santé publique a entrepris de concevoir et de tester un ensemble d'indicateurs afin d'orienter l'action visant l'équité en matière de santé au sein des organismes locaux de santé publique (OLSP). MÉTHODOLOGIE: Le projet a démarré avec un examen de la portée de la littérature, la consultation d'experts sur le sujet et l'élaboration d'un ensemble d'indicateurs de validité apparente conforme aux quatre mandats de la santé publique visant à réduire les inégalités en matière de santé (CCNDS, 2014) auxquels on a ajouté un cinquième ensemble d'indicateurs relatifs au mandat de perfectionnement organisationnel et systémique. Nous rendons compte ici des tests de terrain portant sur la faisabilité, sur la validité apparente (clarté et pertinence), sur la fiabilité et sur la comparabilité de ces indicateurs dans quatre OLSP de l'Ontario. Les données ont été recueillies par deux personnes ou groupes différents dans chaque site et en deux périodes. Ces personnes ont participé à des groupes de discussion à la fin de chaque période d'essai, ce qui a permis pour chaque indicateur un examen approfondi de sa clarté, de la disponibilité des sources de données associées et de sa pertinence. Un troisième groupe de discussion a étudié l'utilisation qui pourrait être faite de ces indicateurs. RÉSULTATS: Les essais de terrain ont montré que les indicateurs ont contribué à résoudre des questions importantes en lien avec tous les mandats en santé publique. Bien que les indicateurs ne possèdent pas tous la même utilité, les sites d'essai les ont tous jugés utiles. Diverses recommandations en matière de clarté ont été suivies pour améliorer l'ensemble final d'indicateurs et pour élaborer un guide d'utilisation des indicateurs d'équité en santé offrant des renseignements généraux et des suggestions de ressources. CONCLUSION: Le processus d'évaluation des activités liées à l'équité en matière de santé dans les OLSP n'en est qu'à ses débuts. Ce projet fournit aux OLSP de l'Ontario un outil d'orientation pour leur travail visant l'équité en matière de santé, outil qui pourrait être adapté aux autres provinces et territoires du Canada.

Organizational level indicators to address health equity work in local public health agencies: A scoping review.

OBJECTIVE: To determine what organizational level indicators exist that could be used by local Ontario public health agencies to monitor and guide their progress in addressing health equity. METHOD: This scoping review employed Arksey and O'Malley's (2005) six-stage framework. Multiple online databases and grey literature sources were searched using a comprehensive strategy. Studies were included if they described or used indicators to assess an organization's health equity activity. Abstracted indicator descriptions were classified using the roles for public health action identified by the Canadian National Collaborating Centre for Determinants of Health (NCCDH). Health equity experts participated in a consultation phase to examine items extracted from the literature. SYNTHESIS: Eighteen peer-reviewed studies and 30 grey literature reports were included. Abstracted indicators were considered for 1) relevance for organizational assessment, 2) ability to highlight equity-seeking populations, and 3) potential feasibility for application. Twenty-eight items formed the basis for consultation with 13 selected health equity experts. Items considered for retention were all noted to require significant clarification, definition and development. Those eliminated were often redundant or not an organizational level indicator. CONCLUSION: Few evidence-based, validated indicators to monitor and guide progress to address health inequities at the level of the local public health organization were identified. There is a need for continued development of identified indicator items, including careful operationalization of concepts and establishing clear definitions for key terms.

Canadian Stroke Best Practice Recommendations: Managing transitions of care following Stroke, Guidelines Update 2016.

Every year, approximately 62,000 people with stroke and transient ischemic attack are treated in Canadian hospitals. For patients, families and caregivers, this can be a difficult time of adjustment. The 2016 update of the Canadian Managing Transitions of Care following Stroke guideline is a comprehensive summary of current evidence-based and consensus-based recommendations appropriate for use by clinicians who provide care to patients following stroke across a broad range of settings. The focus of these recommendations is on support, education and skills training for patients, families and caregivers; effective discharge planning; interprofessional communication; adaptation in resuming activities of daily living; and transition to long-term care for patients who are unable to return to or remain at home. Unlike other modules contained in the Canadian Stroke Best Practice Recommendations (such as acute inpatient care), many of these recommendations are based on consensus opinion, or evidence level C, highlighting the absence of conventional evidence (i.e. randomized controlled trials) in this area of stroke care. The quality of care transitions between stages and settings may have a direct impact on patient and family outcomes such as coping, readmissions and functional recovery. While many qualitative and non-controlled studies were reviewed, this gap in evidence combined with the fact that mortality from stoke is decreasing and more people are living with the effects of stroke, underscores the need to channel a portion of available research funds to recovery and adaptation following the acute phase of stroke.

