Interventions for the uptake of evidence-based recommendations in acute stroke settings.

BACKGROUND: There is a growing body of research evidence to guide acute stroke care. Receiving care in a stroke unit improves access to recommended evidence-based therapies and patient outcomes. However, even in stroke units, evidence-based recommendations are inconsistently delivered by healthcare workers to patients with stroke. Implementation interventions are strategies designed to improve the delivery of evidence-based care. OBJECTIVES: To assess the effects of implementation interventions (compared to no intervention or another implementation intervention) on adherence to evidence-based recommendations by health professionals working in acute stroke units. Secondary objectives were to assess factors that may modify the effect of these interventions, and to determine if single or multifaceted strategies are more effective in increasing adherence with evidence-based recommendations. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, CINAHL, Joanna Briggs Institute and ProQuest databases to 13 April 2022. We searched the grey literature and trial registries and reviewed reference lists of all included studies, relevant systematic reviews and primary studies; contacted corresponding authors of relevant studies and conducted forward citation searching of the included studies. There were no restrictions on language and publication date. SELECTION CRITERIA: We included randomised trials and cluster-randomised trials. Participants were health professionals providing care to patients in acute stroke units; implementation interventions (i.e. strategies to improve delivery of evidence-based care) were compared to no intervention or another implementation intervention. We included studies only if they reported on our primary outcome which was quality of care, as measured by adherence to evidence-based recommendations, in order to address the review aim. DATA COLLECTION AND ANALYSIS: Two review authors independently selected studies for inclusion, extracted data and assessed risk of bias and certainty of evidence using GRADE. We compared single implementation interventions to no intervention, multifaceted implementation interventions to no intervention, multifaceted implementation interventions compared to single implementation interventions and multifaceted implementation interventions to another multifaceted intervention. Our primary outcome was adherence to evidence-based recommendations. MAIN RESULTS: We included seven cluster-randomised trials with 42,489 patient participants from 129 hospitals, conducted in Australia, the UK, China, and the Netherlands. Health professional participants (numbers not specified) included nursing, medical and allied health professionals. Interventions in all studies included implementation strategies targeting healthcare workers; three studies included delivery arrangements, no studies used financial arrangements or governance arrangements. Five trials compared a multifaceted implementation intervention to no intervention, two trials compared one multifaceted implementation intervention to another multifaceted implementation intervention. No included studies compared a single implementation intervention to no intervention or to a multifaceted implementation intervention. Quality of care outcomes (proportions of patients receiving evidence-based care) were included in all included studies. All studies had low risks of selection bias and reporting bias, but high risk of performance bias. Three studies had high risks of bias from non-blinding of outcome assessors or due to analyses used. We are uncertain whether a multifaceted implementation intervention leads to any change in adherence to evidence-based recommendations compared with no intervention (risk ratio (RR) 1.73; 95% confidence interval (CI) 0.83 to 3.61; 4 trials; 76 clusters; 2144 participants, I2 =92%, very low-certainty evidence). Looking at two specific processes of care, multifaceted implementation interventions compared to no intervention probably lead to little or no difference in the proportion of patients with ischaemic stroke who received thrombolysis (RR 1.14, 95% CI 0.94 to 1.37, 2 trials; 32 clusters; 1228 participants, moderate-certainty evidence), but probably do increase the proportion of patients who receive a swallow screen within 24 hours of admission (RR 6.76, 95% CI 4.44 to 10.76; 1 trial; 19 clusters; 1,804 participants; moderate-certainty evidence). Multifaceted implementation interventions probably make little or no difference in reducing the risk of death, disability or dependency compared to no intervention (RR 0.93, 95% CI 0.85 to 1.02; 3 trials; 51 clusters ; 1228 participants; moderate-certainty evidence), and probably make little or no difference to hospital length of stay compared with no intervention (difference in absolute change 1.5 days; 95% CI -0.5 to 3.5; 1 trial; 19 clusters; 1804 participants; moderate-certainty evidence). We do not know if a multifaceted implementation intervention compared to no intervention result in changes to resource use or health professionals' knowledge because no included studies collected these outcomes. AUTHORS' CONCLUSIONS: We are uncertain whether a multifaceted implementation intervention compared to no intervention improves adherence to evidence-based recommendations in acute stroke settings, because the certainty of evidence is very low.

