Reliability of proxy reports on patient reported outcomes measures in stroke: An updated systematic review.

OBJECTIVES: With the rising global burden of stroke-related morbidity, and increased focus on patient-centered healthcare, patient reported outcome measures (PROMs) are increasingly used to inform healthcare decision-making. Some stroke patients with cognitive or motor impairments are unable to respond to PROMs, so proxies may respond on their behalf; the reliability of which remains unclear. The aim of the study is to update a 2010 systematic review to investigate the inter-rater reliability of proxy respondents answering PROMs for stroke patients. MATERIALS AND METHODS: Studies on the reliability of proxy respondents in stroke were searched within CINAHL, Embase, PsycInfo, and WoS databases (01/07/22, 08/07/22). Fifteen studies were included for review. ICC and k-statistic were extracted for PROMs scales and categorized as poor (0.80). Bias was assessed using the CCAT. RESULTS: Five studies reported PROMs with inter-rater reliability scores ranging from 0.80. Two studies reported activities of daily living (ADLs) scores ranging from 0.41 to 0.80 and 8 studies reported quality of life (QoL) measures with scores ranging from 0.80. Subcategories of these scales included physical (ICC/k-statistic 0.41- >0.8), cognitive (ICC/k-statistic 0.40-0.80), communication (ICC/k-statistic <0.4-0.80,) and psychological (ICC/k-statistic <0.40-0.60) measures. CONCLUSIONS: Proxy respondents are reliable sources for PROM reports on physical domains in ADLs, PROMs and QoL scales. Proxy reports for measures of communication and psychological domains had greater variability in reliability scores, ranging from poor to substantial; hence, caution should be applied when interpreting proxy reports for these domains.

Priorities for developing stroke care in Ireland from the perspectives of stroke survivors, family carers and professionals involved in stroke care: A mixed methods study.

INTRODUCTION: Increasing numbers of people are living with stroke, due to population ageing and improved survival, leading to a need for evidence to inform future policy decision-making. This study aimed to engage with stakeholders in Ireland to identify priorities for stroke services development. METHODS: A sequential mixed methods design was used. Phase 1 (qualitative) was exploratory, involving initial priority gathering via an online qualitative survey and interviews, with stroke survivors, family/main carers, and professionals working in stroke care. Framework analysis was used to generate a long-list of improvements to stroke services. Phase 2 involved a quantitative survey, where stakeholders selected five priority improvements from the long-list. Results were discussed in a stakeholder meeting. RESULTS: In-depth interviews were completed with 18 survivors, 13 carers and 8 professionals, while 80 professionals took part in a qualitative survey (phase 1). Priority areas of care were identified and a long-list of 45 priority improvements was generated. In phase 2, 34 survivors, 19 family carers and 42 professionals completed a survey. The highest priority improvements (selected by >20% of respondents) were access to specialist neuro-rehabilitation, ongoing support for life after stroke, recruitment/retention of specialist staff, improved information and support for health system navigation, and access to specialist acute care. Stroke survivors/carers prioritised exploring ways to improve access for strokes with atypical presentation, while professionals prioritised specialist inpatient rehabilitation and early supported discharge. Neither group prioritised stroke prevention. Based on discussions in the stakeholder meeting (n = 12), it was decided that support for mental health should also be included as a priority. DISCUSSION: The development of stroke services benefits from exploring the priorities of those receiving and delivering stroke care. Findings emphasise the need for equitable access to high quality adequately-staffed services, particularly post-discharge, that are easy to navigate, with good communication, and effective information provision.

Professional Identity Formation, Professionalism, Leadership and Resilience (PILLAR) in Medical Students: Methodology and Early Results.

Objectives: The fundamental role of medical education is the transformation of students to doctors, through a process of education and professional identity formation (PIF), which can be informed by several educational, behavioural and emotional factors. PIF has been deemed to be of equal importance to the acquisition of clinical knowledge and skills and includes constructs such as professionalism, leadership and resilience. We aimed to assess professional identity formation, professionalism, leadership and resilience (PILLAR) in the junior years of medical school in the 2020/2021 academic year and illustrate the potential role of quantitative assessment to demonstrate progression in these areas. In this research, we provide the methods and baseline results for the PILLAR study. Methods: We implemented a compulsory assessment in pre-clinical years of graduate entry and direct entry medicine at the Royal College of Surgeons in Ireland University of Medicine and Health Sciences, Dublin, Ireland. Validated scales were used to assess students' PILLAR. Descriptive and univariable statistical techniques were used to compare student scores between respective years. Results: A total of 1311 students (92% response rate) provided their consent for research. For the psychometric scales, there were no evident trends among the years on these assessment measures. Results indicated significant differences in all measures, however, these did not correspond to ascending years of seniority. Conclusion: The PILLAR methodology provides important information on the challenges of quantitatively assessing medical students in the four key areas of PIF, professionalism, leadership, and resilience. Our cross-sectional results point to cohort effects, without the expected progression per year in the cross-sectional data, or suggest that the chosen quantitative measures may be problematic for these constructs in pre-clinical students. Therefore, while we believe that PILLAR has potential as a progress test for these constructs, this will only truly be elucidated by repeated measures of each cohort over time.

