Cost-Effectiveness of a Government Policy to Incentivise Chronic Disease Management following Stroke: A Modelling Study.

INTRODUCTION: Little is known about the cost-effectiveness of government policies that support primary care physicians to provide comprehensive chronic disease management (CDM). This paper aimed to estimate the potential cost-effectiveness of CDM policies over a lifetime for long-time survivors of stroke. METHODS: A Markov model, using three health states (stable, hospitalised, dead), was developed to simulate the costs and benefits of CDM policies over 30 years (with 1-year cycles). Transition probabilities and costs from a health system perspective were obtained from the linkage of data between the Australian Stroke Clinical Registry (cohort n = 12,368, 42% female, median age 70 years, 45% had CDM claims) and government-held hospital, Medicare, and pharmaceutical claims datasets. Quality-adjusted life years (QALYs) were obtained from a comparable cohort (n = 512, 34% female, median age 69.6 years, 52% had CDM claims) linked with Medicare claims and death data. A 3% discount rate was applied to costs in Australian dollars (AUD, 2016) and QALYs beyond 12 months. Probabilistic sensitivity analyses were used to understand uncertainty. RESULTS: Per-person average total lifetime costs were AUD 142,939 and 8.97 QALYs for those with a claim, and AUD 103,889 and 8.98 QALYs for those without a claim. This indicates that these CDM policies were costlier without improving QALYs. The probability of cost-effectiveness of CDM policies was 26.1%, at a willingness-to-pay threshold of AUD 50,000/QALY. CONCLUSION: CDM policies, designed to encourage comprehensive care, are unlikely to be cost-effective for stroke compared to care without CDM. Further research to understand how to deliver such care cost-effectively is needed.

The Alfred Health post-COVID-19 service, Melbourne, 2020-2022: an observational cohort study.

OBJECTIVES: To determine the uptake of the Alfred Health Post-COVID service among people hospitalised with coronavirus disease 2019 (COVID-19) or referred by general practitioners; to describe their characteristics and symptoms at eight weeks and the clinical services they required. STUDY DESIGN: Observational cohort study. SETTING: Outpatient post-COVID-19 follow-up service in a tertiary Melbourne hospital. PARTICIPANTS: All people admitted to Alfred Health (inpatients, hospital-in-the-home) with COVID-19, 19 March 2020 - 28 December 2022; people with persistent symptoms referred by general practitioners in the Alfred Health catchment area during 2022. INTERVENTION: Questionnaire-based symptom assessment eight weeks after onset of COVID-19. Dyspnoea, fatigue, depression, anxiety, and post-traumatic stress disorder were assessed with standardised tools, as were health status and health-related quality of life; return to work or study, weight loss, and altered cognition and memory were also assessed. Screening was followed by physical assessment and management at the service (specialist general medicine review, physiotherapist, allied health assistant, neuropsychologist) and referral to other specialist medical services as required. MAIN OUTCOME MEASURES: Proportion of eligible people who used the service for follow-up at eight weeks; proportions of service users who reported symptoms and return to pre-COVID-19 employment or study; clinical services required by service users. RESULTS: Of 6712 people invited for screening, 726 completed questionnaires (11%). At least one persistent symptom was reported by 385 of 642 respondents (60% of respondents, 5.7% of invitees), most frequently memory (371 of 656, 57%) or concentration problems (431 of 656, 66%), dyspnoea (197 of 703, 28%), and extreme fatigue (189 of 673, 28%). Sixty-seven of 453 respondents had not returned to pre-COVID-19 work or study (15%). People were referred to a variety of medical and non-medical services for management, including specialist medical clinics, allied health, and rehabilitation. Among 71 people who also completed questionnaires at twelve months, the proportions who reported fatigue, anxiety, and memory and concentration changes were similar at both assessments. CONCLUSIONS: After acute COVID-19 that required hospital admission or was followed by persistent symptoms in community care, a small proportion of people (5.7%) reported symptoms that required medical and allied health specialist assessment and management. Our findings may assist planning services for people with long COVID.

Factors associated with self-awareness impairment in an inpatient brain injury rehabilitation cohort.

BACKGROUND: Self-awareness impairment is common following acquired brain injury and can impact rehabilitation outcomes. Knowledge of factors associated with impaired self-awareness may assist with rehabilitation planning. OBJECTIVES: To identify factors associated with self-awareness and determine predictors of self-awareness impairment for adults with traumatic brain injury (TBI) and stroke. DESIGN AND METHODS: A retrospective cohort study of rehabilitation inpatients was conducted by medical record audit. Self-awareness was measured using the Self-awareness of Deficits Interview (SADI). Relationships between SADI scores and demographic and clinical variables were identified with non-parametric statistics. Predictors of SADI scores were identified using ordinal regression analyses for TBI and stroke groups. RESULTS: Participants were 149 adults (18-70 years) with TBI (n = 110) and stroke (n = 39). For TBI, longer post-traumatic amnesia (PTA), lower functional cognition/communication, and behaviors of concern (BoC) were significantly associated with higher SADI scores (i.e. impaired self-awareness). For stroke, lower functional cognition/communication and motor scores were associated with higher SADI scores. Impaired self-awareness was predicted by PTA duration, acute length of stay and presence of BoC for the TBI group, and by functional cognition/communication for the stroke group. CONCLUSION: Different factors were associated with impaired self-awareness for individuals with TBI and stroke during inpatient rehabilitation.