Consumer engagement in health care policy, research and services: A systematic review and meta-analysis of methods and effects.

To assess the effects of consumer engagement in health care policy, research and services. We updated a review published in 2006 and 2009 and revised the previous search strategies for key databases (The Cochrane Central Register of Controlled Trials; MEDLINE; EMBASE; PsycINFO; CINAHL; Web of Science) up to February 2020. Selection criteria included randomised controlled trials assessing consumer engagement in developing health care policy, research, or health services. The International Association for Public Participation, Spectrum of Public Participation was used to identify, describe, compare and analyse consumer engagement. Outcome measures were effects on people; effects on the policy/research/health care services; or process outcomes. We included 23 randomised controlled trials with a moderate or high risk of bias, involving 136,265 participants. Most consumer engagement strategies adopted a consultative approach during the development phase of interventions, targeted to health services. Based on four large cluster-randomised controlled trials, there is evidence that consumer engagement in the development and delivery of health services to enhance the care of pregnant women results in a reduction in neonatal, but not maternal, mortality. From other trials, there is evidence that involving consumers in developing patient information material results in material that is more relevant, readable and understandable for patients, and can improve knowledge. Mixed effects are reported of consumer-engagement on the development and/or implementation of health professional training. There is some evidence that using consumer interviewers instead of staff in satisfaction surveys can have a small influence on the results. There is some evidence that consumers may have a role in identifying a broader range of health care priorities that are complementary to those from professionals. There is some evidence that consumer engagement in monitoring and evaluating health services may impact perceptions of patient safety or quality of life. There is growing evidence from randomised controlled trials of the effects of consumer engagement on the relevance and positive outcomes of health policy, research and services. Health care consumers, providers, researchers and funders should continue to employ evidence-informed consumer engagement in their jurisdictions, with embedded evaluation. Systematic review registration: PROSPERO CRD42018102595.

The evidence for services to avoid or delay residential aged care admission: a systematic review.

BACKGROUND: Interventions that enable people to remain in their own home as they age are of interest to stakeholders, yet detailed information on effective interventions is scarce. Our objective was to systematically search and synthesise evidence for the effectiveness of community-based, aged care interventions in delaying or avoiding admission to residential aged care. METHOD: Nine databases were searched from January 2000 to February 2018 for English publications. Reference lists of relevant publications were searched. The databases yielded 55,221 citations and 50 citations were gleaned from other sources. Where there was sufficient homogeneity of study design, population, intervention and measures, meta-analyses were performed. Studies were grouped by the type of intervention: complex multifactorial interventions, minimal/single focus interventions, restorative programs, or by the target population (e.g. participants with dementia). RESULTS: Data from 31 randomised controlled trials (32 articles) that met our inclusion criteria were extracted and analysed. Compared to controls, complex multifactorial interventions in community aged care significantly improved older adults' ability to remain living at home (risk difference - 0.02; 95% CI -0.03, - 0.00; p = 0.04). Commonalities in the 13 studies with complex interventions were the use of comprehensive assessment, regular reviews, case management, care planning, referrals to additional services, individualised interventions, frequent client contact if required, and liaison with General Practitioners. Complex interventions did not have a significantly different effect on mortality. Single focus interventions did not show a significant effect in reducing residential aged care admissions (risk difference 0, 95% CI -0.01, 0.01; p = 0.71), nor for mortality or quality of life. Subgroup analysis of complex interventions for people with dementia showed significant risk reduction for residential aged care admissions (RD -0.05; 95% CI -0.09, -0.01; p = 0.02). Compared to controls, only interventions targeting participants with dementia had a significant effect on improving quality of life (SMD 3.38, 95% CI 3.02, 3.74; p < 0.000001). CONCLUSIONS: Where the goal is to avoid residential aged care admission for people with or without dementia, there is evidence for multifactorial, individualised community programs. The evidence suggests these interventions do not result in greater mortality and hence are safe. Minimal, single focus interventions will not achieve the targeted outcomes. TRIAL REGISTRATION: PROSPERO Registration CRD42016050086 .