Medical students, mental health and the role of resilience - A cross-sectional study.

BACKGROUND: Medical students have reported high prevalence of mental health difficulties and burnout. However, there are limited investigations examining the association between resilience and these difficulties. We investigated: (1) depression, anxiety, personal and professional burnout, and comorbidity; (2) demographic and education characteristics associated with these outcomes; (3) the association between resilience and these outcomes; and (4) whether these results were attributable to sampling bias. METHODS: Participants were n = 521 medical students from RCSI University of Medicine and Health Sciences. Outcomes were measured using validated scales. We report descriptive statistics, and risk factors for the difficulties were investigated using generalized linear modelling. RESULTS: One-in-three students reported incidence of depression or anxiety (24.5% co-morbidity). 8.9% of students reported all four difficulties. Difficulties were more common in female students and those in middle years of the programme. Resilience was negatively correlated with all outcomes and stable across demographic and educational variables. Weighting the data for sampling bias did not affect these results. CONCLUSIONS: Our results emphasise the high incidence of depression, anxiety, burnout, and comorbidity in students. We advocate for further investigation into the role of resilience as a modifiable factor that may ameliorate the incidence of depression, anxiety, and burnout in medical students.

Designing stroke services for the delivery of cognitive rehabilitation: A qualitative study with stroke rehabilitation professionals.

This qualitative study explored the potential to deliver cognitive rehabilitation for post-stroke cognitive impairment (PSCI), with a specific focus on barriers and facilitators to its delivery from the perspective of Irish stroke rehabilitation professionals. Sixteen semi-structured interviews were completed with healthcare professionals in both hospital and community settings. The sample comprised physiotherapists, occupational therapists, nurses, a stroke physician, a psychologist, a neuropsychologist, a speech and language therapist, a dietician, and a public health nurse. Interviews were audio-recorded and analysed in NVivo using inductive Thematic Analysis. Barriers and facilitators to the delivery of cognitive rehabilitation were identified and described under four key themes: (i) Cognitive screening; (ii) Cognitive rehabilitation: no one size fits all; (iii) Psychology: the lost dimension of stroke rehabilitation; and (iv) Joining the dots in the community. Staffing required to deliver cognitive rehabilitation for PSCI was highlighted as under-resourced in the Republic of Ireland. Inadequate resourcing of neuropsychology and stroke-related psychological services, in particular, has had negative implications for the delivery of cognitive rehabilitation. Stroke-specific cognitive rehabilitation expertise is virtually inaccessible in the community, highlighting an urgent need for investment in specialist rehabilitation teams to deliver cognitive rehabilitation in this setting.

A protocol to evaluate the impact of embedding Public and Patient Involvement in a structured PhD program for stroke care.

Background: Embedding Public and Patient Involvement (PPI) in postgraduate research has been recognized as an important component of post-graduate training, providing research scholars with an awareness and a skillset in an area which prepares them for future roles as healthcare researchers. Improving Pathways for Acute STroke And Rehabilitation (iPASTAR) is a structured PhD training program [Collaborative Doctoral Award (CDA)] which aims to design a person-centered stroke pathway throughout the trajectory of stroke care, to optimize post-stroke health and wellbeing. PPI is embedded at all stages. Purpose: The iPASTAR research programme was strongly informed by a round-table PPI consultation process with individuals who experienced stroke and who provided broad representation across ages, gender, geographical locations (urban and rural) and the PhD themed areas of acute care, early supported discharge and lifestyle-based interventions after stroke. Four PhD scholars taking part in the CDA-iPASTAR now work collaboratively with four stroke champions, supported by a wider PPI advisory panel. Methods: This study will evaluate the process and impact of embedding PPI during a PhD program. We will conduct a longitudinal mixed-methods evaluation, conducting focus groups at 24, 36, and 48 months to explore the experiences of the key stakeholders involved. The participants will include PhD scholars, PPI partners (PPI Advisory Group and PPI Champions), PhD supervisors and a PPI manager. An independent researcher will conduct the evaluation. We will include focus groups, individual interviews and participant reflections. Qualitative data will be analyzed using thematic and content analysis, quantitative data will be analyzed using descriptive statistics. Discussion: PPI and patient voice initiatives bring together researchers, family, and people with health care issues into meaningful dialogue and allow the development of a patient-voice learning network. Embedding PPI training within a PhD program can build meaningful capacity in PPI partnerships in stroke research.