Multicomponent Support Program for Secondary Prevention of Stroke Using Digital Health Technology: Co-Design Study With People Living With Stroke or Transient Ischemic Attack.

BACKGROUND: Few individuals (<2%) who experience a stroke or transient ischemic attack (TIA) participate in secondary prevention lifestyle programs. Novel approaches that leverage digital health technology may provide a viable alternative to traditional interventions that support secondary prevention in people living with stroke or TIA. To be successful, these strategies should focus on user needs and preferences and be acceptable to clinicians and people living with stroke or TIA. OBJECTIVE: This study aims to co-design, with people with lived experience of stroke or TIA (referred to as consumers) and clinicians, a multicomponent digital technology support program for secondary prevention of stroke. METHODS: A consumer user needs survey (108 items) was distributed through the Australian Stroke Clinical Registry and the Stroke Association of Victoria. An invitation to a user needs survey (135 items) for clinicians was circulated via web-based professional forums and national organizations (eg, the Stroke Telehealth Community of Practice Microsoft Teams Channel) and the authors' research networks using Twitter (subsequently rebranded X, X Corp) and LinkedIn (LinkedIn Corp). Following the surveys, 2 rounds of user experience workshops (design and usability testing workshops) were completed with representatives from each end user group (consumers and clinicians). Feedback gathered after each round informed the final design of the digital health program. RESULTS: Overall, 112 consumers (male individuals: n=63, 56.3%) and 54 clinicians (female individuals: n=43, 80%) responded to the survey; all items were completed by 75.8% (n=85) of consumers and 78% (n=42) of clinicians. Most clinicians (46/49, 94%) indicated the importance of monitoring health and lifestyle measures more frequently than current practice, particularly physical activity, weight, and sleep. Most consumers (87/96, 90%) and clinicians (41/49, 84%) agreed that providing alerts about potential deterioration in an individual's condition were important functions for a digital program. Intention to use a digital program for stroke prevention and discussing the data collected during face-to-face consultations was high (consumers: 79/99, 80%; clinicians 36/42, 86%). In addition, 7 consumers (male individuals: n=5, 71%) and 9 clinicians (female individuals: n=6, 67%) took part in the user experience workshops. Participants endorsed using a digital health program to help consumers manage stroke or TIA and discussed preferred functions and health measures in a digital solution for secondary prevention of stroke. They also noted the need for a mobile app that is easy to use. Clinician feedback highlighted the need for a customizable clinician portal that captures individual consumer goals. CONCLUSIONS: Following an iterative co-design process, supported by evidence from user needs surveys and user experience workshops, a consumer-facing app that integrates wearable activity trackers and a clinician web portal were designed and developed to support secondary prevention of stroke. Feasibility testing is currently in progress to assess acceptability and use.

Improving physical movement during stroke rehabilitation: investigating associations between sleep measured by wearable actigraphy technology, fatigue, and key biomarkers.

BACKGROUND: Sleep disturbance and fatigue are common in individuals undergoing inpatient rehabilitation following stroke. Understanding the relationships between sleep, fatigue, motor performance, and key biomarkers of inflammation and neuroplasticity could provide valuable insight into stroke recovery, possibly leading to personalized rehabilitation strategies. This study aimed to investigate the influence of sleep quality on motor function following stroke utilizing wearable technology to obtain objective sleep measurements. Additionally, we aimed to determine if there were relationships between sleep, fatigue, and motor function. Lastly, the study aimed to determine if salivary biomarkers of stress, inflammation, and neuroplasticity were associated with motor function or fatigue post-stroke. METHODS: Eighteen individuals who experienced a stroke and were undergoing inpatient rehabilitation participated in a cross-sectional observational study. Following consent, participants completed questionnaires to assess sleep patterns, fatigue, and quality of life. Objective sleep was measured throughout one night using the wearable Philips Actiwatch. Upper limb motor performance was assessed on the following day and saliva was collected for biomarker analysis. Correlation analyses were performed to assess the relationships between variables. RESULTS: Participants reported poor sleep quality, frequent awakenings, and difficulties falling asleep following stroke. We identified a significant negative relationship between fatigue severity and both sleep quality (r=-0.539, p = 0.021) and participants experience of awakening from sleep (r=-0.656, p = 0.003). A significant positive relationship was found between grip strength on the non-hemiplegic limb and salivary gene expression of Brain-derived Neurotrophic Factor (r = 0.606, p = 0.028), as well as a significant negative relationship between grip strength on the hemiplegic side and salivary gene expression of C-reactive Protein (r=-0.556, p = 0.048). CONCLUSION: The findings of this study emphasize the importance of considering sleep quality, fatigue, and biomarkers in stroke rehabilitation to optimize recovery and that interventions may need to be tailored to the individual. Future longitudinal studies are required to explore these relationships over time. Integrating wearable technology for sleep and biomarker analysis can enhance monitoring and prediction of outcomes following stroke, ultimately improving rehabilitation strategies and patient outcomes.