Access to rehabilitation for patients with stroke in Australia.

OBJECTIVE: To identify factors associated with receiving acute goal-directed treatment, being assessed for ongoing rehabilitation, and receiving post-acute rehabilitation after having a stroke. DESIGN: Retrospective analysis of National Stroke Audit data for patients with acute stroke treated at Australian hospitals during 1 September 2014 - 28 February 2015. SETTING, PARTICIPANTS: 112 Australian hospitals that admit adults with acute stroke. MAIN OUTCOMES: Associations between patient-related and organisational factors and the provision of rehabilitation interventions. RESULTS: Data for 3462 patients were eligible for analysis; their median age was 74 years, 1962 (57%) were men, and 2470 (71%) had received care in a stroke unit. 2505 patients (72%) received goal-directed treatment during their acute admission; it was not provided to 364 patients (10.5%) who were responsive, had not fully recovered, and did not refuse treatment. Factors associated with higher odds of receiving goal-directed treatment included goal-setting with the patient and their family (odds ratio [OR], 6.75; 95% CI, 5.07-8.90) and receiving care in a stroke unit (OR, 2.08; 95% CI, 1.61-2.70). 1358 patients (39%) underwent further rehabilitation after discharge from acute care; factors associated with receiving post-acute rehabilitation included care in a stroke unit (OR, 1.73; 95% CI, 1.34-2.22) and having an arm or speech deficit. Dementia was associated with lower odds of receiving acute goal-directed treatment (OR, 0.49; 95%, 0.33-0.73) and post-acute rehabilitation (OR, 0.43; 95%, 0.30-0.61). CONCLUSIONS: Access to stroke units and to early and ongoing rehabilitation for patients after stroke can be improved in Australia, both to optimise outcomes and to reduce the burden of care on underresourced community and primary care providers.

Inequities in access to inpatient rehabilitation after stroke: an international scoping review.

Background Inequities in accessing inpatient rehabilitation after stroke have been reported in many countries and impact on patient outcomes. Objective To explore variation in international recommendations regarding which patients should receive inpatient rehabilitation after stroke and to describe reported access to rehabilitation. Methods A scoping review was conducted to identify clinical guidelines with recommendations regarding which patients should access inpatient rehabilitation after stroke, and data regarding the proportion of patients accessing stroke rehabilitation. Four bibliographic databases and grey literature were searched. Results Twenty-eight documents were included. Selection criteria for post-acute inpatient rehabilitation were identified for 14 countries or regions and summary data on the proportion of patients receiving inpatient rehabilitation were identified for 14 countries. In Australia, New Zealand, and the United Kingdom, it is recommended that all patients with stroke symptoms should access rehabilitation, whereas guidelines from the United States, Canada, and Europe did not consistently recommend rehabilitation for people with severe stroke. Access to inpatient rehabilitation ranged from 13% in Sweden to 57% in Israel. Differences in availability of early supported discharge/home rehabilitation programs and variations in reporting methods may influence the ability to reliably compare access to rehabilitation between regions. Conclusion Recommendations regarding which patients with moderate and severe strokes should access ongoing rehabilitation are inconsistent. Clinical practice guidelines from different countries regarding post-stroke rehabilitation do not always reflect the evidence regarding the likely benefits to people with stroke. Inequity in access to rehabilitation after stroke is an international issue.

A qualitative study using the Theoretical Domains Framework to investigate why patients were or were not assessed for rehabilitation after stroke.