Pharmacotherapy for Depression Posttraumatic Brain Injury: A Meta-analysis.

OBJECTIVE: To examine the effectiveness of pharmacotherapy for the treatment of depression following traumatic brain injury (TBI). DESIGN: Systematic review and meta-analysis. Multiple electronic databases were searched to identify relevant studies examining effectiveness of pharmacotherapy for depression post-TBI. Clinical trials evaluating the use of pharmacotherapy in individuals with depression at baseline and using standardized assessments of depression were included. Data abstracted included sample size, antidepressant used, treatment timing/duration, method of assessment, and results pertaining to impact of treatment. Study quality was assessed using a modified Jadad scale. RESULTS: Nine studies met criteria for inclusion. Pooled analyses based on reported means (standard deviations) from repeated assessments of depression showed that, over time, antidepressant treatment was associated with a significant effect in favor of treatment (Hedges g = 1.169; 95% confidence interval, 0.849-1.489; P < .001). Similarly, when limited to placebo-controlled trials, treatment was associated with a significant reduction in symptoms (standardized mean difference = 0.84; 95% confidence interval, 0.314-1.366; P = .002). CONCLUSION: Pharmacotherapy after TBI may be associated with a reduction in depressive symptomatology. Given limitations within the available literature, further well-powered, placebo-controlled trials should be conducted to confirm the effectiveness of antidepressant therapy in this population.

PracticeCALM: Coaching Anxiety Lessening Methods for Radiation Therapists: A Pilot Study of a Skills-Based Training Program in Radiation Oncology.

PracticeCALM is an 8-week on-the-job training program to teach radiation therapists (RTs) techniques for assisting patients who are experiencing treatment-related anxiety. Twelve clinical RTs in a regional oncology program were recruited on a volunteer basis to participate in the training. A mixed-method approach was undertaken to evaluate perceived benefits to clinical practice. The quantitative findings from the Perceived Stress Scale (PSS) showed there were no changes before and after training. Qualitative findings showed significant benefits to RTs, including (1) ability to empathically attune more effectively and earlier to signs of anxiety in patients; (2) improved confidence and self-efficacy for effectively intervening in difficult treatment situations; and (3) enhanced creative problem solving in partnership with patients to assist the acutely anxious patient. The PSS results suggest that intrinsic and extrinsic stressors are a variable but consistent part of the everyday reality of RT practice. A training program focusing on the therapeutic presence dimension of RT practice has a direct impact on effectiveness in assisting anxious patients undergoing RT. When embedded in the clinical life of a radiation therapy department, such a training program has the potential to capture the lived practice wisdom and creative skills of RTs, and effectively mediate these skills across a team through group discussions and documentation on patient charts.

Canadian†Stroke†Best†Practice†Recommendations: Mood, Cognition and Fatigue Following Stroke practice guidelines, update 2015.

Every year, approximately 62 000 people with stroke and transient ischemic attack are treated in Canadian hospitals, and the evidence suggests one-third or more will experience vascular-cognitive impairment, and/or intractable fatigue, either alone or in combination. The 2015 update of the Canadian Stroke Best Practice Recommendations: Mood, Cognition and Fatigue Module guideline is a comprehensive summary of current evidence-based recommendations for clinicians in a range of settings, who provide care to patients following stroke. The three consequences of stroke that are the focus of the this guideline (poststroke depression, vascular cognitive impairment, and fatigue) have high incidence rates and significant impact on the lives of people who have had a stroke, impede recovery, and result in worse long-term outcomes. Significant practice variations and gaps in the research evidence have been reported for initial screening and in-depth assessment of stroke patients for these conditions. Also of concern, an increased number of family members and informal caregivers may also experience depressive symptoms in the poststroke recovery phase which further impact patient recovery. These factors emphasize the need for a system of care that ensures screening occurs as a standard and consistent component of clinical practice across settings as stroke patients transition from acute care to active rehabilitation and reintegration into their community. Additionally, building system capacity to ensure access to appropriate specialists for treatment and ongoing management of stroke survivors with these conditions is another great challenge.