Interventions for increasing immunosuppressant medication adherence in solid organ transplant recipients.

BACKGROUND: Non-adherence to immunosuppressant therapy is a significant concern following a solid organ transplant, given its association with graft failure. Adherence to immunosuppressant therapy is a modifiable patient behaviour, and different approaches to increasing adherence have emerged, including multi-component interventions. There has been limited exploration of the effectiveness of interventions to increase adherence to immunosuppressant therapy. OBJECTIVES: This review aimed to look at the benefits and harms of using interventions for increasing adherence to immunosuppressant therapies in solid organ transplant recipients, including adults and children with a heart, lung, kidney, liver and pancreas transplant. SEARCH METHODS: We searched the Cochrane Kidney and Transplant Register of Studies up to 14 October 2021 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register were identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA: All randomised controlled trials (RCTs), quasi-RCTs, and cluster RCTs examining interventions to increase immunosuppressant adherence following a solid organ transplant (heart, lung, kidney, liver, pancreas) were included. There were no restrictions on language or publication type. DATA COLLECTION AND ANALYSIS: Two authors independently screened titles and abstracts of identified records, evaluated study quality and assessed the quality of the evidence using the GRADE approach. The risk of bias was assessed using the Cochrane tool. The ABC taxonomy for measuring medication adherence provided the analysis framework, and the primary outcomes were immunosuppressant medication initiation, implementation (taking adherence, dosing adherence, timing adherence, drug holidays) and persistence. Secondary outcomes were surrogate markers of adherence, including self-reported adherence, trough concentration levels of immunosuppressant medication, acute graft rejection, graft loss, death, hospital readmission and health-related quality of life (HRQoL). Meta-analysis was conducted where possible, and narrative synthesis was carried out for the remainder of the results. MAIN RESULTS: Forty studies involving 3896 randomised participants (3718 adults and 178 adolescents) were included. Studies were heterogeneous in terms of the type of intervention and outcomes assessed. The majority of studies (80%) were conducted in kidney transplant recipients. Two studies examined paediatric solid organ transplant recipients. The risk of bias was generally high or unclear, leading to lower certainty in the results. Initiation of immunosuppression was not measured by the included studies. There is uncertain evidence of an association between immunosuppressant medication adherence interventions and the proportion of participants classified as adherent to taking immunosuppressant medication (4 studies, 445 participants: RR 1.09, 95% CI 0.95 to 1.20; I² = 78%). There was very marked heterogeneity in treatment effects between the four studies evaluating taking adherence, which may have been due to the different types of interventions used. There was evidence of increasing dosing adherence in the intervention group (8 studies, 713 participants: RR 1.14, 95% CI 1.03 to 1.26, I² = 61%).  There was very marked heterogeneity in treatment effects between the eight studies evaluating dosing adherence, which may have been due to the different types of interventions used. It was uncertain if an intervention to increase immunosuppressant adherence had an effect on timing adherence or drug holidays. There was limited evidence that an intervention to increase immunosuppressant adherence had an effect on persistence. There was limited evidence that an intervention to increase immunosuppressant adherence had an effect on secondary outcomes. For self-reported adherence, it is uncertain whether an intervention to increase adherence to immunosuppressant medication increases the proportion of participants classified as medically adherent to immunosuppressant therapy (9 studies, 755 participants: RR 1.21, 95% CI 0.99 to 1.49; I² = 74%; very low certainty evidence). Similarly, it is uncertain whether an intervention to increase adherence to immunosuppressant medication increases the mean adherence score on self-reported adherence measures (5 studies, 471 participants: SMD 0.65, 95% CI -0.31 to 1.60; I² = 96%; very low certainty evidence). For immunosuppressant trough concentration levels, it is uncertain whether an intervention to increase adherence to immunosuppressant medication increases the proportion of participants who reach target immunosuppressant trough concentration levels (4 studies, 348 participants: RR 0.98, 95% CI 0.68 to 1.40; I² = 40%; very low certainty evidence). It is uncertain whether an intervention to increase adherence to immunosuppressant medication may reduce hospitalisations (5 studies, 460 participants: RR 0.67, 95% CI 0.44 to 1.02; I² = 64%; low certainty evidence). There were limited, low certainty effects on patient-reported health outcomes such as HRQoL. There was no clear evidence to determine the effect of interventions on secondary outcomes, including acute graft rejection, graft loss and death. No harms from intervention participation were reported. AUTHORS' CONCLUSIONS: Interventions to increase taking and dosing adherence to immunosuppressant therapy may be effective; however, our findings suggest that current evidence in support of interventions to increase adherence to immunosuppressant therapy is overall of low methodological quality, attributable to small sample sizes, and heterogeneity identified for the types of interventions. Twenty-four studies are currently ongoing or awaiting assessment (3248 proposed participants); therefore, it is possible that findings may change with the inclusion of these large ongoing studies in future updates.