OBJECTIVE: To explore the factors perceived to affect rehabilitation assessment and referral practices for patients with stroke. DESIGN: Qualitative study using data from focus groups analysed thematically and then mapped to the Theoretical Domains Framework. SETTING: Eight acute stroke units in two states of Australia. SUBJECTS: Health professionals working in acute stroke units. INTERVENTIONS: Health professionals at all sites had participated in interventions to improve rehabilitation assessment and referral practices, which included provision of copies of an evidence-based decision-making rehabilitation Assessment Tool and pathway. RESULTS: Eight focus groups were conducted (32 total participants). Reported rehabilitation assessment and referral practices varied markedly between units. Continence and mood were not routinely assessed (4 units), and people with stroke symptoms were not consistently referred to rehabilitation (4 units). Key factors influencing practice were identified and included whether health professionals perceived that use of the Assessment Tool would improve rehabilitation assessment practices (theoretical domain 'social and professional role'); beliefs about outcomes from changing practice such as increased equity for patients or conversely that changing rehabilitation referral patterns would not affect access to rehabilitation ('belief about consequences'); the influence of the unit's relationships with other groups including rehabilitation teams ('social influences' domain) and understanding within the acute stroke unit team of the purpose of changing assessment practices ('knowledge' domain). CONCLUSION: This study has identified that health professionals' perceived roles, beliefs about consequences from changing practice and relationships with rehabilitation service providers were perceived to influence rehabilitation assessment and referral practices on Australian acute stroke units.

Education-only versus a multifaceted intervention for improving assessment of rehabilitation needs after stroke; a cluster randomised trial.

BACKGROUND: In 2011, more than half of the patients with stroke in Australian hospitals were not assessed for the need for rehabilitation. Further, there were no recommended criteria to guide rehabilitation assessment decisions. Subsequently, a decision-making tool called the Assessment for Rehabilitation Tool (ART) was developed. The ART was designed to assist Australian hospital clinicians to identify the rehabilitation needs of patients with stroke using evidence-based criteria. The ART was released and made freely available for use in 2012. This study evaluated the effectiveness of an education-only intervention (1 onsite education session and distribution of the ART) and a multifaceted intervention (2 or more onsite education sessions, distribution of the ART, audit and feedback, barrier identification, site-specific strategy development, promotion of interdisciplinary teamwork, opinion leaders and reminders) for improving assessments of rehabilitation needs after stroke. METHODS: Ten hospitals in 2 states of Australia were randomly assigned to an education-only or a multifaceted intervention. Medical records were audited by assessors blinded to group allocation before and after the implementation period. Difference in the proportion of patients assessed for rehabilitation before and after the intervention was analysed using mixed-effects logistic regression analysis, with time period as the dependent variable, an interaction between intervention type and time included to test for differences between the interventions, and hospital included as the random effect to account for patient clustering. RESULTS: Data from 586 patients (284 pre-intervention; 302 post-intervention; age 76 years, 59 % male) showed that the multifaceted intervention was not more effective than education-only in improving the proportion of patients whose rehabilitation needs were assessed (reference category education-only; odds ratio 1.29, 95 % confidence interval 0.63-2.67, p = 0.483). Post-intervention, the odds of a patient's rehabilitation needs being assessed was 3.69 times greater than pre-intervention (95 % confidence interval 2.57-5.30, p < 0.001). Evidence-based criteria were not consistently used when patients were deemed to have no rehabilitation needs. CONCLUSIONS: A multifaceted intervention was not more effective than education-only in improving the assessment of rehabilitation needs of patients with stroke. Further interventions are required to ensure that all patients are assessed for the need for rehabilitation using evidence-based criteria. TRIAL REGISTRATION: ANZCTR (Australian New Zealand Clinical Trials Registry), ACTRN12616000340437.

Self management programmes for quality of life in people with stroke.