Using realist evaluation to open the black box of knowledge translation: a state-of-the-art review.

BACKGROUND: In knowledge translation, complex interventions may be implemented in the attempt to improve uptake of research-based knowledge in practice. Traditional evaluation efforts that focus on aggregate effectiveness represent an oversimplification of both the environment and the interventions themselves. However, theory-based approaches to evaluation, such as realist evaluation (RE), may be better-suited to examination of complex knowledge translation interventions with a view to understanding what works, for whom, and under what conditions. It is the aim of the present state-of-the-art review to examine current literature with regard to the use of RE in the assessment of knowledge translation interventions implemented within healthcare environments. METHODS: Multiple online databases were searched from 1997 through June 2013. Primary studies examining the application or implementation of knowledge translation interventions within healthcare settings and using RE were selected for inclusion. Varying applications of RE across studies were examined in terms of a) reporting of core elements of RE, and b) potential feasibility of this evaluation method. RESULTS: A total of 14 studies (6 study protocols), published between 2007 and 2013, were identified for inclusion. Projects were initiated in a variety of healthcare settings and represented a range of interventions. While a majority of authors mentioned context (C), mechanism (M) and outcome (O), a minority reported the development of C-M-O configurations or testable hypotheses based on these configurations. Four completed studies reported results that included refinement of proposed C-M-O configurations and offered explanations within the RE framework. In the few studies offering insight regarding challenges associated with the use of RE, difficulties were expressed regarding the definition of both mechanisms and contextual factors. Overall, RE was perceived as time-consuming and resource intensive. CONCLUSIONS: The use of RE in knowledge translation is relatively new; however, theory-building approaches to the examination of complex interventions in this area may be increasing as researchers attempt to identify what works, for whom and under what circumstances. Completion of the RE cycle may be challenging, particularly in the development of C-M-O configurations; however, as researchers approach challenges and explore innovations in its application, rich and detailed accounts may improve feasibility.

Discharge destination of individuals with severe stroke undergoing rehabilitation: a predictive model.

PURPOSE: To determine the predictive value of age, stroke severity and caregiver availability for discharge destination of individuals with severe stroke following inpatient rehabilitation. METHODS: Telephone interviews were conducted with individuals recovering from a severe stroke (Rehabilitation Patient Groups 1100 and 1110), who were discharged from a specialized inpatient stroke rehabilitation unit between April 2005 and December 2009, to determine caregiver availability at the time of discharge. Age and Functional Independence Measure (FIM®) scores were obtained retrospectively by chart review. These three variables were analyzed using logistic regression as potential predictors of discharge destination (home versus long-term care). RESULTS: Data from 189 individuals were analyzed. Younger age, higher admission FIM® scores and the presence of a willing and able caregiver were significantly associated with discharge home. Only one individual was discharged home in the absence of a caregiver. CONCLUSION: Age, admission FIM® and caregiver availability were significant predictors of post-rehabilitation discharge destination. Results of this study suggest that for individuals with severe stroke, discharge home is unlikely in the absence of an available caregiver. Implications for Rehabilitation Age, stroke severity at admission and the availability of a caregiver play an important role in determining post rehabilitation discharge destination of individuals with severe stroke. These factors must be considered to assist with appropriate goal setting and discharge planning during inpatient rehabilitation.

Treatment with botulinum toxin improves upper-extremity function post stroke: a systematic review and meta-analysis.

