WITHDRAWN: The epidemiology of emergency presentations for falls across Western Victoria, Australia.

The Publisher regrets that this article is an accidental duplication of an article that has already been published, https://doi.org/10.1016/j.auec.2019.08.003. The duplicate article has therefore been withdrawn. The full Elsevier Policy on Article Withdrawal can be found at https://www.elsevier.com/about/our-business/policies/article-withdrawal.

Healthcare staff digital literacy levels and their attitudes towards information systems.

This study aimed to assess the digital literacy levels and attitudes towards information systems of staff in a health service that will be implementing an electronic health record so that barriers towards implementation could be addressed. A survey measuring staff confidence levels and their attitudes towards information systems was developed. Data were collected over a five-week period, with data analysed using frequency analysis and a chi-square analysis. There were 407 respondents to the survey. The majority (70-80%) of which reported high digital literacy levels, expressing confidence in using technology. Respondents also reported positive attitudes towards information systems. However, one-fifth reported anxiety using information systems. Given poor staff engagement with information systems adversely affects the safety and quality of patient care, health services should provide targeted education and training to address staff with low digital literacy levels and/or confidence with using information systems prior to implementation of an electronic health record system.

The epidemiology of emergency presentations for falls from height across Western Victoria, Australia.

BACKGROUND: In order to implement intervention strategies to prevent falls from height, epidemiological data are needed. The aim of this study was to map emergency presentations for falls from height in residents aged ≥40yr of the western region of Victoria, Australia. METHODS: Emergency presentations following a fall from height (≥1m) were obtained from electronic medical records for 2014-2016 inclusive. For each Local Government Area, age-standardised incidence rates (per 10,000 population/year) were calculated. RESULTS: The age-standardised incidence rate was lowest in the Northern Grampians (3.4 95%CI 0.8-5.9), which has several main industries including health care, agriculture and manufacturing. The highest rates occurred in Corangamite (26.0 95%CI 19.9-32.0), Colac-Otway (23.7 95%CI 18.5-28.8) and Moyne (22.5 95%CI 16.8-28.3), which are sparsely populated (15,000-20,000 people each). Patterns were similar for men and women. Most falls occurred during "leisure" (38.0%), followed by "other work" (15.4%). Men were more likely than women to experience a fall from height while undertaking work activities. Many falls occurred in the home (53.2%). CONCLUSION: Future research should inform strategies to prevent falls from height in the region. This could include specific locations such as the home or farm, and during leisure activities or work.

Before-after evaluation of patient length of stay in a rehabilitation context following implementation of an electronic patient journey board.

PURPOSE: To investigate whether the installation of electronic patient journey boards in an inpatient adult rehabilitation centre in Victoria, Australia, is associated with shorter lengths of stay for admitted adult rehabilitation patients. METHODS: A retrospective before-after analysis of 3 259 adult inpatient rehabilitation episodes from 2013 to 2018 was performed, analysing case-mix adjusted lengths of stay. RESULTS: A reduction in case-mix adjusted length of stay of 4.1 days per episode (95 % confidence interval: 2.0-6.4 days) was found. The corresponding reduction in hospital costs was estimated to be $3 738 per episode (95 % confidence interval $2 398-$4 983). CONCLUSIONS: Installation of electronic patient journey boards was associated with shorter lengths of stay in an inpatient adult rehabilitation centre. Additional research is needed to 1) provide further evidence of the causal effect of the boards on length of stay, and 2) investigate the mechanisms by which they reduce lengths of stay (e.g., increased currency of information, changes to procedures, remote viewing) in rehabilitation settings.

The epidemiology of emergency presentations for falls across Western Victoria, Australia.