BACKGROUND: Stroke results from an acute lack of blood supply to the brain and becomes a chronic health condition for millions of survivors around the world. Self management can offer stroke survivors a pathway to promote their recovery. Self management programmes for people with stroke can include specific education about the stroke and likely effects but essentially, also focusses on skills training to encourage people to take an active part in their management. Such skills training can include problem-solving, goal-setting, decision-making, and coping skills. OBJECTIVES: To assess the effects of self management interventions on the quality of life of adults with stroke who are living in the community, compared with inactive or active (usual care) control interventions. SEARCH METHODS: We searched the following databases from inception to April 2016: the Cochrane Stroke Group Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, CINAHL, PsycINFO, SCOPUS, Web of Science, OTSeeker, OT Search, PEDro, REHABDATA, and DARE. We also searched the following trial registries: ClinicalTrials.gov, Stroke Trials Registry, Current Controlled Trials, World Health Organization, and Australian New Zealand Clinical Trials Registry. SELECTION CRITERIA: We included randomised controlled trials of adults with stroke living in the community who received self management interventions. These interventions included more than one component of self management or targeted more than a single domain of change, or both. Interventions were compared with either an inactive control (waiting list or usual care) or active control (alternate intervention such as education only). Measured outcomes included changes in quality of life, self efficacy, activity or participation levels, impairments, health service usage, health behaviours (such as medication adherence or lifestyle behaviours), cost, participant satisfaction, or adverse events. DATA COLLECTION AND ANALYSIS: Two review authors independently extracted prespecified data from all included studies and assessed trial quality and risk of bias. We performed meta-analyses where possible to pool results. MAIN RESULTS: We included 14 trials with 1863 participants. Evidence from six studies showed that self management programmes improved quality of life in people with stroke (standardised mean difference (SMD) random effects 0.34, 95% confidence interval (CI) 0.05 to 0.62, P = 0.02; moderate quality evidence) and improved self efficacy (SMD, random effects 0.33, 95% CI 0.04 to 0.61, P = 0.03; low quality evidence) compared with usual care. Individual studies reported benefits for health-related behaviours such as reduced use of health services, smoking, and alcohol intake, as well as improved diet and attitude. However, there was no superior effect for such programmes in the domains of locus of control, activities of daily living, medication adherence, participation, or mood. Statistical heterogeneity was mostly low; however, there was much variation in the types and delivery of programmes. Risk of bias was relatively low for complex intervention clinical trials where participants and personnel could not be blinded. AUTHORS' CONCLUSIONS: The current evidence indicates that self management programmes may benefit people with stroke who are living in the community. The benefits of such programmes lie in improved quality of life and self efficacy. These are all well-recognised goals for people after stroke. There is evidence for many modes of delivery and examples of tailoring content to the target group. Leaders were usually professionals but peers (stroke survivors and carers) were also reported - the commonality is being trained and expert in stroke and its consequences. It would be beneficial for further research to be focused on identifying key features of effective self management programmes and assessing their cost-effectiveness.

Implementing a complex rehabilitation intervention in a stroke trial: a qualitative process evaluation of AVERT.

BACKGROUND: The implementation of multidisciplinary stroke rehabilitation interventions is challenging, even when the intervention is evidence-based. Very little is known about the implementation of complex interventions in rehabilitation clinical trials. The aim of study was to better understand how the implementation of a rehabilitation intervention in a clinical trial within acute stroke units is experienced by the staff involved. This qualitative process evaluation was part of a large Phase III stroke rehabilitation trial (AVERT). METHODS: A descriptive qualitative approach was used. We purposively sampled 53 allied health and nursing staff from 19 acute stroke units in Australia, New Zealand and Scotland. Semi-structured interviews were conducted by phone, voice-internet, or face to face. Digitally recorded interviews were transcribed and analysed by two researchers using rigorous thematic analysis. RESULTS: Our analysis uncovered ten important themes that provide insight into the challenges of implementing complex new rehabilitation practices within complex care settings, plus factors and strategies that assisted implementation. Themes were grouped into three main categories: staff experience of implementing the trial intervention, barriers to implementation, and overcoming the barriers. Participation in the trial was challenging but had personal rewards and improved teamwork at some sites. Over the years that the trial ran some staff perceived a change in usual care. Barriers to trial implementation at some sites included poor teamwork, inadequate staffing, various organisational barriers, staff attitudes and beliefs, and patient-related barriers. Participants described successful implementation strategies that were built on interdisciplinary teamwork, education and strong leadership to 'get staff on board', and developing different ways of working. CONCLUSIONS: The AVERT stroke rehabilitation trial required commitment to deliver an intervention that needed strong collaboration between nurses and physiotherapists and was different to current care models. This qualitative process evaluation contributes unique insights into factors that may be critical to successful trials teams, and as AVERT was a pragmatic trial, success factors to delivering complex intervention in clinical practice. TRIAL REGISTRATION: AVERT registered with Australian New Zealand Clinical Trials Registry ACTRN12606000185561 .