OBJECTIVE: To examine whether treatment with botulinum toxin type A (BTX-A) is associated with improvements in activity capacity or performance associated with poststroke spasticity in the upper extremity. DATA SOURCES: MEDLINE, EMBASE, Scopus, and ISI Web of Science databases were searched from 1985 to November 2011. DATA SELECTION: Studies were included if (1) the study design was a randomized controlled trial comparing injection of BTX-A with placebo or a nonpharmacologic treatment condition; (2) at least 60% of the sample was composed of adult subjects recovering from either first or subsequent stroke; (3) subjects presented with moderate to severe upper-extremity spasticity of the wrist, finger, or shoulder; and (4) activity was assessed as an outcome. Studies were limited to those published in the English language. DATA EXTRACTION: Data pertaining to participant characteristics, treatment contrasts, and outcomes assessing activity limitations were extracted from each trial. The World Health Organization's International Classification of Functioning, Disability and Health was used to identify outcomes that captured the domain of activity used within each of the included studies. Where possible, a treatment effect size was calculated for each study using the standardized mean difference ± standard error (95% confidence interval) and the results pooled. DATA SYNTHESIS: Sixteen randomized controlled trials were identified, 10 of which reported sufficient data for inclusion in the pooled analysis (n=1000). Six different outcomes that assessed activity limitations had been used, including the Disability Assessment Scale, the Action Research Arm Test, and the Barthel Index. Overall, BTX-A was associated with a moderate treatment effect (standardized mean difference=.536±.094, 95% confidence interval=.352-.721, P<.0001). CONCLUSIONS: The use of BTX-A was associated with moderate improvement in upper-extremity activity capacity or performance after stroke.

Prevention of poststroke depression: does prophylactic pharmacotherapy work?

BACKGROUND: Given the negative influence of poststroke depression (PSD) on functional recovery, cognition, social participation, quality of life, and risk for mortality, the early initiation of antidepressant therapy to prevent its development has been investigated; however, individual studies have offered conflicting evidence. The present systematic review and meta-analysis examined available evidence from published randomized controlled trials (RCTs) evaluating the effectiveness of pharmacotherapy for the prevention of PSD to provide updated pooled analyses. METHODS: Literature searches of 6 databases were performed for the years 1990 to 2011. RCTs meeting study inclusion criteria were evaluated for methodologic quality. Data extracted included the antidepressant therapy used, treatment timing and duration, method(s) of assessment, and study results pertaining to the onset of PSD. Pooled analyses were conducted. RESULTS: Eight RCTs were identified for inclusion. Pooled analyses demonstrated reduced odds for the development of PSD associated with pharmacologic treatment (odds ratio [OR] 0.34; 95% confidence interval [CI] 0.22-0.53; P<.001), a treatment duration of 1 year (OR 0.31; 95% CI 0.18-0.56; P<.001), and the use of a selective serotonin reuptake inhibitor (OR 0.37; 95% CI 0.22-0.61; P<.001). CONCLUSIONS: The early initiation of antidepressant therapy, in nondepressed stroke patients, may reduce the odds for development of PSD. Optimum timing and duration for treatment and the identification of the most appropriate recipients for a program of indicated prevention require additional examination.

Inpatient stroke rehabilitation in Ontario: are dedicated units better?

BACKGROUND: The superiority of dedicated stroke rehabilitation over generalized rehabilitation services has been suggested by the literature; however, these models of service delivery have not been evaluated in terms of their relative effectiveness in situ. AIMS: A comparison of the process indicators associated with these two models of service provision was undertaken within the Ontario healthcare system. METHODS: All adults admitted with a diagnosis of stroke for inpatient rehabilitation in Ontario, Canada during the years 2006-2008 were identified from the National Rehabilitation Reporting System database. Each of the admitting institutions was classified as providing rehabilitation services on either a stroke dedicated or nondedicated unit. A dedicated unit was identified by the presence of a collection of geographically distinct, stroke-dedicated beds and dedicated therapists. Selected process indicators from the National Rehabilitation Reporting System database were compared between the two facility types. RESULTS: Sixty-seven facilities provided stroke rehabilitation services to 6709 adult stroke patients during the years 2006-2008. Of the total number of patients who entered inpatient rehabilitation, 1725 (25·7%) received care in eight facilities that met basic criteria for a dedicated stroke rehabilitation unit. On average, these patients took significantly longer to arrive for inpatient rehabilitation (37·2 ± 155·5 vs. 22·8 ± 95·0 days, P < 0·001), were admitted with higher Functional Independence Measure scores (77·5 ± 22·5 vs. 74·8 ± 24·5, P < 0·001), had significantly longer lengths of stay (42·1 ± 25·9 vs. 35·4 ± 27·2 days, P < 0·001), and demonstrated significantly lower Functional Independence Measure efficiency scores (0·62 ± 0·47 vs. 0·88 ± 1·03, P > 0·001) compared with patients who were admitted to nondedicated units. The proportion of patients admitted to a dedicated unit and subsequently discharged home was similar to that of patients discharged from nondedicated units (70·5% vs. 68·8%, P = 0·206). CONCLUSIONS: In Ontario, patients admitted to dedicated stroke rehabilitation units fared no better on commonly-used process metrics compared with patients admitted to nondedicated rehabilitation units.

