Access to inpatient mood management services after stroke in Australian acute and rehabilitation hospitals.

OBJECTIVE: Post-stroke mental health impairments are common, but under-assessed and under-treated. We aim to describe trends in the provision of mood management to patients with stroke, and describe factors associated with adoption of national mood management recommendations for stroke within Australian hospitals. DESIGN: Secondary analysis of cross-sectional data from the biennial Stroke Foundation Audit Program. SETTING: Participating acute (2011-2021) and rehabilitation hospitals (2012-2020) in Australia. PARTICIPANTS: In the acute audit, 22,937 stroke cases were included from 133 hospitals. In the rehabilitation audit, 15,891 stroke cases were included from 127 hospitals. MAIN MEASURES: Hospital- and patient-level mood management processes. RESULTS: Among 133 acute hospitals (22,937 stroke episodes), improvements were made between 2011 and 2021 in utilization of mood screening (17% [2011], 33% [2021]; p < 0.001) and access to psychologists during hospital stay (18% [2011], 45% [2021]; p < 0.001). There was no change in access to a psychologist among those with a mood impairment (p = 0.34). Among 127 rehabilitation hospitals (15,891 stroke episodes) improvements were observed for mood screening (35% [2012], 61% [2020]; p < 0.001), and access to a psychologist during hospital stay (38% [2012], 68% [2020]; p < 0.001) and among those with a mood-impairment (30% [2012], 50% [2020]; p < 0.001). Factors associated with receiving mood management processes included: younger age, not requiring an interpreter and longer length of stay. CONCLUSIONS: Adherence to mood management recommendations has improved over 10 years within Australian hospitals. Those aged over 65, requiring an interpreter, or with shorter hospital stays are at risk of missing out on appropriate mood management.

Statistical analysis plan for the Recovery-focused Community support to Avoid readmissions and improve Participation after Stroke randomised controlled clinical trial.

BACKGROUND: Unplanned hospital presentations may occur post-stroke due to inadequate preparation for transitioning from hospital to home. The Recovery-focused Community support to Avoid readmissions and improve Participation after Stroke (ReCAPS) trial was designed to test the effectiveness of receiving a 12-week, self-management intervention, comprising personalised goal setting with a clinician and aligned educational/motivational electronic messages. Primary outcome is as follows: self-reported unplanned hospital presentations (emergency department/admission) within 90-day post-randomisation. We present the statistical analysis plan for this trial. METHODS/DESIGN: Participants are randomised 1:1 in variable block sizes, with stratification balancing by age and level of baseline disability. The sample size was 890 participants, calculated to detect a 10% absolute reduction in the proportion of participants reporting unplanned hospital presentations/admissions, with 80% power and 5% significance level (two sided). Recruitment will end in December 2023 when funding is expended, and the sample size achieved will be used. Logistic regression, adjusted for the stratification variables, will be used to determine the effectiveness of the intervention on the primary outcome. Secondary outcomes will be evaluated using appropriate regression models. The primary outcome analysis will be based on intention to treat. A p-value ≤ 0.05 will indicate statistical significance. An independent Data Safety and Monitoring Committee has routinely reviewed the progress and safety of the trial. CONCLUSIONS: This statistical analysis plan ensures transparency in reporting the trial outcomes. ReCAPS trial will provide novel evidence on the effectiveness of a digital health support package post-stroke. TRIAL REGISTRATION: ClinicalTrials.gov ACTRN12618001468213. Registered on August 31, 2018. SAP version 1.13 (October 12 2023) Protocol version 1.12 (October 12, 2022) SAP revisions Nil.

Comparisons between group- and individual-based interventions to support recovery from stroke and ischaemic heart disease in the community: a scoping review.

PURPOSE: To map and summarise available literature on the effectiveness or other benefits of group- and individual-based interventions provided for adults living with stroke or ischaemic heart disease (IHD) in the community. MATERIAL AND METHODS: The review was conducted based on JBI methodology and reported using Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews. Articles were retrieved from: Medline, PsychInfo, Embase, Scopus, and CINAHL from 2002-2022. Extracted data from eligible studies included type of health outcomes (e.g., impairments), retention and adherence, social connectedness, and the costs associated with group- and individual-based interventions. RESULTS: After screening, five articles (representing 4 unique studies) comparing a group- and individual-based intervention were included (total sample size n = 87). Three types of interventions were assessed: exercise (3/5), communication (1/5), and occupational therapy (1/5). Effectiveness of group- and individual-based interventions at improving health outcomes (i.e. physical ability, communication, motivation, and quality of life) is unclear. Currently there is insufficient evidence to guide clinical practice. CONCLUSIONS: There is limited evidence comparing interventions delivered in a group and individual modality for adults living with stroke or IHD. Adequately powered studies are needed to determine if mode of delivery is equivalent or more cost effective.