BACKGROUND: In order to develop and implement prevention strategies for falls, comprehensive epidemiological data are required. Therefore, this study mapped emergency presentations for falls across the western region of Victoria, Australia, encompassing urban, regional and rural areas. METHODS: This cross-sectional study utilised electronic data for emergency presentations following a fall from <1m for individuals aged ≥40yr during 2014-2016 inclusive. Age-standardised incidence rates (per 1000 population/year) were calculated for each Local Government Area (LGA). RESULTS: Age-standardised falls incidence varied across the LGAs, with the lowest occurring in the Rural City of Ararat LGA (4.4; 95%CI:3.5-5.4) and the highest for the City of Warrnambool (25.1; 95%CI:23.7-26.6), Colac-Otway (24.7; 95%CI:23.0-26.4) and Moyne (23.0; 95%CI:21.2-24.8). Patterns were similar for men and women when stratified by sex across these LGAs. For men and women combined, most patients arrived at the hospital using private transportation (55.3%) or road ambulance service (43.1%). Most falls occurred during leisure activities (48.0%) in a home setting (54.8%). CONCLUSIONS: Higher rates of falls presentations were observed in southern LGAs and most commonly occurred at home, during leisure activity. Future research should identify specific intervention strategies to reduce falls in the region, based on the data reported from this study.

Mapping Cancer incidence across Western Victoria: the association with age, accessibility, and socioeconomic status among men and women.

BACKGROUND: Cancer is a leading burden of disease in Australia and worldwide, with incidence rates varying with age, sex and geographic location. As part of the Ageing, Chronic Disease and Injury study, we aimed to map the incidence rates of primary cancer diagnoses across western Victoria and investigate the association of age, accessibility/remoteness index of Australia (ARIA) and area-level socioeconomic status (SES) with cancer incidence. METHODS: Data on cancer incidence in the study region were extracted from the Victorian Cancer Registry (VCR) for men and women aged 40+ years during 2010-2013, inclusive. The age-adjusted incidence rates (per 10,000 population/year), as well as specific incidence for breast, prostate, lung, bowel and melanoma cancers, were calculated for the entire region and for the 21 Local Government Areas (LGA) that make up the whole region. The association of aggregated age, ARIA and SES with cancer incidence rates across LGAs was determined using Poisson regression. RESULTS: Overall, 15,120 cancer cases were identified; 8218 (54%) men and 6902 women. For men, the age-standardised rate of cancer incidence for the whole region was 182.1 per 10,000 population/year (95% CI 177.7-186.5) and for women, 162.2 (95% CI: 157.9-166.5). The incidence of cancer (overall) increased with increasing age for men and women. Geographical variations in cancer incidence were also observed across the LGAs, with differences identified between men and women. Residents of socioeconomically disadvantaged and less accessible areas had higher cancer incidence (p < 0.001). CONCLUSION: Cancer incidence rates varied by age, sex, across LGAs and with ARIA. These findings not only provide an evidence base for identifying gaps and assessing the need for services and resource allocation across this region, but also informs policy and assists health service planning and implementation of preventative intervention strategies to reduce the incidence of cancer across western Victoria. This study also provides a model for further research across other geographical locations with policy and clinical practice implications, both nationally and internationally.

Revision joint replacement surgeries of the hip and knee across geographic region and socioeconomic status in the western region of Victoria: a cross-sectional multilevel analysis of registry data.

BACKGROUND: Residents of rural and regional areas, compared to those in urban regions, are more likely to experience geographical difficulties in accessing healthcare, particularly specialist services. We investigated associations between region of residence, socioeconomic status (SES) and utilisation of all-cause revision hip replacement or revision knee replacement surgeries. METHODS: Conducted in western Victoria, Australia, as part of the Ageing, Chronic Disease and Injury study, data from the Australian Orthopaedic Association National Joint Replacement Registry (2011-2013) for adults who underwent a revision hip replacement (n = 542; 54% female) or revision knee replacement (n = 353; 54% female) were extracted. We cross-matched residential addresses with 2011 census data from the Australian Bureau of Statistics (ABS), and using an ABS-derived composite index, classified region of residence according to local government areas (LGAs), and area-level SES into quintiles. For analyses, the control population (n = 591,265; 51% female) was ABS-determined and excluded adults already identified as cases. Mixed-effects logistic regression was performed. RESULTS: We observed that 77% of revision hip surgeries and 83% of revision knee surgeries were performed for residents in the three most socially disadvantaged quintiles. In adjusted multilevel models, total variances contributed by the variance in LGAs for revisions of the hip or knee joint were only 1% (SD random effects ±0.01) and 3% (SD ± 0.02), respectively. No differences across SES or sex were observed. CONCLUSIONS: No differences in utilisation were identified between SES groups in the provision of revision surgeries of the hip or knee, independent of small between-LGA differences.