Inpatient rehabilitation following stroke: amount of therapy received and associations with functional recovery.

PURPOSE: Canada's Best Practice Recommendations for Stroke Care state that a minimum of one hour per day of each of the relevant core therapies be provided to patients admitted for inpatient rehabilitation. We examined whether this standard was met on a single, specialized stroke rehabilitation unit and if amount of therapy was an independent contributor to functional improvement. METHODS: One-hundred and twenty-three, consecutive patients admitted to a 30-bed stroke rehabilitation program over a 6-month period with the confirmed diagnosis of stroke, were included. Workload measurement data were used to estimate the amount of therapy that patients received from core therapists during their inpatient stay. A multivariable model to predict Functional Independence Measure (FIM) gains achieved was also developed using variables that were significantly correlated with functional gain on univariate analysis. RESULTS: On average, patients received 37 min of active therapy from both physiotherapists (PT) and occupational therapists (OT) and 13 min from speech-language pathologists per day. Admission FIM, length of stay, total OT and PT therapy time (hrs) were significantly correlated with FIM gain. In the final model, which explained 35% of the variance, admission FIM score and total amount of occupational therapy (OT) emerged as significant predictors of FIM gain. CONCLUSIONS: Patients admitted to a specialized rehabilitation unit received an average of 37 min a day engaged in therapeutic activities with both occupational and physical therapists. Although this value did not reach the standard of one hour, total amount of OT time contributed significantly to gains in FIM points during hospital stay.

Rehabilitation of individuals with severe stroke: synthesis of best evidence and challenges in implementation.

PURPOSE: The rehabilitation of patients who are recovering from severe stroke is associated with a substantial use of resources but limited potential for functional improvement. As a result, these individuals are not perceived as being ideal candidates for inpatient stroke rehabilitation. The objective of this review was to describe the evidence for and discuss some of the challenges of providing inpatient rehabilitation services for individuals with severe stroke. METHODS: A literature search was conducted to identify relevant studies. Studies were included if (a) inpatient rehabilitation was compared to other rehabilitation settings and (b) the study population included individuals with severe stroke-related disability. Following data abstraction, the methodological quality of randomized controlled trials (RCTs) that met inclusion criteria was assessed using the PEDro scale. RESULTS: Fourteen studies (including 4 RCTs) met inclusion criteria. Despite making limited functional improvement, persons with severe strokes who received inpatient rehabilitation had reduced mortality, decreased lengths of hospital stay, and increased likelihood of discharge home when compared to those who received rehabilitation in other settings. Rehabilitation on specialized stroke units resulted in better outcomes than other forms of inpatient rehabilitation for this group. CONCLUSION: Inpatient rehabilitation is beneficial for individuals with severe stroke. However, for this group, it may be necessary to rethink the emphasis on functional improvement and focus more on discharge planning. These individuals may still have restricted access to rehabilitation as a result of limited resources, the perception that they have poor rehabilitation potential, limited understanding of the goals of rehabilitation for this population, and a lack of research.

Adherence to Canadian best practice recommendations for stroke care: assessment and management of poststroke depression in an Ontario rehabilitation facility.