The impact of stroke, cognitive function and post-stroke cognitive impairment (PSCI) on healthcare utilisation in Ireland: a cross-sectional nationally representative study.

BACKGROUND: Cognitive impairment after stroke is associated with poorer health outcomes and increased need for long-term care. The aim of this study was to determine the impact of stroke, cognitive function and post-stroke cognitive impairment (PSCI) on healthcare utilisation in older adults in Ireland. METHODS: This cross-sectional study involved secondary data analysis of 8,175 community-dwelling adults (50 + years), from wave 1 of The Irish Longitudinal Study on Ageing (TILDA). Participants who had been diagnosed with stroke by a doctor were identified through self-report in wave 1. Cognitive function was measured using the Montreal Cognitive Assessment (MoCA). The main outcome of the study was healthcare utilisation, including General Practitioner (GP) visits, emergency department visits, outpatient clinic visits, number of nights admitted to hospital, and use of rehabilitation services. The data were analysed using multivariate adjusted negative binomial regression and logistic regression. Incidence-rate ratios (IRR), odds ratios (OR) and 95% confidence intervals (CI) are presented. RESULTS: The adjusted regression analyses were based on 5,859 participants who completed a cognitive assessment. After adjusting for demographic and clinical covariates, stroke was independently associated with an increase in GP visits [IRR (95% CI): 1.27 (1.07, 1.50)], and outpatient service utilisation [IRR: 1.49 (1.05, 2.12)]. Although participants with poor cognitive function also visited the GP more frequently than participants with normal cognitive function [IRR: 1.07 (1.04, 1.09)], utilisation of outpatient services was lower in this population [IRR: 0.92 (0.88, 0.97)]. PSCI was also associated with a significant decrease in outpatient service utilisation [IRR: 0.75 (0.57, 0.99)]. CONCLUSIONS: Stroke was associated with higher utilisation of GP and outpatient services. While poor cognitive function was also associated with more frequent GP visits, outpatient service utilisation was lower in participants with poor cognitive function, indicating that cognitive impairment may be a barrier to outpatient care. In Ireland, the lack of appropriate neurological or cognitive rehabilitation services appears to result in significant unaddressed need among individuals with cognitive impairment, regardless of stroke status.

Regulating emotional responses to aphasia to re-engage in life: a qualitative interview study.

BACKGROUND: People with post-stroke aphasia (PWA) are more likely to experience serious mood disorders compared with those without. Emotional regulation may be important for influencing life participation after stroke. Understanding emotional regulation in the context of aphasia is important for promoting personally defined recovery, psychological well-being and life participation. AIMS: To explore how individuals experience and regulate negative emotional responses to aphasia as part of re-engaging with life. METHODS & PROCEDURES: In-depth semi-structured qualitative interviews with 14 PWA were conducted. The focus and design were developed with public and patient involvement contributors. Reflexive thematic analysis was applied. OUTCOMES & RESULTS: Analysis generated three themes, which captured inherent diversity across participants in terms of emotional experiences, responses and regulation strategies: (1) emotional upheaval at all stages of recovery; (2) regulating emotional upheaval; and (3) discerning possibilities for life participation. Emotional regulation occurred both within and without the context of formal support services. CONCLUSIONS & IMPLICATIONS: Individuals may be differently (en)abled in responding positively, with implications for aphasia psychological support and self-management interventions. The findings may inform future interventions to optimize well-being and personally meaningful outcomes for PWA. WHAT THIS PAPER ADDS: What is already known on the subject PWA experience significant psychosocial upheaval and are at risk of mood disorders. Emotional regulation may be important for influencing one's emotional state, social participation and relationships after stroke. There is a need to better understand the ways in which PWA experience and regulate their emotions to develop better support for personally defined recovery. What this paper adds to existing knowledge PWA may experience significant and pervasive mood disorders in the long term after stroke. This may be compounded by worries for their children's well-being. Some, but not all, regulate emotions by drawing on positivity, determination, gratitude or stoicism. Having (supportive) opportunities to experience the impact of aphasia is important for discerning helpful strategies and participation opportunities. What are the potential or actual clinical implications of this work? Confronting altered abilities requires supportive, responsive opportunities sensitive to emotional responses. Opportunities for peer support and/or meaningful emotional support and compassion from family and friends are important therapeutic targets. Therapeutic input should pay attention to any familial and parenting concerns that may be compounding low mood. Although emotional regulation and recovery may occur without formal support, mental health services must be organized in such a way that PWA can access as needed.