Rehabilitation interventions can be offered individually or in group settings with clinicians choosing the most appropriate modality.Both group- and individual-based interventions have advantages and disadvantages, with clinical, practical, and economic factors as important considerations when deciding between the two modalities.Based on this scoping review, the authors conclude that there is currently insufficient evidence to guide clinical practice in deciding which mode of delivery (group or individual) is optimal.There is insufficient research evidence to guide clinicians in their choice between offering rehabilitation interventions for stroke or IHD in groups or individually.

Sustaining a New Model of Acute Stroke Care: A Mixed-Method Process Evaluation of the Melbourne Mobile Stroke Unit.

BACKGROUND: Internationally, Mobile Stroke Unit (MSU) ambulances have changed pre-hospital acute stroke care delivery. MSU clinical and cost-effectiveness studies are emerging, but little is known about important factors for achieving sustainability of this innovative model of care. METHODS: Mixed-methods study from the Melbourne MSU (operational since November 2017) process evaluation. Participant purposive sampling included clinical, operational and executive/management representatives from Ambulance Victoria (AV) (emergency medical service provider), the MSU clinical team, and receiving hospitals. Sustainability was defined as ongoing MSU operations, including MSU workforce and future model considerations. Theoretically-based on-line survey with Unified Theory of Acceptance and Use of Technology (UTAUT), Self Determination Theory (SDT, Intrinsic Motivation), and open-text questions targeting barriers and benefits was administered (June-September 2019). Individual/group interviews were conducted, eliciting improvement suggestions and requirements for ongoing use. Descriptive and regression analyses (quantitative data) and directed content and thematic analysis (open text and interview data) were conducted. RESULTS: There were 135 surveys completed. Identifying that the MSU was beneficial to daily work (ß=0.61), not experiencing pressure/tension about working on the MSU (ß=0.17) and thinking they did well working within the team model (ß=0.17) were significantly associated with wanting to continue working within the MSU model [R2=0.76; F(15, 60)=12.76, P<.001]. Experiences varied between those on the MSU team and those working with the MSU. Advantages were identified for patients (better, faster care) and clinicians (interdisciplinary learning). Disadvantages included challenges integrating into established systems, and establishing working relationships. Themes identified from 35 interviews were MSU team composition, MSU vehicle design and layout, personnel recruitment and rostering, communication improvements between organisations, telemedicine options, MSU operations and dispatch specificity. CONCLUSION: Important factors affecting the sustainability of the MSU model of stroke care emerged. A cohesive team approach, with identifiable benefits and good communication between participating organisations is important for clinical and operational sustainability.

Interdisciplinary interactions, social systems and technical infrastructure required for successful implementation of mobile stroke units: A qualitative process evaluation.

RATIONALE: Mobile stroke units (MSUs) are increasingly being implemented to provide acute stroke care in the prehospital environment, but a comprehensive implementation evaluation has not been undertaken. AIM: To identify successes and challenges in the pre- and initial operations of the first Australian MSU service from an interdisciplinary perspective. METHODS: Process evaluation of the Melbourne MSU with a mixed-methods design. Purposive sampling targeted key stakeholder groups. Online surveys (administered June-September 2019) and semistructured interviews (October-November 2019) explored experiences. Directed content analysis (raters' agreement 85%) and thematic analysis results are presented using the Interactive Sociotechnical Analysis framework. RESULTS: Participants representing executive/program operations, MSU clinicians and hospital-based clinicians completed 135 surveys and 38 interviews. Results converged, with major themes addressing successes and challenges: stakeholders, vehicle, knowledge, training/education, communication, work processes and working relationships. CONCLUSIONS: Successes and challenges of establishing a new MSU service extend beyond technical, to include operational and social aspects across prehospital and hospital environments.

Feedback of aggregate patient-reported outcomes (PROs) data to clinicians and hospital end users: findings from an Australian codesign workshop process.