?Until you're in the chair and executing your role, you don't know': A qualitative study of the needs and perspectives of people with stroke-related communication disabilities when returning to vocational activity.

BACKGROUND: People with communication disability after stroke experience low rates of return to vocational roles. Vocational rehabilitation is recommended; however, there are no clear guidelines informing vocational rehabilitation for people with communication disability. Understanding the needs and experiences of this population is critical to improving vocational stroke rehabilitation outcomes. AIMS: This study aimed to: (1) investigate the experience of vocational rehabilitation for people with communication disability after stroke, (2) identify gaps and, (3) provide preliminary recommendations for tailored service delivery. METHODS: Seven participants with an identified communication impairment following stroke were recruited from a larger clinical trial of early vocational rehabilitation (20% of total sample, n = 34). To address the study aims, a qualitative design was employed. Semi-structured, in-depth interviews were conducted and analysed using thematic analysis. Data were integrated with demographic and intervention audit data to contextualise participant experiences, identify vocational rehabilitation gaps and inform preliminary recommendations. RESULTS: Participants were five men and two women aged 24-69 years whose communication profiles included difficulties with auditory comprehension and information processing, reading comprehension, thinking, executive function and self-regulation, as well as difficulties with verbal and written expression. Vocational rehabilitation was perceived as beneficial but participants identified gaps including limited access to psychological and peer-based support during early rehabilitation, limitations to accessing specialist vocational rehabilitation programs, barriers to accessing ongoing rehabilitation after resumption of vocational activity, and limited preparedness for the degree of impact that their communication changes had on execution of vocational roles and responsibilities. CONCLUSION: Vocational environments are communicatively demanding and people living with acquired communication difficulties face a range of vocation-related participation barriers even when communication difficulties are mild. Greater emphasis on evaluating the vocational communication environment and targeted communication training and preparation for colleagues within the workplace is recommended to reduce barriers faced. Interdisciplinary rehabilitation, inclusive of psychological care, may support working-age stroke survivors to recognise and acknowledge changes in their communication function, lead to improved engagement in the rehabilitation process, and ensure early identification of factors likely to influence successful return-to-vocational activity. WHAT THIS PAPER ADDS: What is already known on the subject Stroke is common amongst people of working age yet fewer than half of stroke survivors will return to pre-stroke vocational roles. Communication difficulties affect anywhere between 24% and 45% of people after stroke and include changes to language abilities, motor speech, vision, hearing and cognition. This group experiences much lower rates of return to vocational roles when compared to people with stroke who do not have a concomitant communication difficulty. Vocational rehabilitation is recommended. However, currently there is limited evidence to inform vocational rehabilitation guidelines for people with stroke and communication difficulties. Achieving a successful return to vocational activity is associated with improved life satisfaction for people with communication difficulties after stroke and is a key research priority for this population. What this study adds This study investigated the experiences of people with communication difficulty after stroke who reported a goal of returning to pre-stroke vocational activity. Data associated with types of interventions received, the experiences and perceptions of vocational rehabilitation, and experiences of returning to vocational activity were analysed to identify core rehabilitation needs and develop preliminary recommendations to inform future vocational rehabilitation guidelines for this population. What are the clinical implications of this work? The present study provides preliminary evidence that people experiencing communication difficulties after stroke require a more integrated rehabilitation pathway. During early stages of vocational rehabilitation psychological and peer-based support is indicated to support adjustment to changed communication function and to enable productive goal setting and engagement in rehabilitation. Clinicians need to complete a detailed analysis of the vocational communication environment and consider the communication activities involved in the individual's future vocational duties in order to plan meaningful rehabilitation. A multidisciplinary approach is required and additional training for clinicians is indicated to support clinicians to work collaboratively within the vocational setting.

Receipt of Mental Health Treatment in People Living With Stroke: Associated Factors and Long-Term Outcomes.