The impact of telemedicine enabled pre-hospital triage in acute stroke - a protocol for a mixed methods systematic review.

Introduction: Increasing access to thrombolysis and thrombectomy through improved pathway organisation remains a health service challenge that requires contextualisation to the geographic, demographic and resourcing status of any regional stroke service. Pre-hospital delays or delays during inter-hospital transfers can result in patients being outside the window for one or both interventions. Pre-hospital triage using technology-enabled interdisciplinary communication networks may facilitate rapid individualized care decisions, permitting streamlined care pathways to hospital sites most appropriate to their clinical presentation and history in the first instance. Understanding the experience of those involved in efforts to improve or reorganise care may help to explain the impact observed. Objectives: 1. To review the impact of pre-hospital telemedicine enabled workflow intervention strategies on patient outcomes and on service process metrics in hyper-acute stroke care2. To examine how the experience of those involved in providing or receiving such interventions might identify key characteristics of effective interventions. Inclusion criteria: Quantitative, qualitative and primary mixed methods studies will be included. Quantitative studies will assess effectiveness of telemedicine-enabled interventions that facilitate pre-hospital acute stroke triage. Intervention effects on functional outcomes of patients, on intervention rates and on key time metrics in hyperacute stroke care will be assessed. Qualitative studies will explore the experiences of people involved in or impacted by these interventions. Methods and analysis: A convergent segregated mixed methods systematic review will synthesise and integrate primary qualitative, quantitative and mixed methods studies using the Joanna Briggs Institute methodology. Database searches will include OVID (MEDLINE), EMBASE, The Cochrane Library, CINAHL and Web of Science. Critical appraisal will include the Mixed Methods Assessment Tool. Results of quantitative studies and findings of qualitative studies will be integrated and configured to explore and contextualize each single method synthesis. Systematic review registration: This protocol has been submitted for registration with PROSPERO.

Inclusion of stroke patients in expanded cardiac rehabilitation services: a cross-national qualitative study with cardiac and stroke rehabilitation professionals.

PURPOSE: This qualitative study explored healthcare professionals' views in relation to the potential expansion of cardiac rehabilitation services to include stroke patients, thereby becoming a cardiovascular rehabilitation model. DESIGN AND METHODS: 23 semi-structured interviews were completed with hospital and community-based stroke and cardiac rehabilitation professionals in Switzerland (n = 7) and Ireland (n = 19). The sample comprised physiotherapists, occupational therapists, speech and language therapists, stroke physicians, cardiologists, psychologists, dieticians and nurses. Interviews were audio-recorded and the transcripts were analysed in NVivo using inductive Thematic Analysis. RESULTS: Barriers and facilitators to cardiovascular rehabilitation were captured under four broad themes; (i) Cardiac rehabilitation as "low-hanging fruit," (ii) Cognitive impairment ("the elephant in the room"), (iii) Adapted cardiac rehabilitation for mild stroke, and (iv) Resistance to change. CONCLUSIONS: Hybrid cardiac rehabilitation programmes could be tailored to deliver stroke-specific education, exercises and multidisciplinary expertise. Post-stroke cognitive impairment was identified as a key barrier to participation in cardiac rehabilitation. A cognitive rehabilitation intervention could potentially be delivered as part of cardiac rehabilitation, to address the cognitive needs of stroke and cardiac patients.Implications for rehabilitationThe cardiac rehabilitation model has the potential to be expanded to include mild stroke patients given the commonality of secondary prevention needs.Up to half of stroke survivors are affected by post-stroke cognitive impairment, consequently mild stroke patients may not be such an "easy fit" for cardiac rehabilitation.A cardiovascular programme which includes common rehabilitation modules, in addition to stroke- and cardiac-specific content is recommended.A cognitive rehabilitation module could potentially be added as part of the cardiac rehabilitation programme to address the cognitive needs of stroke and cardiac patients.

The relevance of stroke care for living well with post-stroke aphasia: a qualitative interview study with working-aged adults.