BACKGROUND AND PURPOSE: Although Canadian best practice recommendations regarding assessment and management of poststroke depression (PSD) have been established, the degree to which these evidence-based guidelines have been translated into practice is not known. The objectives of the present study are to compare current and recommended best practice and examine possible reasons for identified care gaps. METHODS: Practice audit by chart review was performed to identify recorded screening, assessment, and treatment for PSD in patients discharged from a specialized inpatient rehabilitation program over a 6-month period. A questionnaire was administered to all clinical staff addressing current screening practices as well as opinions regarding the importance and feasibility of identification and treatment of PSD. RESULTS: Of 123 patients, 40 (32.5%) had been prescribed antidepressants at discharge. However, evidence of screening was found for 4.9% of patients; another 9.8% were referred for psychological consult. Treatment was associated with previous antidepressant use or history of depression, but not screening or assessment. Of the survey respondents, 56.2% were not aware of best practice recommendations. However, most felt screening and assessment to be important and treatment was regarded as both simple and effective. CONCLUSIONS: Despite potential benefit associated with identification and treatment of PSD and the availability of evidence-based best practice recommendations, PSD may remain unrecognized and undertreated. Given the juxtaposition of perceived importance with the lack of documented best practice, education regarding standardized screening and the development of consistent clinical protocols including roles and responsibilities in the identification, diagnosis, and treatment of PSD are underway.

Adherence to Canadian Best Practice Recommendations for Stroke Care: vascular cognitive impairment screening and assessment practices in an Ontario inpatient stroke rehabilitation facility.

BACKGROUND: The Canadian Best Practice Recommendations for Stroke Care suggest that (1) all patients with stroke should be screened for cognitive impairment and (2) persons who are detected as having cognitive impairment on a screening test should receive additional cognitive assessment. The purpose of this study is to determine whether care in an Ontario inpatient stroke rehabilitation facility is consistent with these recommendations. METHODS: Stroke patients discharged from an inpatient stroke rehabilitation program located in Southwestern Ontario, Canada, from May to October 2009 were included in this study. Charts were reviewed to identify current screening and assessment practices. The percentages of patients formally screened and/or assessed as well as differences between those who were and were not screened are reported. RESULTS: The study included 123 patients (62 male; mean age = 67.3,SD 15.1). During inpatient rehabilitation, 82.9% of patients were screened using a formal cognitive screening instrument. Patients with cognitive and/or communication deficits were significantly less likely to be screened than those with intact cognitive and communicative abilities. Although 77.5% of those screened scored below the threshold for cognitive impairment, evidence of referral for a comprehensive cognitive assessment was found for only 3 patients. CONCLUSIONS: Although the majority of patients were screened for cognitive impairment while in inpatient rehabilitation, few patients were referred for a comprehensive diagnostic examination. On the basis of these results from a single inpatient stroke rehabilitation unit, it appears that specific cognitive deficits are likely underidentified in stroke rehabilitation patients in Ontario.

Are recommendations regarding inpatient therapy intensity following acute stroke really evidence-based?

BACKGROUND: Recommendations regarding the daily minimum dose of therapy that patients should receive following stroke are included in many clinical practice guidelines. We examined the related literature to determine whether a specific evidence-based recommendation could be supported. METHOD: Six clinical practice guidelines were retrieved and examined to determine what recommendation, if any, had been made regarding the daily provision of therapy during inpatient rehabilitation. All studies cited by the guideline authors to support their recommendations were identified and retrieved. Studies in which treatment was (a) focused on motor recovery, (b) initiated during inpatient rehabilitation, and (c) provided within 3 months of stroke onset were reviewed in greater detail. RESULTS: Three of the 6 identified guidelines recommended daily minimum amounts of therapy, ranging from 45 to 60 minutes each day of occupational (OT) and physiotherapy (PT), and 3 made general statements indicating that increased intensity of therapy was either recommended or was not recommended. Among the 6 guidelines, 37 studies had been cited to support the recommendations. Of these, 15 were reviewed in detail. On average, patients in the control condition received 48 minutes of therapy per day while those in the experimental group received 63% more, or 78 minutes per day. Patients in the experimental group performed significantly better on the primary outcome in only 5 (33%) studies. CONCLUSIONS: We believe the evidence base cannot support a specific recommendation related to therapy intensity during inpatient rehabilitation following stroke.

Organized stroke rehabilitation in Canada: redefining our objectives.