BACKGROUND: Untreated poststroke mood problems may influence long-term outcomes. We aimed to investigate factors associated with receiving mental health treatment following stroke and impacts on long-term outcomes. METHODS: Observational cohort study derived from the Australian Stroke Clinical Registry (AuSCR; Queensland and Victorian registrants: 2012-2016) linked with hospital, primary care billing and pharmaceutical dispensing claims data. Data from registrants who completed the AuSCR 3 to 6 month follow-up survey containing a question on anxiety/depression were analyzed. We assessed exposures at 6 to 18 months and outcomes at 18 to 30 months. Factors associated with receiving treatment were determined using staged multivariable multilevel logistic regression models. Cox proportional hazards regression models were used to assess the impact of treatment on outcomes. RESULTS: Among 7214 eligible individuals, 39% reported anxiety/depression at 3 to 6 months following stroke. Of these, 54% received treatment (88% antidepressant medication). Notable factors associated with any mental health treatment receipt included prestroke psychological support (odds ratio [OR], 1.80 [95% CI, 1.37-2.38]) or medication (OR, 17.58 [95% CI, 15.05-20.55]), self-reported anxiety/depression (OR, 2.55 [95% CI, 2.24-2.90]), younger age (OR, 0.98 [95% CI, 0.97-0.98]), and being female (OR, 1.30 [95% CI, 1.13-1.48]). Those who required interpreter services (OR, 0.49 [95% CI, 0.25-0.95]) used a health benefits card (OR, 0.73 [95% CI, 0.59-0.92]) or had continuity of primary care visits (ie, with a consistent physician; OR, 0.78 [95% CI, 0.62-0.99]) were less likely to access mental health services. Among those who reported anxiety/depression, those who received mental health treatment had an increased risk of presenting to hospital (hazard ratio, 1.06 [95% CI, 1.01-1.11]) but no difference in survival (hazard ratio, 0.86 [95% CI, 0.58-1.27]). CONCLUSIONS: Nearly half of the people living with mood problems following stroke did not receive mental health treatment. We have highlighted subgroups who may benefit from targeted mood screening and factors that may improve treatment access.

Factors Associated With Transition From Community to Permanent Residential Aged Care Following Stroke: A Linked Registry Data Study.

BACKGROUND: Understanding factors that influence the transition to permanent residential aged care following a stroke or transient ischemic attack may inform strategies to support people to live at home longer. We aimed to identify the demographic, clinical, and system factors that may influence the transition from living in the community to permanent residential care in the 6 to 18 months following stroke/transient ischemic attack. METHODS: Linked data cohort analysis of adults from Queensland and Victoria aged ≥65 years and registered in the Australian Stroke Clinical Registry (2012-2016) with a clinical diagnosis of stroke/transient ischemic attack and living in the community in the first 6 months post-hospital discharge. Participant data were linked with primary care, pharmaceutical, aged care, death, and hospital data. Multivariable survival analysis was performed to determine demographic, clinical, and system factors associated with the transition to permanent residential care in the 6 to 18 months following stroke, with death modeled as a competing risk. RESULTS: Of 11 176 included registrants (median age, 77.2 years; 44% female), 520 (5%) transitioned to permanent residential care between 6 and 18 months. Factors most associated with transition included the history of urinary tract infections (subhazard ratio [SHR], 1.41 [95% CI, 1.16-1.71]), dementia (SHR, 1.66 [95% CI, 1.14-2.42]), increasing age (65-74 versus 85+ years; SHR, 1.75 [95% CI, 1.31-2.34]), living in regional Australia (SHR, 31 [95% CI, 1.08-1.60]), and aged care service approvals: respite (SHR, 4.54 [95% CI, 3.51-5.85]) and high-level home support (SHR, 1.80 [95% CI, 1.30-2.48]). Protective factors included being dispensed antihypertensive medications (SHR, 0.68 [95% CI, 0.53-0.87]), seeing a cardiologist (SHR, 0.72 [95% CI, 0.57-0.91]) following stroke, and less severe stroke (SHR, 0.71 [95% CI, 0.58-0.88]). CONCLUSIONS: Our findings provide an improved understanding of factors that influence the transition from community to permanent residential care following stroke and can inform future strategies designed to delay this transition.

Fracture Risk Increases After Stroke or Transient Ischemic Attack and Is Associated With Reduced Quality of Life.

BACKGROUND: Fractures are a serious consequence following stroke, but it is unclear how these events influence health-related quality of life (HRQoL). We aimed to compare annualized rates of fractures before and after stroke or transient ischemic attack (TIA), identify associated factors, and examine the relationship with HRQoL after stroke/TIA. METHODS: Retrospective cohort study using data from the Australian Stroke Clinical Registry (2009-2013) linked with hospital administrative and mortality data. Rates of fractures were assessed in the 1-year period before and after stroke/TIA. Negative binomial regression, with censoring at death, was used to identify factors associated with fractures after stroke/TIA. Respondents provided HRQoL data once between 90 and 180 days after stroke/TIA using the EuroQoL 5-dimensional 3-level instrument. Adjusted logistic regression was used to assess differences in HRQoL at 90 to 180 days by previous fracture. RESULTS: Among 13 594 adult survivors of stroke/TIA (49.7% aged ≥75 years, 45.5% female, 47.9% unable to walk on admission), 618 fractures occurred in the year before stroke/TIA (45 fractures per 1000 person-years) compared with 888 fractures in the year after stroke/TIA (74 fractures per 1000 person-years). This represented a relative increase of 63% (95% CI, 47%-80%). Factors associated with poststroke fractures included being female (incidence rate ratio [IRR], 1.34 [95% CI, 1.05-1.72]), increased age (per 10-year increase, IRR, 1.35 [95% CI, 1.21-1.50]), history of prior fracture(s; IRR, 2.56 [95% CI, 1.77-3.70]), and higher Charlson Comorbidity Scores (per 1-point increase, IRR, 1.18 [95% CI, 1.10-1.27]). Receipt of stroke unit care was associated with fewer poststroke fractures (IRR, 0.67 [95% CI, 0.49-0.93]). HRQoL at 90 to 180 days was worse among patients with prior fracture across the domains of mobility, self-care, usual activities, and pain/discomfort. CONCLUSIONS: Fracture risk increases substantially after stroke/TIA, and a history of these events is associated with poorer HRQoL at 90 to 180 days after stroke/TIA.

