Large-scale implementation of stroke early supported discharge: the WISE realist mixed-methods study

Background In England, the provision of early supported discharge is recommended as part of an evidence-based stroke care pathway. Objectives To investigate the effectiveness of early supported discharge services when implemented at scale in practice and to understand how the context within which these services operate influences their implementation and effectiveness. Design A mixed-methods study using a realist evaluation approach and two interlinking work packages was undertaken. Three programme theories were tested to investigate the adoption of evidence-based core components, differences in urban and rural settings, and communication processes. Setting and interventions Early supported discharge services across a large geographical area of England, covering the West and East Midlands, the East of England and the North of England. Participants Work package 1: historical prospective patient data from the Sentinel Stroke National Audit Programme collected by early supported discharge and hospital teams. Work package 2: NHS staff (n = 117) and patients (n = 30) from six purposely selected early supported discharge services. Data and main outcome Work package 1: a 17-item early supported discharge consensus score measured the adherence to evidence-based core components defined in an international consensus document. The effectiveness of early supported discharge was measured with process and patient outcomes and costs. Work package 2: semistructured interviews and focus groups with NHS staff and patients were undertaken to investigate the contextual determinants of early supported discharge effectiveness. Results A variety of early supported discharge service models had been adopted, as reflected by the variability in the early supported discharge consensus score. A one-unit increase in early supported discharge consensus score was significantly associated with a more responsive early supported discharge service and increased treatment intensity. There was no association with stroke survivor outcome. Patients who received early supported discharge in their stroke care pathway spent, on average, 1 day longer in hospital than those who did not receive early supported discharge. The most rural services had the highest service costs per patient. NHS staff identified core evidence-based components (e.g. eligibility criteria, co-ordinated multidisciplinary team and regular weekly multidisciplinary team meetings) as central to the effectiveness of early supported discharge. Mechanisms thought to streamline discharge and help teams to meet their responsiveness targets included having access to a social worker and the quality of communications and transitions across services. The role of rehabilitation assistants and an interdisciplinary approach were facilitators of delivering an intensive service. The rurality of early supported discharge services, especially when coupled with capacity issues and increased travel times to visit patients, could influence the intensity of rehabilitation provision and teams’ flexibility to adjust to patients’ needs. This required organising multidisciplinary teams and meetings around the local geography. Findings also highlighted the importance of good leadership and communication. Early supported discharge staff highlighted the need for collaborative and trusting relationships with patients and carers and stroke unit staff, as well as across the wider stroke care pathway. Limitations Work package 1: possible influence of unobserved variables and we were unable to determine the effect of early supported discharge on patient outcomes. Work package 2: the pragmatic approach led to ‘theoretical nuggets’ rather than an overarching higher-level theory. Conclusions The realist evaluation methodology allowed us to address the complexity of early supported discharge delivery in real-world settings. The findings highlighted the importance of context and contextual features and mechanisms that need to be either addressed or capitalised on to improve effectiveness. Trial registration Current Controlled Trials ISRCTN15568163. Funding This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 22. See the NIHR Journals Library website for further project information.

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Effectiveness of Stroke Early Supported Discharge

Circulation Cardiovascular Quality and Outcomes ◽

10.1161/circoutcomes.119.006395 ◽

2020 ◽

Vol 13 (8) ◽

Author(s):

Rebecca J. Fisher ◽

Adrian Byrne ◽

Niki Chouliara ◽

Sarah Lewis ◽

Lizz Paley ◽

...