PURPOSE: This study aimed to explore the perspectives of working-aged adults with post-stroke aphasia (PWA) towards what has or would help them in living well with aphasia (LWA). This paper reports the findings in relation to stroke care and its relevance for LWA. MATERIALS AND METHODS: This qualitative study was designed with input from a Public and Patient Involvement advisory group. We conducted in-depth, semi-structured interviews with 14 PWA. Data were analysed following principles of reflexive thematic analysis. RESULTS: Support services and LWA spanned five themes: Inpatient care; Support in the community; Speech therapy; Mental health; and Aphasia education and training. Per the findings, all aspects of stroke care were affected and challenged by aphasia. Access to services and information was variable. PWA of working-age, their families and children need access to person-centred stroke care and information responsive to their changing needs at all stages of recovery. Healthcare workers must be equipped with aphasia competency. CONCLUSIONS: The results highlight a need for equitable, transparent, responsive access to services, information and stroke liaison support. The findings extend knowledge of the importance of stroke care for supporting working-aged adults and their families to live well in the context of aphasia.Implications for rehabilitationThere is a need for equitable, transparent access to a responsive integrated pathway of stroke care to support living well with aphasia.People with aphasia post-stroke and their families need access to person-centred stroke care and information responsive to their changing needs at all stages of recovery.This includes flexible access to mental healthcare and speech and language therapy.In order to access relevant care, people with post-stroke aphasia need access to information and stroke liaison support.Training to improve aphasia competency is imperative for healthcare workers.

Adverse drug reactions in an ageing PopulaTion (ADAPT) study: Prevalence and risk factors associated with adverse drug reaction-related hospital admissions in older patients.

Background: Older people experience greater morbidity with a corresponding increase in medication use resulting in a potentially higher risk of adverse drug reactions (ADRs). Objectives: The aim of this study was to; 1) determine the prevalence and characteristics of ADR-related hospital admissions among older patients (≥65 years) in Ireland; and 2) identify the risk factors associated with ADR-related hospital admissions. Methods: A cross-sectional study of ADR prevalence in patients aged ≥65 years admitted acutely to hospital in Ireland over a 8 month period (November 2016- June 2017). A multifaceted review of each hospital admission was undertaken to assess the likelihood of an ADR being a reason for admission (cause of admission or contributing to admission) in the context of the patient's medication, clinical conditions, comorbidities and investigations. A number of decision aids were applied by two independent reviewers to assess ADR causality, avoidability and severity. A random sample of patients, determined not to have a suspected ADR on screening, were assigned to a non-ADR control group. Multivariable logistic regression was used to assess the association between potential risk factors for ADR-related admissions compared with non-ADR-related admissions. Results: In total, 3,760 hospital admission episodes (in 3,091 patients) were screened and 377 admissions were considered ADR-related (10.0%, 95% CI 9.1%, 11.0%). 219 (58.1%) ADR-related admissions were caused by an ADR, while ADRs contributed to 158 (41.9%) admissions. 268 (71.1%) of all ADR-related admissions were deemed definitely or possibly preventable/avoidable. 350 (92.8%) ADRs were classified as being of moderate severity, with 27 (7.2%) classified as severe. Antithrombotic agents, mainly aspirin and warfarin, were the drugs most frequently associated with ADR-related admissions (gastrointestinal and vascular haemorrhagic disorders). In multivariable analysis, immobility, frailty, having delirium or ulcer disease and taking anticoagulant and antiplatelet medication on admission were significantly associated with an ADR-related hospital admission. Conclusion: One in ten hospital admissions, among those aged 65 + years, were considered ADR-related, with approximately 70% potentially avoidable. Reliable and validated ADR detection and prediction tools are needed to develop prevention strategies.

StrokeCog Markov Model: Projected Prevalent and Incident Cases of Stroke and Poststroke Cognitive Impairment to 2035 in Ireland.

BACKGROUND AND PURPOSE: Cognitive impairment no dementia (CIND) and dementia are common stroke outcomes, with significant health and societal implications for aging populations. These outcomes are not included in current epidemiological models. We aimed to develop an epidemiological model to project incidence and prevalence of stroke, poststroke CIND and dementia, and life expectancy, in Ireland to 2035, informing policy and service planning. METHODS: We developed a probabilistic Markov model (the StrokeCog model) applied to the Irish population aged 40 to 89 years to 2035. Data sources included official population and hospital-episode statistics, longitudinal cohort studies, and published estimates. Key assumptions were varied in sensitivity analysis. Results were externally validated against independent sources. The model tracks poststroke progression into health states characterized by no cognitive impairment, CIND, dementia, disability, stroke recurrence, and death. RESULTS: We projected 69 051 people with prevalent stroke in Ireland in 2035 (22.0 per 1000 population [95% CI, 20.8-23.1]), with 25 274 (8.0 per 1000 population [95% CI, 7.1-9.0]) of those projected to have poststroke CIND, and 12 442 having poststroke dementia (4.0 per 1000 population [95% CI, 3.2-4.8]). We projected 8725 annual incident strokes in 2035 (2.8 per 1000 population [95% CI, 2.7-2.9]), with 3832 of these having CIND (1.2 per 1000 population [95% CI, 1.1-1.3]), and 1715 with dementia (0.5 per 1000 population [95% CI, 0.5-0.6]). Life expectancy for stroke survivors at age 50 was 23.4 years (95% CI, 22.3-24.5) for women and 20.7 (95% CI, 19.5-21.9) for men. CONCLUSIONS: This novel epidemiological model of stroke, poststroke CIND, and dementia draws on the best available evidence. Sensitivity analysis indicated that findings were robust to assumptions, and where there was uncertainty a conservative approach was taken. The StrokeCog model is a useful tool for service planning and cost-effectiveness analysis and is available for adaptation to other national contexts.