The Influence of Substance Use on Traumatic Brain Injury Recovery and Rehabilitation Outcomes: The Outcome-ABI Study.

OBJECTIVE: This study characterized substance use (alcohol, illicit drugs, amphetamines) in patients with traumatic brain injury (TBI) receiving rehabilitation to determine potential benefit of rehabilitation and whether substance use influenced outcomes in moderate-severe TBI. DESIGN: Prospective, longitudinal study of adults with moderate or severe TBI receiving inpatient rehabilitation. SETTING: Specialist-staffed acquired brain injury rehabilitation center in Melbourne, Australia. PARTICIPANTS: A total of 153 consecutive inpatients with TBI admitted between January 2016 and December 2017 (24 months). INTERVENTIONS: All inpatients with TBI (n=153) received specialist-provided brain injury rehabilitation in accordance with evidence-based guideline care at one 42-bed rehabilitation center. MAIN OUTCOME MEASURES: Data were collected at time of TBI, upon rehabilitation admission, and discharge and 12 months' post-TBI. Recovery was measured by posttraumatic amnesia posttraumatic amnesia length-days and change in Glasgow Coma Scale (admission-discharge). Functional independence was measured on the FIM, Functional Assessment Measure, and Mayo Portland Adaptability Index. Quality of life (QOL) was measured on the EuroQOL-5D-5L and Quality of Life After Brain Injury (QOLIBRI) instruments. RESULTS: Inpatients with history of illicit drug use (n=54) reported lower QOL and adjustment at 12 months' post-TBI compared with those with no history (QOLIBRI social relationships: ratio of means=0.808, P=.028; Mayo Portland Adaptability Index adjustment: incidence rate ratio, 1.273; P=.032). Amphetamine use at time of injury (n=10) was associated with quicker recovery (posttraumatic amnesia length-days: incidence rate ratio, 0.173; P<.01); however, lower QOL at 12 months post-TBI was noted in those with a history of amphetamine use (n=34) compared with those without (QOLIBRI bothered feelings: ratio of means, 0.489, P=.036). CONCLUSIONS: All participants made improvements with rehabilitation post-TBI; however, a history of substance use was associated with lower reported 12-month QOL. These findings add insight to the associations between substance use and acute recovery, potentially suggestive of a short-term recovery-promoting effect of amphetamines but highlighting the importance of rehabilitation to address long-term sequalae.

Examining Dose Frameworks to Improve Aphasia Rehabilitation Research.

The effect of treatment dose on recovery of post-stroke aphasia is not well understood. Inconsistent conceptualization, measurement, and reporting of the multiple dimensions of dose hinders efforts to evaluate dose-response relations in aphasia rehabilitation research. We review the state of dose conceptualization in aphasia rehabilitation and compare the applicability of 3 existing dose frameworks to aphasia rehabilitation research-the Frequency, Intensity, Time, and Type (FITT) principle, the Cumulative Intervention Intensity (CII) framework, and the Multidimensional Dose Articulation Framework (MDAF). The MDAF specifies dose in greater detail than the CII framework and the FITT principle. On this basis, we selected the MDAF to be applied to 3 diverse examples of aphasia rehabilitation research. We next critically examined applicability of the MDAF to aphasia rehabilitation research and identified the next steps needed to systematically conceptualize, measure, and report the multiple dimensions of dose, which together can progress understanding of the effect of treatment dose on outcomes for people with aphasia after stroke. Further consideration is required to enable application of this framework to aphasia interventions that focus on participation, personal, and environmental interventions and to understand how the construct of episode difficulty applies across therapeutic activities used in aphasia interventions.

Defining ready for discharge from sub-acute care: a qualitative exploration from multiple stakeholder perspectives.