Inequities in access to rehabilitation: exploring how acute stroke unit clinicians decide who to refer to rehabilitation.

PURPOSE: Less than half of the patients with stroke in Australian hospitals are assessed by rehabilitation specialists. We sought to explore how clinicians working in acute stroke units (ASUs) determine which patients to refer to rehabilitation services. METHOD: Qualitative descriptive study. Team meetings were observed and medical records were reviewed over four weeks at two ASUs. Focus groups were conducted with staff from eight ASUs in two states of Australia. RESULTS: Rehabilitation was mentioned in team meetings for 50/64 patients (78%) during the observation period. Rehabilitation referrals were organised for 47 patients (94%) for whom rehabilitation was discussed (74% of the sample); and for no patients when rehabilitation was not discussed. Factors identified that influenced whether referrals were organised included the anticipated discharge destination; severity of stroke; staff expectations of the patient's recovery; and if there was advocacy by families about rehabilitation. Clinicians tended to refer the patients they considered would be accepted by the rehabilitation service. Staff at two ASUs expressed concern that referring all patients with stroke-related deficits to rehabilitation would be unfavourable with rehabilitation providers. CONCLUSIONS: Decisions made by ASU staff regarding who to refer to stroke rehabilitation are often not solely based on patients' rehabilitation requirements. Implications for Rehabilitation Not all patients on acute stroke units (ASUs) who may have benefited from rehabilitation were offered rehabilitation referrals. Criteria for rehabilitation referrals need to be made explicit and discussed openly with consumers, ASU clinicians and rehabilitation specialists. A change in rehabilitation assessment practices is required to provide data regarding the unmet rehabilitation needs of patients with stroke. New models of rehabilitation service delivery or increased rehabilitation services may be required to meet the rehabilitation needs of all patients with stroke.

Carers' experiences, needs and preferences during inpatient stroke rehabilitation: a protocol for a systematic review of qualitative studies.

BACKGROUND: Large numbers of people provide carer roles for survivors of stroke. Person-centred stroke rehabilitation must consider the perspectives of carers, as stroke affects not only the stroke survivor but also the quality of life and health of the carers. There is little collective knowledge about stroke carers' experiences, needs and preferences during the inpatient stroke rehabilitation process to then inform person-centred service improvements. Our objective is to report and synthesise experiences, needs and preferences of the carers of stroke survivors undergoing rehabilitation in inpatient settings. METHODS/DESIGN: We will conduct a systematic review of qualitative studies using a thematic synthesis methodology. We will follow the Enhancing Transparency in Reporting the Synthesis of Qualitative Research Guidelines (ENTREQ) and search the following databases for relevant articles: MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO, Embase, and Web of Science. No language or publication date constraints will be applied. Eligible studies will have to use qualitative methods of data collection and analysis and reported data from the carers of stroke survivors who underwent inpatient stroke rehabilitation. Studies will be eligible for inclusion if they report the experiences, needs and preferences of carers regarding inpatient rehabilitation environments, organisation, care systems, therapeutic interventions, information exchange, carer training, discharge and community service planning and other issues of relevance to their roles as carers. Study selection and assessment of quality will be performed independently by two reviewers. Any disagreement will be resolved by a third reviewer. Data will be extracted by one reviewer, tabled, and checked for accuracy by another reviewer. All text reported in studies' results, discussion and conclusion sections will be entered into the NVivo software for analysis. Extracted texts will be inductively coded independently by two reviewers and analysed in three phases using thematic synthesis. Descriptive and analytical themes will be developed. DISCUSSION: This study is expected to provide new insights into the perspectives of stroke survivors' carers. Increased knowledge about carer perspectives and preferences will inform person-centred improvements in stroke rehabilitation. STUDY REGISTRATION: PROSPERO registration number: CRD42015017315 .

Rehabilitation assessments for patients with stroke in Australian hospitals do not always reflect the patients' rehabilitation requirements.