Association between area-level socioeconomic status, accessibility and diabetes-related hospitalisations: a cross-sectional analysis of data from Western Victoria, Australia.

OBJECTIVE: Hospitalisation rates for many chronic conditions are higher in socioeconomically disadvantaged and less accessible areas. We aimed to map diabetes hospitalisation rates by local government area (LGA) across Western Victoria, Australia, and investigate their association with socioeconomic status (SES) and accessibility/remoteness. DESIGN: Cross-sectional study METHODS: Data were acquired from the Victorian Admitted Episodes Dataset for all hospitalisations (public and private) with a diagnosis of type 1 or type 2 diabetes mellitus during 2011-2014. Crude and age-standardised hospitalisation rates (per 1000 population per year) were calculated by LGA for men, women and combined data. Associations between accessibility (Accessibility/Remoteness Index of Australia, ARIA), SES (Index of Relative Socioeconomic Advantage and Disadvantage, IRSAD) and diabetes hospitalisation were investigated using Poisson regression analyses. RESULTS: Higher LGA-level accessibility and SES were associated with higher rates of type 1 and type 2 diabetes hospitalisation, overall and for each sex. For type 1 diabetes, higher accessibility (ARIA category) was associated with higher hospitalisation rates (men incidence rate ratio [IRR]=2.14, 95% CI 1.64 to 2.80; women IRR=2.45, 95% CI 1.87 to 3.19; combined IRR=2.30, 95% CI 1.69 to 3.13; all p<0.05). Higher socioeconomic advantage (IRSAD decile) was also associated with higher hospitalisation rates (men IRR=1.25, 95% CI 1.09 to 1.43; women IRR=1.32, 95% CI 1.16 to 1.51; combined IRR=1.23, 95% CI 1.07 to 1.42; all p<0.05). Similarly, for type 2 diabetes, higher accessibility (ARIA category) was associated with higher hospitalisation rates (men IRR=2.49, 95% CI 1.81 to 3.43; women IRR=2.34, 95% CI 1.69 to 3.25; combined IRR=2.32, 95% CI 1.66 to 3.25; all p<0.05) and higher socioeconomic advantage (IRSAD decile) was also associated with higher hospitalisation rates (men IRR=1.15, 95% CI 1.02 to 1.30; women IRR=1.14, 95% CI 1.01 to 1.28; combined IRR=1.13, 95% CI 1.00 to 1.27; all p<0.05). CONCLUSION: Our observations could indicate self-motivated treatment seeking, and better specialist and hospital services availability in the advantaged and accessible areas in the study region. The determinants for such variations in hospitalisation rates, however, are multifaceted and warrant further research.

Correction to: Geographic region, socioeconomic position and the utilisation of primary total joint replacement for hip or knee osteoarthritis across western Victoria: a cross-sectional multilevel study of the Australian Orthopaedic Association National Joint Replacement Registry.

The names of the co-authors Steven Graves and Michelle Lorimer were missing from the manuscript supplied for publication. The lead authors regret this error and apologize for any inconvenience.

The epidemiology of hip fractures across western Victoria, Australia.

BACKGROUND: Hip fractures are associated with considerable morbidity and mortality. Hip fracture incidence varies across different levels of accessibility/remoteness and socioeconomic status (SES). As part of the Ageing, Chronic Disease and Injury Study, we aimed to map the pattern of hip fractures across the western region of the Australian state of Victoria, which contains a range of remoteness levels and SES. METHODS: Data on hip fractures resulting in hospital admission were extracted from the Victorian Admitted Episodes Dataset (VAED) for men and women aged 40+years during 2010-2013 inclusive. An age-adjusted incidence rate (per 10,000population/year) was calculated for the entire region. Crude incidence rates and length of acute care hospital stay (excluding rehabilitation) were calculated for each Local Government Area (LGA). The impact of aggregated age, accessibility/remoteness index of Australia (ARIA) and SES on hip fracture rates aggregated across LGAs was determined using Poisson regression. RESULTS: For men, the age-standardised rate of hospitalisations for hip fracture across the whole region was 19.2 per 10,000population/year (95%CI 18.0-20.4) and for women, 40.0 (95%CI 38.3-41.7). The highest incidence rates for both sexes occurred in the less accessible LGAs of Yarriambiack and Hindmarsh, as well as the LGA with the lowest SES, Central Goldfields. In both sexes, approximately two thirds of individuals were discharged from acute hospital care within 14days. Increasing age, higher remoteness and lower SES were all associated with higher hip fracture rates. CONCLUSION: Crude incidence rates varied by location. Given that a high proportion of patients had acute hospital care of ≤14days, and accessibility and SES were associated with hip fracture rates, these results can inform policy and provide a model for other groups to conduct similar research in their local environment.