BACKGROUND: Planning discharges from subacute care facilities is becoming increasingly complex due to an ageing population and a high demand on services. The use of non-standardised assessments to determine a patient's readiness for discharge places a heavy reliance on a clinician's judgement which can be influenced by system pressures, past experiences and team dynamics. The current literature focusses heavily on discharge-readiness from clinicians' perspectives and in the acute care setting. This paper aimed to explore the perceptions of discharge-readiness from the perspectives of key stakeholders in subacute care: inpatients, family members, clinicians and managers. METHODS: A qualitative descriptive study was conducted, exploring the views of inpatients (n = 16), family members (n = 16), clinicians (n = 17) and managers (n = 12). Participants with cognitive deficits and those who did not speak English were excluded from this study. Semi-structured interviews and focus groups were conducted and audio-recorded. Following transcription, inductive thematic analysis was completed. RESULTS: Participants identified that there are both patient-related and environmental factors that influence discharge-readiness. Patient-related factors discussed included continence, functional mobility, cognition, pain and medication management skills. Environmental factors centred around the discharge (home) environment, and were suggested to include a safe physical environment alongside a robust social environment which was suggested to assist to fill any gaps in functional capabilities (i.e. patient-related factors). CONCLUSIONS: These findings make a unique contribution to the literature by providing a thorough exploration of determining discharge-readiness as a combined narrative from the perspectives from key stakeholders. Findings from this qualitative study identified key personal and environmental factors influencing patients' discharge-readiness, which may allow health services to streamline the determination of discharge-readiness from subacute care. Understanding how these factors might be assessed within a discharge pathway warrants further attention.

Prospective application of theoretical implementation frameworks to improve health care in hospitals - a systematic review.

BACKGROUND: Health Service implementation projects are often guided by theoretical implementation frameworks. Little is known about the effectiveness of these frameworks to facilitate change in processes of care and patient outcomes within the inpatient setting. The aim of this review was to assess the effectiveness of the application of theoretical implementation frameworks in inpatient healthcare settings to change processes of care and associated patient outcomes. METHOD: We conducted a search in CINAHL, MEDLINE, EMBASE, PsycINFO, EMCARE and Cochrane Library databases from 1st January 1995 to 15th June 2021. Two reviewers independently applied inclusion and exclusion criteria to potentially eligible studies. Eligible studies: implemented evidence-based care into an in-patient setting using a theoretical implementation framework applied prospectively; used a prospective study design; presented process of care or patient outcomes; and were published in English. We extracted theoretical implementation frameworks and study design against the Workgroup for Intervention Development and Evaluation Research (WIDER) Checklist and implementation strategies mapped to the Cochrane Effective Practice and Organisation of Care (EPOC) taxonomy. We summarised all interventions using the Template for Intervention Description and Replication (TIDieR) checklist. We appraised study quality using the Item bank on risk of bias and precision of observational studies and the revised Cochrane risk of bias tool for cluster randomised trials. We extracted process of care and patient outcomes and described descriptively. We conducted meta-analysis for process of care and patient outcomes with reference to framework category. RESULTS: Twenty-five studies met the inclusion criteria. Twenty-one used a pre-post (no comparison), two a pre-post with a comparison, and two a cluster randomised trial design. Eleven theoretical implementation frameworks were prospectively applied: six process models; five determinant frameworks; and one classic theory. Four studies used two theoretical implementation frameworks. No authors reported their justification for selecting a particular framework and implementation strategies were generally poorly described. No consensus was reached for a preferred framework or subset of frameworks based on meta-analysis results. CONCLUSIONS: Rather than the ongoing development of new implementation frameworks, a more consistent approach to framework selection and strengthening of existing approaches is recommended to further develop the implementation evidence base. TRIAL REGISTRATION: CRD42019119429.

Profiling self-awareness in brain injury rehabilitation: A mixed methods study.

ABSTRACTImpaired self-awareness impacts outcomes for individuals with brain injury. Self-awareness is a complex construct, with little known about how its presentation differs across diagnostic groups, or how brain injury-related changes are expressed by individuals in the early phase post-brain injury. This study aims to identify differences and similarities in patterns of self-awareness between patients with different brain injury diagnoses, and provide a clinical account of how individuals with ABI describe changes to themselves arising from brain injury. This is a mixed methods retrospective cohort study involving an audit of medical files that included extraction of data from the Self-Awareness of Deficits Interview. Quantitative and qualitative techniques were used to analyse data from 173 participants. Individuals identified a range of brain injury-related impairments across domains, with greatest difficulty noted with linking impairments to functional implications and setting realistic goals. There were similarities and distinct differences in the expression of changes across diagnostic groups. Two main themes that aligned with self-awareness theory were identified from the data: 1/ Development of self-awareness; and 2/ Dimensions of self-awareness. These interrelated themes demonstrated the multifaceted nature of the clinical presentation of self-awareness, and highlight the need for an individualized approach to cognitive rehabilitation.

The role of collaborative decision-making in discharge planning: Perspectives from patients, family members and health professionals.