OBJECTIVES: To examine the frequency and factors associated with patients with stroke in Australian hospitals receiving documented rehabilitation assessments; to examine the criteria used when rehabilitation was not recommended; and to examine whether being assessed for rehabilitation affected access to rehabilitation. DESIGN: Retrospective medical record audit of patients with a diagnosis of stroke who were discharged consecutively between 2013 and 2014. SETTING: Acute care public hospitals. PARTICIPANTS: Adults with stroke (N=333) receiving care in participating hospitals. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Documented assessment regarding patient suitability for rehabilitation during acute hospitalization. RESULTS: Data from 292 patients were included for analysis (60% men; mean age, 72y). Of the patients, 42% were assessed for rehabilitation by a health professional providing care in the hospital, 43% were assessed for rehabilitation by a representative from a rehabilitation service, and 37% did not receive any documented rehabilitation assessment. In multivariable analysis, patients were significantly more likely to be assessed for rehabilitation if they lived in the community before their stroke, had moderate severity strokes, or received occupational therapy during hospital admission. Rehabilitation was not recommended in 9% of assessments despite the presence of stroke-related symptoms. Patients not assessed for rehabilitation were significantly less likely to access rehabilitation than patients who were assessed. CONCLUSIONS: More than one third of patients were not assessed for rehabilitation. When assessed, rehabilitation was not consistently recommended for patients with stroke-related symptoms. This study highlights factors that increase the likelihood of being assessed for rehabilitation.

A qualitative exploration of discharge destination as an outcome or a driver of acute stroke care.

BACKGROUND: Many patients with acute stroke do not receive recommended care in tertiary hospital settings. Allied health professionals have important roles within multidisciplinary stroke teams and influence the quality of care patients receive. Studies examining the role of allied health professionals in acute stroke management are scarce, and very little is known about the clinical decision making of these stroke clinicians. In this study we aimed to describe factors that influence the complex clinical decision making of these professionals as they prioritise acute stroke patients for recommended care. This qualitative study was part of a larger mixed methods study. METHODS: The qualitative methodology applied was a constructivist grounded theory approach.Fifteen allied health professionals working with acute stroke patients at three metropolitan tertiary care hospitals in South Australia were purposively sampled.Semi-structured interviews were conducted face to face using a question guide, and digital recording. Interviews were transcribed and analysed by two researchers using rigorous grounded theory processes. RESULTS: Our analysis highlighted 'predicted discharge destination' as a powerful driver of care decisions and clinical prioritisation for this professional group. We found that complex clinical decision making to predict discharge destination required professionals to concurrently consider patient's pre-stroke status, the nature and severity of their stroke, the course of their recovery and multiple factors from within the healthcare system. The consequences of these decisions had potentially profound consequences for patients and sometimes led to professionals experiencing considerable uncertainty and stress. CONCLUSIONS: Our qualitative enquiry provided new insights into the way allied health professionals make important clinical decisions for patients with acute stroke. This is the first known study to demonstrate that the subjective prediction of discharge destination made early in an acute admission by allied health professionals, has a powerful influence over the care and rehabilitation provided, and the ultimate outcomes for stroke patients.

Age and gender as predictors of allied health quality stroke care.

BACKGROUND: Improvement in acute stroke care requires the identification of variables which may influence care quality. The nature and impact of demographic and stroke-related variables on care quality provided by allied health (AH) professionals is unknown. AIMS: Our research explores the association of age and gender on an index of acute stroke care quality provided by AH professionals. METHODS: A retrospective clinical audit of 300 acute stroke patients extracted data on AH care, patients' age and gender. AH care quality was determined by the summed compliance with 20 predetermined process indicators. Our analysis explored relationships between this index of quality, age, and gender. Age was considered in different ways (as a continuous variable, and in different categories). It was correlated with care quality, using gender-specific linear and logistic regression models. Gender was then considered as a confounder in an overall model. RESULTS: No significant association was found for any treatment of age and the index of AH care quality. There were no differences in gender-specific models, and gender did not significantly adjust the age association with care quality. CONCLUSION: Age and gender were not predictors of the quality of care provided to acute stroke patients by AH professionals.

Demographic and stroke-related factors as predictors of quality of acute stroke care provided by allied health professionals.