OBJECTIVES: Patient-reported outcomes (PROs) are increasingly used to measure the patient's perspective of their outcomes following healthcare interventions. The aim of this study was to determine the preferred formats for reporting service-level PROs data to clinicians, researchers and managers to support greater utility of these data to improve healthcare and patient outcomes. SETTING: Healthcare professionals receiving PRO data feedback at the health service level. PARTICIPANTS: An interdisciplinary Project Working Group comprised of clinicians participated in three workshops to codesign reporting templates of summarised PRO data (modified Rankin Scale, EuroQol Five Dimension Descriptive System, EuroQol Visual Analogue Scale and Hospital Anxiety and Depression Scale) using a modified Delphi process. An electronic survey was then distributed to short list the preferred templates among a broad sample of clinical end users. A final workshop was undertaken with the Project Working Group to review results and reach consensus on the final templates. PRIMARY AND SECONDARY OUTCOME MEASURES: The recommendation of preferred PRO summary data feedback templates and guiding principles for reporting aggregate PRO data to clinicians was the primary outcome. A secondary outcome was the identification of perceived barriers and enablers to the use of PRO data in hospitals. For each outcome measure, quantitative and qualitative data were summarised. RESULTS: 31 Working Group members (19 stroke, 2 psychology, 1 pharmacy, 9 researchers) participated in the workshops, where 25/55 templates were shortlisted for wider assessment. The survey was completed by 114 end users. Strongest preferences were identified for bar charts (37/82 votes, 45%) and stacked bar charts (37/91 votes, 41%). At the final workshop, recommendations to enhance communication of PROs data for comparing health service performance were made including tailoring feedback to professional roles and use of case-mix adjustment to ensure fair comparisons. CONCLUSIONS: Our research provides guidance on PROs reporting for optimising data interpretation and comparing hospital performance.

Feedback of patient-reported outcomes to healthcare professionals for comparing health service performance: a scoping review.

OBJECTIVE: Patient-reported outcomes (PROs) provide self-reported patient assessments of their quality of life, daily functioning, and symptom severity after experiencing an illness and having contact with the health system. Feeding back summarised PROs data, aggregated at the health-service level, to healthcare professionals may inform clinical practice and quality improvement efforts. However, little is known about the best methods for providing these summarised data in a way that is meaningful for this audience. Therefore, the aim of this scoping review was to summarise the emerging approaches to PROs data for 'service-level' feedback to healthcare professionals. SETTING: Healthcare professionals receiving PROs data feedback at the health-service level. DATA SOURCES: Databases selected for the search were Embase, Ovid Medline, Scopus, Web of Science and targeted web searching. The main search terms included: 'patient-reported outcome measures', 'patient-reported outcomes', 'patient-centred care', 'value-based care', 'quality improvement' and 'feedback'. Studies included were those that were published in English between January 2009 and June 2019. PRIMARY AND SECONDARY OUTCOME MEASURES: Data were extracted on the feedback methods of PROs to patients or healthcare providers. A standardised template was used to extract information from included documents and academic publications. Risk of bias was assessed using Joanna Briggs Institute Levels of Evidence for Effectiveness. RESULTS: Overall, 3480 articles were identified after de-duplication. Of these, 19 academic publications and 22 documents from the grey literature were included in the final review. Guiding principles for data display methods and graphical formats were identified. Seven major factors that may influence PRO data interpretation and use by healthcare professionals were also identified. CONCLUSION: While a single best format or approach to feedback PROs data to healthcare professionals was not identified, numerous guiding principles emerged to inform the field.

Nurses' Role in Implementing and Sustaining Acute Telemedicine: A Mixed-Methods, Pre-Post Design Using an Extended Technology Acceptance Model.

PURPOSE: Technology-based systems like telemedicine are frequently being implemented into healthcare settings, impacting clinician practices. Little is known about factors influencing acute telemedicine uptake, if factors differ across time, or between nurses and non-nurses. DESIGN: A mixed-methods, pre-post design with implementation of a new acute stroke telemedicine service. METHODS: A survey based on an extended Technology Acceptance Model (TAM) was administered to clinicians involved in acute stroke care at 16 regional hospitals (2014-2017). Open-ended questions postimplementation (at 6 months) included strengths of the program and areas to improve. Subsequently, a secondary analysis of nurses' semistructured interviews at the first telemedicine site (2010-2011) was completed to provide greater explanatory detail. FINDINGS: Surveys were completed by nurses (preimplementation n = 77, postimplementation n = 92) and non-nurses (pre n = 90, post n = 44). Preimplementation, perceived usefulness was the only significant predictor of intending to use telemedicine for nurses, while perceived ease of use and social influence were significant for non-nurses. Postimplementation, perceived usefulness was significant for both groups, as was facilitating conditions for nurses. Specific examples aligned to TAM categories from our detailed interviews (n = 11 nurses) included perceived usefulness (improved clinical support and patient care), perceived ease of use (technical, clinical aspects), facilitating conditions (setting, education, confidence), and social influence (working relationships). CONCLUSIONS: Important factors for acute stroke telemedicine varied between nurses and non-nurses, and changed after implementation. The benefits of telemedicine should be emphasized to nurses. Preimplementation, more non-nurses wanted systems to be easy. Support in clinical, technical, and relationship aspects of telemedicine consultations is required. CLINICAL RELEVANCE: Nurses are influential in implementing acute telemedicine, which is complex, with clinical and technical aspects entwined. Evidence-based implementation strategies must be tailored over time, and between nurses and non-nurses, to ensure initial uptake and ongoing use.

