Postcode Lottery in Healthcare? Findings from the Scottish National Comprehensive Geriatric Assessment in Secondary Care Audit 2019.

Comprehensive Geriatric Assessment (CGA) is provided differently across Scotland. The Scottish Care of Older People (SCoOP) CGA Audit was a national audit conducted in 2019 to assess this variation in acute hospitals. Two versions of audit questionnaires about the provision of CGA were developed (one each for larger hospitals and remote/rural areas) and piloted. The questionnaires were sent to representatives from all hospitals in Scotland using the REDCap (Research Electronic Data Capture) system. The survey asked each service to provide information on CGA service delivery at the 'front door'. The questionnaire was open for completion between February and July 2019. Of the 28 Scottish hospitals which receive acute admissions, we received information from 26 (92.9% response rate). Reporting sites included seven hospitals from remote and rural locations in the Scottish Highlands and Islands. Significant variations were observed across participating sites for all key aspects studied: dedicated frailty units, routes of admission, staffing, liaison with other services and rehabilitation provision. The 2019 SCoOP CGA audit highlights areas of CGA services that could be improved and variation in specialist CGA service access, structure and staffing at the front door across Scotland. Whether this variation has an impact on the outcomes of older people requires further evaluation.

Variation in acute and community service provision of care of the elderly services across Scotland: findings from the Scottish Care of Older People (SCoOP) initial scoping survey.

BACKGROUND: This scoping survey is a preliminary part of the Scottish Care of Older People (SCoOP) audit programme, which aims to assess specialist service provision for older people with frailty in Scotland, and provide benchmarking data for improving services. METHODS: The survey was distributed to nominated consultant geriatricians based in 12 of the 14 Scottish health boards who completed data to the 'best of their knowledge'. Data collected were: consultant and specialty doctor level workforce; days of frailty unit operation; multidisciplinary team discussion frequency; and, physiotherapy and occupational therapy availability. Consultant cover was correlated with population data, and scores for service components used to derive separate acute and community service provision scores. RESULTS: Consultant geriatrician availability varies widely across Scottish health boards with a median of 1.45 [range: 0.54-2.40; interquartile range (IQR): 0.71-2.28] full-time equivalent consultant geriatricians per 10,000 people ≥65 years. Variation was also present in the service provision scores [score range 0 (none) to 1.0 (very good)]: for acute services, the median national service provision score was 0.81 (range: 0.50-0.89; IQR: 0.75-0.85) and for community services 0.60 (range: 0.48-0.82; IQR: 0.52-0.65). CONCLUSIONS: This report clearly demonstrates mismatch between workforce and services in both acute and community settings in the context of the population size. Future surveys will build on this preliminary information to audit service provision for older people at an individual hospital level.

Home-Time Is a Feasible and Valid Stroke Outcome Measure in National Datasets.

Background and Purpose- Home-time (HT) is a stroke outcome measure based on time spent at home after stroke. We hypothesized that HT assessment would be feasible and valid using national data. Methods- We linked the Scottish Stroke Care Audit to routine healthcare data and calculated 90-day HT for all strokes, 2005 to 2017. We described prognostic validity (Spearman rank correlation) of HT to baseline factors. Results- We were able to calculate HT for 101 969 strokes (99.3% of total Scottish strokes). Mean HT was 46 days (95% CI, 45.8-46.2; range, 0-90). HT showed consistent correlation with our prespecified prognostic factors: age: ρ, -0.35 (95% CI, -0.35 to -0.36); National Institutes of Health Stroke Scale score, -0.54 (95% CI, -0.52 to -0.55); and 6 simple variables (ordinal), -0.61 (95% CI, -0.61 to -0.62). Conclusions- HT can be derived at scale using routine clinical data and appears to be a valid proxy measure of functional recovery. Other national databases could use HT as a time and cost efficient measure of medium and longer-term outcomes.

Impact of a clinical pathway on end-of-life care following stroke: a mixed methods study.