Geographic region, socioeconomic position and the utilisation of primary total joint replacement for hip or knee osteoarthritis across western Victoria: a cross-sectional multilevel study of the Australian Orthopaedic Association National Joint Replacement Registry.

Compared to urban residents, those in rural/regional areas often experience inequitable healthcare from specialist service providers. Independent of small between-area differences in utilisation, socially advantaged groups had the greatest uptake of joint replacement. These data suggest low correlation between 'need' vs. 'uptake' of surgery in rural/regional areas. BACKGROUND AND PURPOSE: Compared to urban residents, those in rural and regional areas often experience inequitable healthcare from specialist service providers, often due to geographical issues. We investigated associations between socioeconomic position (SEP), region of residence and utilisation of primary total knee replacement (TKR) and/or total hip replacement (THR) for osteoarthritis. DESIGN AND METHODS: As part of the Ageing, Chronic Disease and Injury study, we extracted data from the Australian Orthopaedic Association National Joint Replacement Registry (2011-2013) for adults that utilised primary TKR (n = 4179; 56% female) and/or THR (n = 3120; 54% female). Residential addresses were matched with the Australian Bureau of Statistics (ABS) 2011 census data: region of residence was defined according to local government areas (LGAs), and area-level SEP (quintiles) defined using an ABS-derived composite index. The ABS-determined control population (n = 591,265; 51% female) excluded individuals identified as cases. We performed multilevel logistic regression modelling using a stratified two-stage cluster design. RESULTS: TKR was higher for those aged 70-79 years (AOR 1.4 95%CI 1.3-1.5; referent = 60-69 years) and in the most advantaged SEP quintile (AOR 2.1, 95%CI 1.8-2.3; referent = SEP quintile 3); results were similar for THR (70-79 years = AOR 1.7, 95%CI 1.5-1.8; SEP quintile 5 = AOR 2.5, 95%CI 2.2-2.8). Total variances contributed by the variance in LGAs were 2% (SD random effects ± 0.28) and 3% (SD ± 0.32), respectively. CONCLUSION: Independent of small between-LGA differences in utilisation, and in contrast to the expected greater prevalence of osteoarthritis in disadvantaged populations, we report greater TKR and THR in more advantaged groups. Further research should investigate whether more advantaged populations may be over-serviced.

Improving the accuracy of admitted subacute clinical costing: an action research approach.

Objective The aim of the present study was to determine whether action research could be used to improve the breadth and accuracy of clinical costing data in an admitted subacute setting Methods The setting was a 100-bed in-patient rehabilitation centre. Using a pre-post study design all admitted subacute separations during the 2011-12 financial year were eligible for inclusion. An action research framework aimed at improving clinical costing methodology was developed and implemented. Results In all, 1499 separations were included in the study. A medical record audit of a random selection of 80 separations demonstrated that the use of an action research framework was effective in improving the breadth and accuracy of the costing data. This was evidenced by a significant increase in the average number of activities costed, a reduction in the average number of activities incorrectly costed and a reduction in the average number of activities missing from the costing, per episode of care. Conclusions Engaging clinicians and cost centre managers was effective in facilitating the development of robust clinical costing data in an admitted subacute setting. Further investigation into the value of this approach across other care types and healthcare services is warranted. What is known about this topic? Accurate clinical costing data is essential for informing price models used in activity-based funding. In Australia, there is currently a lack of robust admitted subacute cost data to inform the price model for this care type. What does this paper add? The action research framework presented in this study was effective in improving the breadth and accuracy of clinical costing data in an admitted subacute setting. What are the implications for practitioners? To improve clinical costing practices, health services should consider engaging key stakeholders, including clinicians and cost centre managers, in reviewing clinical costing methodology. Robust clinical costing data has the potential to be used beyond mandatory reporting requirements; however, health services need to balance the cost of improving their costing data with the additional value obtained from that data.