The change in quality of life for older Australians: A rural and urban comparison.

OBJECTIVE: To assess the quality of life of older Australians living in rural and urban communities over time. DESIGN: Panel survey conducted in 2012-2013 and 2014-2015. SETTING: Participants lived in metropolitan Melbourne (urban sample, N = 279), rural Victoria (N = 98) or Tasmania (N = 47). PARTICIPANTS: All participants (N = 424) were clients of aged care providers or residents in retirement housing or residential care. MAIN OUTCOME MEASURES: Quality of life. RESULT: A repeated-measures analysis of variance showed a decrease in quality of life over time. There was no difference in change in quality of life over time by location of participants (urban vs rural). Multiple regression analysis showed that resilience predicted baseline quality of life in all three locations. CONCLUSION: These findings generally did not support significant differences between geographic locations in trajectories of older adults' quality of life over time. Instead, individuals' resilience appears to be the strongest predictor of quality of life.

Understanding ageing well in Australian rural and regional settings: Applying an age-friendly lens.

OBJECTIVE: This study investigates how rural community-dwelling older adults' views on what is important in maintaining health and wellbeing align with the eight age-friendly domains proposed by the World Health Organisation, and which domains are most salient. DESIGN: Data were gathered through open-ended response postcards distributed using a whole-of-community approach. SETTING: The Rural City of Wangaratta, a rural local government area located in north-east Victoria. PARTICIPANTS: 262 postcards were returned by rural older adults, carers and family members. MAIN OUTCOME MEASURE: Thematic analysis of open-ended responses to the following question: what is important to you as you grow older (or your loved one), in terms of keeping healthy and well? RESULTS: Even though all eight age-friendly domains were identified as important for health and wellbeing, community and health services was the most frequently discussed domain, followed by transportation and access to outdoor spaces and buildings. However, individual-level factors, inclusive of personal activities, attitudes and capacities, were also identified as important to rural older adults. CONCLUSION: Findings support the use of the World Health Organization's age-friendly city framework in assessing what is important to rural older adults' health and wellbeing, with the community and health services domain most salient. However, individual-level activities, attitudes and capacities must also be considered.

Predicting wellness among rural older Australians: a cross- sectional study.

INTRODUCTION: Prior research on older people's wellbeing and quality of life has lacked clarity and consistency. Research examining older people's health has tended to use these different terms and measurement tools interchangeably, which might explain why the evidence is somewhat mixed. There is a paucity of research that uses the multi-dimensional construct of wellness in rural older people. Addressing both limitations, this study seeks to make a unique contribution to knowledge testing an ecological model of wellness that includes intrapersonal factors, interpersonal processes, institutional factors, community factors and public policy. METHODS: Six rural case study sites were chosen across two Australian sites, the states of Queensland and Victoria. A community saturation recruitment strategy was utilised. Telephone surveys were conducted with community-dwelling rural older people (n=266) aged ≥65 years across the sites. The central variable of the study was wellness as measured by the Perceived Wellness Survey. The ecological model developed included the following intrapersonal factors: physical and mental health, loneliness and social demographic characteristics (age, sex, marital status and financial capability). Interpersonal factors included a measure of social and community group participation, social network size and support provided. Institutional factors were measured by series of questions devised around the resource base environment and access to amenities and services. RESULTS: A hierarchical regression analysis was conducted to determine which variables in the model predict wellness. The results showed that a combination of intrapersonal factors (physical health, mental health, loneliness and financial capability) and interpersonal factors (size of social network and community participation) predicted wellness. However, institutional factors, the resource base environment, and access to amenities and services, contributed only marginally to the model. Community factors, including the personal and physical characteristics of community, also only made a marginal contribution. CONCLUSIONS: The study identified the usefulness of using an integrated model of measurement in wellness. This model recognised the interrelated physical, social and economic influences that impact on rural older people throughout their life course. The study found that physical health made the greatest contribution to perceived wellness, followed by mental health. These findings support a body of research that has found that rural older people experience poorer health outcomes than those in urban areas. Lower levels of loneliness were also a strong predictor of perceived wellness, thus supporting research that has examined the impact of loneliness on physical and mental health. The presence of social capital, as measured by social network size, and the degree of community participation, were also predictors of perceived wellness. Overall, the findings of the present study implications for policy as well as subsequent strategies designed to increase the capacity of wellness in rural older people. Such strategies need to consider the contribution of a range of factors.