'I hated being ghosted' - The relevance of social participation for living well with post-stroke aphasia: Qualitative interviews with working aged adults.

BACKGROUND: In the context of increasing incidence of stroke in working aged adults, there is a specific need to explore the views of working aged adults with post-stroke aphasia, whose communication difficulties may result in restricted social participation, loss of employment and changed relationship and parenting roles. This study aimed to explore the perspectives of working aged adults with post-stroke aphasia in relation to social participation and living well with aphasia (LWA). DESIGN AND PARTICIPANTS: We conducted qualitative interviews with 14 people with post-stroke aphasia (PWA). Data were analysed following principles of reflexive, thematic analysis. Patient or Public Contribution: A Public and Patient Involvement aphasia advisory group inputted into the study design and interpretation of data. RESULTS: Social participation spanned 5 themes: Relationships and roles; Social support; Peer network, Aphasia awareness; and Employment and training. Meaningful, interesting social participation for LWA is individually defined. Working aged PWA may require flexible support with parenting, accessing a diverse social network and finding opportunities for meaningful social connection, training and employment. CONCLUSIONS: The findings extend knowledge of social participation in the context of LWA for working aged adults by elucidating the individually defined nature of meaningful participation and how PWA may need flexible support with parenting, accessing a diverse social network and training and employment. For aphasia research, policy and services to be relevant, it is crucial that working aged PWA are meaningfully involved in setting the aphasia agenda.

National and Institutional Trends in Adverse Events Over Time: A Systematic Review and Meta-analysis of Longitudinal Retrospective Patient Record Review Studies.

OBJECTIVE: This study aimed to determine if the implementation of large-scale patient safety initiatives have been successful in reducing overall and preventable adverse event rates in hospital inpatients. DESIGN: The design used in this study was systematic review and meta-analysis. DATA RESOURCES: We followed our published protocol (PROSPERO [CRD42019140058]) and searched the following databases: PubMed, CINAHL, PsycINFO, Cochrane Library, and Embase from inception to February 2020. The reference lists of eligible studies were also searched. ELIGIBILITY: All longitudinal retrospective record review studies that examined adverse event rates before and after the introduction of patient safety initiatives in hospital inpatients were included. DATA EXTRACTION: Data extraction, quality, and risk of bias assessment were carried out by 2 independent reviewers. Information on study design, setting, demographics, interventions, and safety outcome measures was extracted. RESULTS: A total of 3894 articles were screened, and 7 articles met the eligibility criteria for our systematic review with 5 of these providing sufficient information for inclusion in the meta-analysis. The degree of heterogeneity was high among studies. The meta-analysis demonstrated a minimal risk reduction in overall adverse event rates of 0.017 (95% confidence interval, 0.002-0.032) when the lower-quality studies were excluded, with one adverse event being prevented for every 59 hospital admissions. CONCLUSIONS: These findings are significant when the large numbers of admissions to a hospital every year are considered. Given the low numbers of large-scale implementation studies, there is a need for more research on the effectiveness of patient safety initiatives to further assess the impact of such initiatives on adverse events.

The Irish National Adverse Event Study-2 (INAES-2): longitudinal trends in adverse event rates in the Irish healthcare system.