Ageing, Chronic Disease and Injury: A Study in Western Victoria (Australia).

Background: An increasing burden of chronic disease and associated health service delivery is expected due to the ageing Australian population. Injuries also affect health and wellbeing and have a long-term impact on health service utilisation. There is a lack of comprehensive data on disease and injury in rural and regional areas of Australia. The aim of the Ageing, Chronic Disease and Injury study is to compile data from various sources to better describe the patterns of chronic disease and injury across western Victoria. Design: Ecological study. Methods: Information on demographics, socioeconomic indicators and lifestyle factors are obtained from health surveys and government departments. Data concerning chronic diseases and injuries will be sourced from various registers, health and emergency services, local community health centres and administrative databases and compiled to generate profiles for the study region and for sub-populations within the region. Expected impact for public health: This information is vital to establish current and projected population needs to inform policy and improve targeted health services delivery, care transition needs and infrastructure development. This study provides a model that can be replicated in other geographical settings.

Public sector physiotherapists believe that staff supervision should be broad ranging, individualised, structured, and based on needs and goals: a qualitative study.

QUESTION: What do physiotherapists consider to be the structure and content of an effective clinical supervision program for public sector staff? DESIGN: Qualitative study using emergent-systematic focus group design. PARTICIPANTS: 46 physiotherapists and six physiotherapy assistants from a large, regional, Australian health service participated in one of seven focus groups. RESULTS: Data were represented by three major categories: the content of supervision; the structure of supervision; and participants' roles and attributes. The content of supervision should encompass all issues affecting workplace experience and performance; supervision should be individualised and needs based. For the structure of supervision, a variety of methods and formats should be available, including: scheduled and unscheduled supervision (unscheduled supervision addresses needs as they arise but its usefulness can be restricted by supervisor availability); the environment should be organised to facilitate supervision; supervision should be integrated into existing practices; and supervision should be adequately prioritised and resourced to enable sustainability. In relation to participants' roles and attributes, respondents recommended: clearly defined supervisor and supervisee roles, responsibilities, skills and attributes are required to facilitate a constructive relationship on which successful supervision depends; the supervisee should take primary responsibility for leading and organising their supervision; the supervisor provides support and accountability and assists with goal setting and attainment; and successful supervision requires considerable knowledge and skills from the supervisee and supervisor (supervision education and training might be necessary). CONCLUSION: The physiotherapists' perspectives that were identified in this study are important to consider when assessing current clinical supervision models, as well as when designing and implementing effective physiotherapy supervision programs.

Implementing an inpatient rehabilitation Saturday service is associated with improved patient outcomes and facilitates patient flow across the health care continuum.

PURPOSE: To evaluate the effectiveness of the introduction of a Saturday inpatient rehabilitation service in improving patient outcomes and facilitating hospital access and flow. METHODS: A quasi-experimental study with a historical comparison group is presented. Data were evaluated for the 477 patients admitted and discharged in the 6 months following the implementation (October 2012-March 2013) of the service and 499 patients in the historical control group (April 2012-September 2012). RESULTS: Prior to the introduction of the service median number of patients admitted on a Saturday was 0 (range 0-3), post-implementation the median number of patients admitted on a Saturday increased to 2 (range 0-5), this difference was statistically significant (Z = -3.61, p < 0.001). Median regression modelling demonstrated that, after adjusting for admission Functional Independence (FIM) score, gender, length of stay (LOS) and age, there was a small but significant increase in discharge FIM scores (median increase 2.28, p = 0.027) for those patients admitted in the post-implementation phase. There was no such effect of the service on LOS. CONCLUSIONS: The implementation of the Saturday inpatient rehabilitation service was associated with improved patient outcomes and supported an increase in patient flow throughout the organization as evidenced by an increased number of Saturday patient admissions. IMPLICATIONS FOR REHABILITATION: Inpatient rehabilitation services do not operate in isolation; they are a critical link in the healthcare continuum. There is a mounting body of evidence that the introduction of weekend rehabilitation services has a positive impact on patient outcomes. To maximize health outcomes, access to critical services and patient flow, organizations and staff need to move away from the long-standing 5-day/week inpatient rehabilitation model and start transitioning to a model that incorporates weekend therapy services.