AIM: To explore discharge planning with a range of key stakeholders in subacute care, including consumers. DESIGN: Qualitative descriptive study. METHODS: Patients (n = 16), families (n = 16), clinicians (n = 17) and managers (n = 12) participated in semi-structured interviews or focus groups. Following transcription, data were analysed thematically. RESULTS: The overarching facilitator of effective discharge planning was collaborative communication, leading to shared expectations by all stakeholders. Collaborative communication was underpinned by four key themes: patient- and family-centred decision-making, early goal setting, strong inter- and intra-disciplinary teamwork, and robust patient/family education. CONCLUSION: Effective planning for discharge from subacute care is enabled by shared expectations and collaborative communication between key stakeholders. IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE: Effective discharge planning processes are underpinned by effective inter- and intra-disciplinary teamwork. Healthcare networks should foster environments that promote effective communication between and within multidisciplinary team members as well as with patients and their families. Applying these principles to discharge planning may assist in reducing length of stays and rates of preventable readmissions post-discharge. IMPACT: This study addressed a lack of knowledge about effective discharge planning in Australian subacute care. It found that collaborative communication between stakeholders was an overarching facilitator of effective discharge planning. This finding impacts subacute service design and professional education. REPORTING METHOD: COREQ guidelines were followed in reporting this study. PATIENT OR PUBLIC CONTRIBUTION: No patient or public contribution in the design, data analysis or preparation of the manuscript.

Understanding the workflow of nurses in acute and subacute medical wards: A time and motion study.

AIMS AND OBJECTIVES: The aim of this study was to determine how much time nurses spend on direct and indirect patient care in acute and subacute hospital settings. BACKGROUND: Quantifying direct and indirect nursing care provided during inpatient stay is vital to optimise the quality of care and manage resources. DESIGN: Time and motion cross-sectional observational study and reported the study according to the STROBE guideline. METHODS: Nurses working in an acute or subacute medical wards of a single health service participated. Nurses were observed twice for 2 h on the same day with an observer break in between sessions. Real-time task-related data were digitally recorded using the Work Observation Method By Activity Timing (WOMBAT) tool by a single research assistant. Frequency and time spent on pre-determined tasks were recorded and included direct care, indirect care, documentation, medication-related tasks, communication (professional) and other tasks. Task interruptions and multitasking were also recorded. RESULTS: Twenty-one nurses (acute n = 12, subacute n = 9) were observed during shifts between 7 AM and 9 PM in May-July 2021. A total of 7240 tasks were recorded. Nurses spent a third of their time on direct patient care (27% direct care and 3% medication administration). A total of 556 task interruptions occurred, mostly during documentation, and medication-related tasks. A further 1385 tasks were performed in parallel with other tasks, that is multitasking. CONCLUSIONS: Time spent on tasks was similar regardless of the setting and was consistent with previous research. We found differences in the distribution of tasks throughout the day between settings, which could have implications for workforce planning and needs to be investigated further. Interruptions occurred during documentation, direct care and medication-related tasks. Local-level strategies should be in place and regularly revised to reduce interruptions and prevent errors. Relevance to clinical practice The association between interruption and increased risk of error is well-established and should be an ongoing area of attention including observations and education provided in local settings.

Factors Associated with Receiving a Discharge Care Plan After Stroke in Australia: A Linked Registry Study.

Background: Discharge planning is recommended to optimise the transition from acute care to home for patients admitted with stroke. Despite this guideline recommendation, many patients do not receive a discharge care plan. Also, there is limited evidence on factors influencing the provision of discharge care plan post-stroke. We evaluated patient, clinical and system factors associated with receiving a care plan on discharge from hospital back to the community after stroke. Methods: This was an observational cohort study of patients with acute stroke who were discharged to the community between 2009-2013, using data from the Australian Stroke Clinical Registry linked to hospital administrative data. For this analysis, we used merged dataset containing information on patient demographics, clinical characteristics, and receipt of acute care processes. Multivariable logistic regression models were used to determine factors associated with receiving a discharge care plan. Results: Among 7812 eligible patients (39 hospitals, median age 73 years, 44.7% female, 56.9% ischaemic stroke), 47% received a care plan at discharge. The odds of receiving a discharge care plan increased over time (odds ratio [OR] 1.39 per year, 95% CI 1.37-1.48), and varied between hospitals. Factors associated with receiving a discharge care plan included greater socioeconomic position (OR 1.18, 95% CI 1.02-1.38), diagnosis of ischaemic stroke (OR 1.18, 95% CI 1.05-1.33), greater stroke severity (OR 1.15, 95% CI 1.01-1.31), or being discharged on antihypertensive medication (OR 3.07, 95% CI 2.69-3.50). In contrast, factors associated with a reduced odds of receiving a discharge care plan included being aged 85+ years (vs < 85 years; OR 0.79, 95% CI 0.64-0.96), discharged on a weekend (OR 0.56, 95% CI 0.46-0.67), discharged to residential aged care (OR 0.48, 95% CI 0.39-0.60), or being treated in a large hospital ( > 300 beds; OR 0.30, 95% CI 0.10-0.92). Conclusions: Implementing practices to target people who are older, discharged to residential aged care, or discharged on a weekend may improve discharge planning and post-discharge care after stroke.