BACKGROUND: We recently indicated that patient age on its own is not a determinant of quality of allied health care received after an acute stroke. It has not been tested whether other non-age variables influence care decisions made by allied health professionals. This paper explores demographic and stroke-related variables that are putatively associated with the quality of care provided to acute stroke patients by allied health professionals. METHODS: Data were retrospectively audited from 300 acute stroke patient records regarding allied health care. Compliance with each of 20 indicators of allied health care quality was established. The influence of various demographic and stroke-related variables on each performance indicator was examined. We undertook a series of analyses using univariate logistic regression models to establish the influence of these variables on care quality. RESULTS: Patient age had a significant correlation with only one process indicator (early mobilization). Seven variables, including stroke severity and level of dependence, were associated with patient age. The majority of these age proxies had significant associations with process indicator compliance. Correlations between non-age variables, in particular stroke severity and comorbidity, suggest the potential for complex confounding relationships between non-age variables and quality of allied health care. CONCLUSION: Compliance with individual indicators of allied health care was significantly associated with variables other than patient age, and included stroke severity, previous independence, comorbidities, day of admission, stroke unit admission, and length of stay. The inter-relationships between these non-age variables suggest that their influence on quality of care is complex.

Patients' age as a determinant of care received following acute stroke: a systematic review.

BACKGROUND: Evidence-based care should improve acute stroke outcomes with the same magnitude of effect for stroke patients of all ages. However, there is evidence to suggest that, in some instances, older stroke patients may receive poorer quality care than younger patients.Our aim was to systematically review evidence of the quality of care provided to patients with acute stroke related to their age. Quality of care was determined by compliance with recommended care processes. METHODS: We systematically searched MEDLINE, CINAHL, ISI Web of Knowledge, Ageline and the Cochrane Library databases to identify publications (1995-2009) that reported data on acute stroke care process indicators by patient age. Data extracted included patient demographics and process indicator compliance. Included publications were critically appraised by two independent reviewers using the Critical Appraisal Skills Programme tool, and a comparison was made of the risk of bias according to studies' findings. The evidence base for reported process indicators was determined, and meta-analysis was undertaken for studies with sufficient similarity. RESULTS: Nine from 163 potential studies met the inclusion criteria. Of the 56 process indicators reported, eleven indicators were evidence-based. Seven of these indicators (64%) showed significantly poorer care for older patients compared to younger ones, while younger patients received comparatively inferior care for only antihypertensive therapy at discharge. Our findings are limited by the variable methodological quality of included studies. CONCLUSION: Patients' age may be a factor in the care they receive after an acute stroke. However, the possible influence of patients' age on clinicians' decision-making must be considered in terms of the many complex issues that surround the provision of optimal care for older patients with acute stroke.

Measuring the quality of dysphagia management practices following stroke: a systematic review.

UNLABELLED: Adherence to recommended clinical practices improves stroke outcomes. As a result, stroke clinicians are increasingly expected to evaluate the quality of the care they provide so that areas for improvement can be targeted. Finding the best method to evaluate the quality of dysphagia management can be challenging. AIM: To systematically review process indicators used to assess the quality of care provided to patients with dysphagia following acute stroke and examine the level of evidence underpinning these indicators. METHODS: Databases were systematically searched to identify publications (January 2006-April 2009) that describe process indicators relating to the clinical management of acute stroke-related dysphagia. Relevant process indicators were extracted from the reviewed publications for detailed post hoc analysis including supporting evidence and alignment to the current Australian and English stroke guidelines. RESULTS: Title and abstract review found 150 potential studies. Full-text review resulted in 25 publications that met the study's inclusion criteria. Thirteen process indicators were identified in the literature that related to the initial assessment, clinical management, rehabilitation and discharge planning for patients with acute stroke-related dysphagia. These processes were supported by levels of evidence ranging from high 'level 1' (8%) down to 'expert opinion' evidence (46%). Two process indicators did not align to recommendations in the clinical guidelines. This systematic review underpins informed selection of process indicators for evaluating the quality of dysphagia management following stroke. The selection of quality indicators is complicated by equivocal supporting evidence; however, indicators should reflect expected local practices, align with national stroke guidelines and be feasible for clinical auditing.