Selection for inpatient rehabilitation after severe stroke: what factors influence rehabilitation assessor decision-making?

OBJECTIVES: This study aimed to identify factors that assessors considered important in decision-making regarding suitability for inpatient rehabilitation after acute severe stroke. DESIGN: Multi-site prospective observational cohort study. SUBJECTS: Consecutive acute, severe stroke patients and their assessors for inpatient rehabilitation. METHODS: Rehabilitation assessors completed a questionnaire, rating the importance (10 point visual analogue scale) and direction (positive, negative or neutral) of 15 patient related and 2 organisational items potentially affecting their decision regarding patients' acceptance to rehabilitation. RESULTS: Of the 75 patients referred to rehabilitation and included in this study 61 (81.3%) were accepted for inpatient rehabilitation. The items considered to be most important in the decision to accept the patient for rehabilitation were pre-morbid cognition, pre-morbid mobility and pre-morbid communication. For those not accepted the most important items were current mobility, social support and current cognition. Factor analysis revealed 3 underlying factors, interpreted as post-stroke status, pre-morbid status, and social attributes, accounting for 61.8% of the total variance. All were independently associated with acceptance for rehabilitation (p < 0.05). CONCLUSIONS: This study highlights the importance of pre-morbid function and social factors in addition to post-stroke function in the decision making process for acceptance to rehabilitation following severe stroke. Future models for selection for rehabilitation should consider inclusion of these factors.

Accessing inpatient rehabilitation after acute severe stroke: age, mobility, prestroke function and hospital unit are associated with discharge to inpatient rehabilitation.

The objective of this study was to identify the variables associated with discharge to inpatient rehabilitation following acute severe stroke and to determine whether hospital unit contributed to access. Five acute hospitals in Victoria, Australia participated in this study. Patients were eligible for inclusion if they had suffered an acute severe stroke (Mobility Scale for Acute Stroke ≤ 15). Physiotherapists assessed patients on day 3 poststroke, collecting demographic information and information relating to their prestroke status, social status and current status. Stepwise logistic-regression modelling was used to examine the association between age, type of stroke, prestroke living situation, comorbidities, availability of carer on discharge, current mobility, bladder continence, bowel continence, cognition and communication and the dependent variable, discharge destination (rehabilitation/other). The resulting model was analysed using hierarchical logistic regression with hospital unit as the clustering variable. Of the 108 patients fulfilling the inclusion criteria, 70 (64.8%) were discharged to rehabilitation. The variables independently associated with discharge to rehabilitation were younger age [odds ratio (OR)=0.89, 95% confidence interval (CI)=0.83-0.95, P=0.001], independent premorbid functional status (OR=14.92, 95% CI=2.43-91.60, P=0.004) and higher level of current mobility (OR=1.31, 95% CI=1.02-1.66, P<0.03). The multilevel model estimated that 12% of the total variability in discharge destination was explained by differences between the hospital units (ρ=0.12, 95% CI=0.02-0.55, P=0.048). The results indicate that the variables associated with discharge to rehabilitation following severe stroke are younger age, independent prestroke functional status and higher level of current mobility. In addition, organizational factors play a role in selection for rehabilitation, suggesting inequity in access for this patient group.

Selection for inpatient rehabilitation after acute stroke: a systematic review of the literature.