Are Medicare Funded Multidisciplinary Care Policies Being Claimed in accordance to Rehabilitation Needs in Patients with Stroke?

Background: Australian Primary Care Practitioners are incentivised through Medicare funded policies to provide chronic disease management and facilitate multidisciplinary care. Little is known about how these policies are claimed in the long-term management of stroke. The objective of this study was to describe the use of funded primary care policies for people with stroke by impairment status. Methods: Linked Australian Stroke Clinical Registry (2010-2014) and Medicare data from adults with 90-180 days post-stroke EQ-5D health status survey data and admitted to one of 26 participating Australian hospitals were analysed. Medicare item claims for Primary Care Practitioner led chronic disease management and multidisciplinary care coordination policies, during the 18 months following stroke are described. Registrants were classified into impairment groups using their EQ-5D dimension responses through Latent Class Analysis. Associations between impairment and use of relevant primary care policies were explored using multivariable regression. Results: 5432 registrants were included (median age 74 years, 44% female, 86% ischaemic), 39% had a chronic disease management claim and 39% a multidisciplinary care coordination claim. Three latent classes emerged representing minimal, moderate and severe impairment. Compared to minimal, those with severe impairment were least likely to receive chronic disease management (adjusted Odds Ratio (aOR): 0.61, 95% Confidence Interval (CI): 0.49, 0.75) but were most likely to receive multidisciplinary care coordination. Podiatry was the commonest allied health service prescribed, regardless of impairment. Conclusions: Less than half of people living with stroke had a claim for primary care initiated chronic disease management, with mixed access for those with severe impairments.

Long-term effect of additional rehabilitation following botulinum toxin-A on upper limb activity in chronic stroke: the InTENSE randomised trial.

BACKGROUND: It is common for people with persistent spasticity due to a stroke to receive an injection of botulinum toxin-A in the upper limb, however post-injection intervention varies. AIM: To determine the long-term effect of additional upper limb rehabilitation following botulinum toxin-A in chronic stroke. METHOD: An analysis of long-term outcomes from national, multicenter, Phase III randomised trial with concealed allocation, blinded measurement and intention-to-treat analysis was carried out. Participants were 140 stroke survivors who were scheduled to receive botulinum toxin-A in any muscle(s) that cross the wrist because of moderate to severe spasticity after a stroke greater than 3 months ago, who had completed formal rehabilitation and had no significant cognitive impairment. Experimental group received botulinum toxin-A plus 3 months of evidence-based movement training while the control group received botulinum toxin-A plus a handout of exercises. Primary outcomes were goal attainment (Goal Attainment Scale) and upper limb activity (Box and Block Test) at 12 months (ie, 9 months beyond the intervention). Secondary outcomes were spasticity, range of motion, strength, pain, burden of care, and health-related quality of life. RESULTS: By 12 months, the experimental group scored the same as the control group on the Goal Attainment Scale (MD 0 T-score, 95% CI -5 to 5) and on the Box and Block Test (MD 0.01 blocks/s, 95% CI -0.01 to 0.03). There were no differences between groups on any secondary outcome. CONCLUSION: Additional intensive upper limb rehabilitation following botulinum toxin-A in chronic stroke survivors with a disabled upper limb is not more effective in the long-term. TRIAL REGISTRATION: ACTRN12615000616572 (12/06/2015).

Self-reported quality of life following stroke: a systematic review of instruments with a focus on their psychometric properties.

PURPOSE: To evaluate the psychometric properties of common health-related quality-of-life instruments used post stroke and provide recommendations for research and clinical use with this diagnostic group. METHODS: A systematic review of the psychometric properties of the five most commonly used quality-of-life measurement tools (EQ-5D, SF-36, SF-6D, AQoL, SS-QOL) was conducted. Electronic searches were performed in MEDLINE, CINAHL, and EMBASE on November 27th 2019. Two authors screened papers against the inclusion criteria and where consensus was not reached, a third author was consulted. Included papers were appraised using the COnsensus-based Standards for the selection of health status Measurement INstruments (COSMIN) checklist and findings synthesized to make recommendations. RESULTS: A total of n = 50,908 papers were screened and n = 45 papers reporting on 40 separate evaluations of psychometric properties met inclusion criteria (EQ-5D = 19, SF-36 = 16, SF-6D = 4, AQoL = 2, SS-QOL = 4). Studies reported varied psychometric quality of instruments, and results show that psychometric properties of quality-of-life instruments for the stroke population have not been well established. The strongest evidence was identified for the use of the EQ-5D as a quality-of-life assessment for adult stroke survivors. CONCLUSIONS: This systematic evaluation of the psychometric properties of self-reported quality-of-life instruments used with adults after stroke suggests that validity across tools should not be assumed. Clinicians and researchers alike may use findings to help identify the most valid and reliable measurement instrument for understanding the impact of stroke on patient-reported quality of life.