BACKGROUND: Death after stroke is common, but little is known about end-of-life care processes in acute stroke units. AIM: (1) To identify family and health-care worker perceptions of an end-of-life care pathway for patients who die after acute stroke. (2) To determine whether patients with fatal stroke judged to require an end-of-life care pathway differ from patients with fatal stroke who die without introduction of such a pathway. DESIGN: Mixed methods study integrating qualitative semistructured interviews with quantitative casenote review. SETTING/PARTICIPANTS: In four Scottish acute stroke units, 17 relatives of deceased stroke patients and 23 health-care professionals were interviewed. Thematic analysis used a modified grounded theory approach. Multivariate analysis was performed on casenote data, identified prospectively from 100 consecutive stroke deaths. RESULTS: Deciding pathway use was a consultative process, occurring within normal working hours. Families were commonly involved and could veto or trigger aspects of end-of-life care. Families sometimes felt responsible for decisions such as pathway use, resuscitation or hydration. Families were often led to expect their relative's death early in the post-stroke period. Prolonged dying processes, particularly where patients had severe dysphagia, added to distress for families. Preferences for place of care were discussed infrequently. No link was found between demographic or clinical characteristics and care pathway use. CONCLUSION: Distressing stroke-related clinical problems dominated relatives' concerns rather than use of the end-of-life care pathway. At times, relatives felt primarily responsible for key aspects of decision-making. Relatives often felt unprepared for a prolonged dying process after stroke, particularly where patients had persistent major swallowing difficulties.

The evidence-base for stroke education in care homes.

RESEARCH QUESTIONS: 1. What are registered care home nurses' educational priorities regarding stroke care? 2. What are senior care home assistants' educational priorities regarding stroke care? 3. How do care home nurses conceive stroke care will be delivered in 2010? STUDY DESIGN: This was a 2-year study using focus groups, stroke guidelines, professional recommendations and stroke literature for the development of a questionnaire survey for data collection. Workshops provided study feedback to participants. Data were collected in 2005-2006. STUDY SITE: Greater Glasgow NHS Health Board. POPULATION AND SAMPLE: A stratified random selection of 16 private, 3 voluntary and 6 NHS continuing care homes from which a sample of 115 trained nurses and 19 senior care assistants was drawn. RESULTS: The overall response rate for care home nurses was 64.3% and for senior care assistants, 73.6%. Both care home nurses and senior care assistants preferred accredited stroke education. Care home nurses wanted more training in stroke assessment, rehabilitation and acute interventions whereas senior care assistants wanted more in managing depression, general stroke information and communicating with dysphasic residents. Senior care assistants needed more information on multidisciplinary team working while care home nurses were more concerned with ethical decision-making, accountability and goal setting. CONCLUSIONS: Care home staff need and want more stroke training. They are clear that stroke education should be to the benefit of their resident population. Guidelines on stroke care should be developed for care homes and these should incorporate support for continuing professional learning in relation to the resident who has had a stroke.

Stroke education for healthcare professionals: making it fit for purpose.

TITLE: Stroke education for healthcare professionals: Making it fit for purpose. RESEARCH QUESTIONS: 1. What are healthcare professionals' (HCPs) educational priorities regarding stroke care? 2. Do stroke care priorities vary across the primary and secondary sectors? 3. How do HCPs conceive stroke care will be delivered in 2010? STUDY DESIGN: This was a two-year study using focus groups and interviews for instrument development, questionnaires for data collection and workshops to provide study feedback. Data were collected in 2005-06. STUDY SITE: One Scottish health board. INCLUSION CRITERIA: All National Health Service healthcare professionals working wherever stroke care occurred. POPULATION AND SAMPLE: Participants were drawn from 4 university teaching hospitals, 2 community hospitals, 1 geriatric medicine day hospital, 48 general practices (GPs), 12 care homes and 15 community teams. The sample comprised 155 doctors, 313 nurses, 133 therapists (physiotherapists, occupational therapists, speech and language therapists), and 29 'other HCPs' (14 dieticians, 7 pharmacists, 2 podiatrists and 6 psychologists). RESULTS: HCPs prefer face-to-face, accredited education but blended approaches are required that accommodate uni- and multidisciplinary demands. Doctors and nurses are more inclined towards discipline-specific training compared to therapists and other healthcare professionals (HCPs). HCPs in primary care and stroke units want more information on the social impact of stroke while those working in stroke units in particular are concerned with leadership in the multidisciplinary team. Nurses are the most interested in teaching patients and carers. CONCLUSIONS: Stroke requires more specialist stroke staff, the upskilling of current staff and a national education pathway given that stroke care is most effectively managed by specialists with specific clinical skills. The current government push towards a flexible workforce is welcome but should be educationally-sound and recognise the career aspirations of healthcare professionals.