OBJECTIVE: To identify patient-related factors that have been found to correlate with functional outcomes post acute stroke to guide clinical decision making with regard to rehabilitation admission after acute stroke. DATA SOURCES: We systematically searched the scientific literature between 1966 and January 2010. The primary source of studies was the electronic databases Medline, CINAHL, and Embase. The search was supplemented with citation tracking. STUDY SELECTION: Two reviewers independently applied the inclusion criteria to identify relevant articles from the citations obtained through the literature search. Eligible studies included systematic reviews of prognostic indicators, studies of prognostic indicators of acute discharge disposition, and studies of rehabilitation admission criteria after acute stroke. Of the 8895 studies identified, 83 articles, representing 79 studies, were included in the review. DATA EXTRACTION: One reviewer extracted the data relating to the participants, prognostic indicators, and outcomes. A second reviewer independently checked data extracted with disagreement resolved by a third reviewer. Quality of included studies was assessed for internal and external validity. DATA SYNTHESIS: Of the 79 studies, 26 were systematic reviews of prognostic indicators of functional level and/or discharge disposition, 48 were studies of prognostic indicators of acute discharge disposition, and 6 were studies of rehabilitation selection criteria. The methodologic quality of the included studies was generally poor. Age, cognition, functional level after stroke, and, to a lesser extent, continence were found to have a consistent association with outcome across all 3 research areas. In addition, stroke severity was also associated with acute discharge disposition, final discharge disposition, and functional level. Sex and side of stroke appeared to have no association across all 3 of the research areas. CONCLUSIONS: This review highlights a number of important prognostic indicators and rehabilitation selection criteria that may assist clinicians in improving selection procedures and standardizing access to inpatient rehabilitation after stroke, although the quality of many studies is low. Further high quality studies and reviews of prognostic indicators and clinician decision making with regards to rehabilitation acceptance are required.

Measures for assessing practice change in medical practitioners.

BACKGROUND: There are increasing numbers of randomised trials and systematic reviews examining the efficacy of interventions designed to bring about a change in clinical practice. The findings of this research are being used to guide strategies to increase the uptake of evidence into clinical practice. Knowledge of the outcomes measured by these trials is vital not only for the interpretation and application of the work done to date, but also to inform future research in this expanding area of endeavour and to assist in collation of results in systematic reviews and meta-analyses. METHODS: The objective of this review was to identify methods used to measure change in the clinical practices of health professionals following an intervention aimed at increasing the uptake of evidence into practice. All published trials included in a recent, comprehensive Health Technology Assessment of interventions to implement clinical practice guidelines and change clinical practice (n = 228) formed the sample for this study. Using a standardised data extraction form, one reviewer (SH), extracted the relevant information from the methods and/or results sections of the trials. RESULTS: Measures of a change of health practitioner behaviour were the most common, with 88.8% of trials using these as outcome measures. Measures that assessed change at a patient level, either actual measures of change or surrogate measures of change, were used in 28.8% and 36.7% of studies (respectively). Health practitioners' knowledge and attitudes were assessed in 22.8% of the studies and changes at an organisational level were assessed in 17.6%. CONCLUSION: Most trials of interventions aimed at changing clinical practice measured the effect of the intervention at the level of the practitioner, i.e. did the practitioner change what they do, or has their knowledge of and/or attitude toward that practice changed? Less than one-third of the trials measured, whether or not any change in practice, resulted in a change in the ultimate end-point of patient health status.

Constraint-induced movement therapy following stroke: a systematic review of randomised controlled trials.

This systematic review investigated the effects on function, quality of life, health care costs, and patient/carer satisfaction of constraint-induced movement therapy (CIMT) for upper limb hemiparesis following stroke. A comprehensive search of the complete holdings of MEDLINE, CINAHL, EMBASE, Cochrane Library, PEDro and OTseeker to March 2005 was conducted. Fourteen eligible randomised controlled trials were identified and relevant data extracted by two independent reviewers. Effect sizes were calculated and results were pooled where possible. Method quality of the trials, assessed using the PEDro scale, had a mean score of five (range three to seven). Thirteen trials compared CIMT to an alternative treatment and/or a control group. One trial compared two CIMT protocols. Acute, subacute, and chronic conditions were studied. Effect sizes could be estimated for nine trials. Results were significant and in favour of CIMT in eight of these for at least one measure of upper limb function. The pooled standardised mean difference could be calculated for five outcome measures producing moderate to large effect sizes, only one of which attained statistical significance. Results indicate that CIMT may improve upper limb function following stroke for some patients when compared to alternative or no treatment. Rigorous evaluation of constraint-induced movement therapy using well-designed and adequately powered trials is required to evaluate the efficacy of different protocols on different stroke populations and to assess impact on quality of life, cost and patient/carer satisfaction.