INTRODUCTION: Evidence suggests that patients who receive care in organized stroke units experience better outcomes compared to patients who receive care in general rehabilitation units. As such, the Canadian Stroke Strategy has consistently included provision of "organized" stroke rehabilitation in their best practice recommendations for stroke care. However, recent research in Ontario suggests that development of organized stroke rehabilitation units has not led to the better patient outcomes that had been expected. METHODS: In this article, we review the evidence in favour of organized stroke rehabilitation units, assess the state of organized rehabilitation in Canada (as exemplified by care in Ontario), and discuss potential solutions for better application of best evidence and guideline recommendations for organized stroke care in Canada. RESULTS: The most up-to-date evidence in Canada suggests that best practice recommendations around organized stroke care are currently not adhered to well. However, further exploration suggests that some of the recommendations themselves may not be attainable as currently defined. CONCLUSIONS: It appears that organized stroke care is not available to many Canadians, and better application of recommendations is necessary. Still, re-evaluation of current recommendations may also be necessary to ensure that they fit with the reality of providing care in Canada.

Determining the need for in-patient rehabilitation services post-stroke: results from eight ontario hospitals.

BACKGROUND: The number of patients requiring in-patient rehabilitation services following acute stroke is unknown. METHODS: All consecutive patients admitted with a diagnosis of stroke to eight community hospitals in southwestern Ontario from May 2008 to December 2009 were screened for in-patient rehabilitation eligibility using the Stroke Rehabilitation Candidacy Screening Tool. RESULTS: Three hundred ninety-six patients were included, of which 147 (37.1%) were identified as candidates for in-patient rehabilitation. Of these patients, 111 (75%) were discharged to an in-patient rehabilitation unit. The most frequently documented reason that candidates were not transferred was lack of an available bed (n=19). Two hundred forty-nine (62.9%) patients were not considered candidates. The majority (80%) of these patients had experienced either mildly or severely disabling stroke and went home or directly to long-term care upon discharge. CONCLUSION: The reported estimate of 37% who required in-patient rehabilitation services is important for the purposes of planning and allocation of healthcare resources.

CONTEXTE : On ne connaît pas bien le nombre de patients qui ont besoin de services de réadaptation après un accident cérébrovasculaire aigu. MÉTHODE : Tous les patients admis suite à un diagnostic d'accident cérébrovasculaire dans huit hôpitaux communautaires du sud-ouest ontarien entre mai 2008 et décembre 2009 ont été soumis au protocole de dépistage pour les candidats à la réadaptation après un accident cérébrovasculaire (Stroke Rehabilitation Candidacy Screening Tool). RÉSULTATS : Trois cent quatre-vingt-seize patients ont été considérés. Parmi eux, 147 (37,1 %) ont été désignés comme candidats à la réadaptation. De ces patients, 111 (75 %) ont été dirigés vers une unité de réadaptation pour patients hospitalisés. La raison la plus évoquée pour ne pas y diriger un patient était le manque de lits disponibles (n=19). Deux cent quarante-neuf (62,9 %) patients n'ont pas été désignés candidats. La majorité (80 %) de ces patients avaient subit un accident cérébrovasculaire causant une invalidité de moyenne à sévère et ont reçu leur congé ou sont allés directement aux soins de longue durée. CONCLUSION : La proportion estimée de 37 pour cent des patients ayant besoin de services de réadaptation pour patients hospitalisés est importante pour la panification et la répartition des ressources en santé.

Stroke rehabilitation in ontario: an opportunity for health care transformation.

In this article, Ontario's stroke rehabilitation system is used to exemplify the challenges faced by rehabilitation and healthcare systems across Canada who are attempting to provide quality care to patients in the face of increasing demands. Currently, Ontario's rehabilitation system struggles in its efforts to provide accessible and comprehensive care to patients recovering from stroke. We begin our exploration by identifying both the primary stakeholders and the underlying factors that have contributed to the current challenges. The framework put forward in the Canadian Medical Association's recommendations for transformation is then used to suggest a vision for a more patient-focused system incorporating three key principles: a broader perspective, a patient-first approach, and greater unity. The use of health information technology, proper incentives, and greater accountability are discussed as mechanisms to improve the quality and efficiency of care.