OBJECTIVES: To quantify the prevalence and nature of adverse events in acute Irish hospitals in 2015 and to assess the impact of the National Clinical Programmes and the National Clinical Guidelines on the prevalence of adverse events by comparing these results with the previously published data from 2009. DESIGN AND METHODS: A retrospective chart review of 1605 admissions to eight Irish hospitals in 2015, using identical methods to those used in 2009. RESULTS: The percentage of admissions associated with one or more adverse events was unchanged (p=0.48) at 14% (95% CI=10.4% to 18.4%) in 2015 compared with 12.2% (95% CI=9.5% to 15.5%) in 2009. Similarly, the prevalence of preventable adverse events was unchanged (p=0.3) at 7.4% (95% CI=5.3% to 10.5%) in 2015 compared with 9.1% (95% CI=6.9% to 11.9%) in 2009. The incidence densities of preventable adverse events were 5.6 adverse events per 100 admissions (95% CI=3.4 to 8.0) in 2015 and 7.7 adverse events per 100 admissions (95% CI=5.8 to 9.6) in 2009 (p=0.23). However, the percentage of preventable adverse events due to hospital-associated infections decreased to 22.2% (95% CI=15.2% to 31.1%) in 2015 from 33.1% (95% CI=25.6% to 41.6%) in 2009 (p=0.01). CONCLUSION: Adverse event rates remained stable between 2009 and 2015. The percentage of preventable adverse events related to hospital-associated infection decreased, which may represent a positive impact of the related national programmes and guidelines.

Development of a national stroke audit in Ireland: scoping review protocol.

Introduction Recent advances in stroke management and care have resulted in improved survival and outcomes. However, providing equitable access to acute care, rehabilitation and longer-term stroke care is challenging. Recent Irish evidence indicates variation in stroke outcomes across hospitals, and a need for continuous audit of stroke care to support quality improvement. The aim of this project is to develop a core minimum dataset for use in the new Irish National Audit of Stroke (INAS), which aims to improve the standard of stroke care in Ireland. This paper outlines the protocol for conducting a scoping review of international practice and guidelines in auditing acute and non-acute stroke care. Objective Identify data items that are currently collected by stroke audits internationally, and identify audit guidelines that exist for recommending inclusion of content in stroke audit datasets. Methods and analysis This scoping review will be conducted in accordance with the Preferred Reporting Items for Systematic Reviews extension for Scoping Reviews (PRISMA-ScR). We will search the following databases: Medline Ovid; Embase; CINAHL EBSCOHost. Grey literature will also be searched for relevant materials, as will relevant websites. Study selection and review will be carried out independently by two researchers, with discrepancies resolved by a third. Data charting and synthesis will involve sub-dividing relevant sources of evidence, and synthesising data into three categories: i) acute stroke care; ii) non-acute stroke care; and iii) audit data collection procedures and resourcing. Data will be charted using a standardised form specific to each category. Consultation with knowledge users will be conducted at all stages of the scoping review. Discussion This scoping review will contribute to a larger project aimed at developing an internationally benchmarked stroke audit tool that will be used prospectively to collect data on all stroke admissions in Ireland, encompassing both acute and non-acute data items.

A systematic review and meta-analysis of the effects of cardiac rehabilitation interventions on cognitive impairment following stroke.

PURPOSE: The cardiac rehabilitation model has potential as an approach to providing rehabilitation following stroke. This review aims to identify evidence for the participation of stroke patients in cardiac/cardiovascular rehabilitation programs internationally, whether or not such programs offer a cognitive intervention as part of treatment, and the impact of rehabilitation on post-stroke cognitive function. METHOD: Five electronic databases were searched from inception to 1 May 2019, namely: MEDLINE, PsycINFO, the Cumulative Index to Nursing and Allied Health Literature, the Cochrane Central Register of Controlled Trials, and the Web of Science. Eligible studies included both randomized and non-randomized studies of cardiac rehabilitation-type interventions which measured cognitive function in patients with transient ischemic attack (TIA) or stroke. RESULTS: Of 14,153 records reviewed, nine studies which delivered cardiac rehabilitation-type interventions to stroke patients were finally included. Only three of these studies delivered cognitive rehabilitation as part of the intervention. Cardiac rehabilitation had no statistically significant effect on cognitive function in five randomized controlled trials (standardized mean difference= 0.28, 95% CI= -0.16 to 0.73) or in three one group pre-post studies (standardized mean difference= 0.15, 95% CI= -0.03 to 0.33). CONCLUSIONS: This review highlights that there are very few studies of delivery of cardiac rehabilitation to stroke patients and that the inclusion of cognitive interventions is even less common, despite the high prevalence of post-stroke cognitive impairment.IMPLICATIONS FOR REHABILITATIONThe cardiac rehabilitation model has the potential to be expanded to include patients post-stroke given the commonality of secondary prevention needs, thereby becoming a cardiovascular rehabilitation model.Up to half of patients experience cognitive impairment after stroke; suggesting that a post-stroke cardiovascular rehabilitation model should incorporate specific cognitive strategies for patients.This systematic review identified three cardiovascular rehabilitation programmes which delivered cognitive rehabilitation as part of treatment; however, evidence for efficacy is weak.