Keyword(s):

Stroke Survivor ◽

Evidence Based ◽

Modified Rankin Scale ◽

National Audit ◽

Item Score ◽

Unique Identifier ◽

Early Supported Discharge ◽

Consensus Score ◽

Service Models ◽

Core Components

Background: Implementation of stroke early supported discharge (ESD) services has been recommended in many countries’ clinical guidelines, based on clinical trial evidence. This is the first observational study to investigate the effectiveness of ESD service models operating in real-world conditions, at scale. Methods and Results: Using historical prospective data from the United Kingdom Sentinel Stroke National Audit Programme (January 1, 2016–December 31, 2016), measures of ESD effectiveness were “days to ESD” (number of days from hospital discharge to first ESD contact; n=6222), “rehabilitation intensity” (total number of treatment days/total days with ESD; n=5891), and stroke survivor outcome (modified Rankin scale at ESD discharge; n=6222). ESD service models (derived from Sentinel Stroke National Audit Programme postacute organizational audit data) were categorized with a 17-item score, reflecting adoption of ESD consensus core components (evidence-based criteria). Multilevel modeling analysis was undertaken as patients were clustered within ESD teams across the Midlands, East, and North of England (n=31). A variety of ESD service models had been adopted, as reflected by variability in the ESD consensus score. Controlling for patient characteristics and Sentinel Stroke National Audit Programme hospital score, a 1-unit increase in ESD consensus score was significantly associated with a more responsive ESD service (reduced odds of patient being seen after ≥1 day of 29% [95% CI, 1%–49%] and increased treatment intensity by 2% [95% CI, 0.3%–4%]). There was no association with stroke survivor outcome measured by the modified Rankin Scale. Conclusions: This study has shown that adopting defined core components of ESD is associated with providing a more responsive and intensive ESD service. This shows that adherence to evidence-based criteria is likely to result in a more effective ESD service as defined by process measures. Registration: URL: http://www.isrctn.com/ ; Unique identifier: ISRCTN15568163.

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Influence of stroke coordinators on delivery of acute stroke care and hospital outcomes: An observational study

International Journal of Stroke ◽

10.1177/1747493017741382 ◽

2017 ◽

Vol 13 (6) ◽

pp. 585-591 ◽

Cited By ~ 5

Author(s):

Tara Purvis ◽

Monique F Kilkenny ◽

Sandy Middleton ◽

Dominique A Cadilhac

Keyword(s):

Length Of Stay ◽

Observational Study ◽

Acute Stroke ◽

Patient Outcomes ◽

Stroke Unit ◽

Stroke Care ◽

Initial Assessment ◽

Evidence Based ◽

Clinical Practices ◽

Evidence Based Care

Background Stroke coordinators have been inconsistently used in various countries to support stroke care in hospital. Aim To investigate the association between stroke coordinators and the provision of evidence-based care and patient outcomes in hospitals with acute stroke units. Methods Observational study using cross-sectional data from the 2015 National Acute Services Audit Program (Australia): including a retrospective medical record audit (40 records from each hospital) and a self-reported survey of organizational resources for stroke. Multilevel random effects logistic regression for patient outcomes including complications, independence on discharge, and death. Median regression for length of stay comparisons. Results A total of 109 hospitals submitted 4060 cases; 59 (54%) had a stroke coordinator. Compared with patients from stroke unit hospitals with no stroke coordinator ( N = 33, 1333 cases), patients in stroke unit hospitals with a stroke coordinator ( N = 53, 2072 cases) were more likely to receive clinical practices including rehabilitation therapy within 48 hours of initial assessment (88 vs. 82%, p < 0.001), risk factor modification advice (62 vs. 55%, p = 0.003) and receive a discharge care plan (65 vs. 48%, p < 0.001). No differences in complications, independence on discharge, or deaths were evident. Patients from hospitals with a stroke coordinator were more likely to access inpatient rehabilitation (adjusted odds ratio 1.8, 95% confidence interval 1.1–2.8) and have a reduced length of acute stay if discharged (median 14 h, p = 0.03). Conclusion Presence of stroke coordinators was associated with reduced length of stay and improved delivery of evidence-based care in hospitals with a stroke unit.

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Impact of Evidence‐Based Stroke Care on Patient Outcomes: A Multilevel Analysis of an International Study

Journal of the American Heart Association ◽

10.1161/jaha.119.012640 ◽

2019 ◽

Vol 8 (13) ◽

Cited By ~ 1

Author(s):

Paula Muñoz Venturelli ◽

Xian Li ◽

Sandy Middleton ◽

Caroline Watkins ◽

Pablo M. Lavados ◽

...

Keyword(s):

Multilevel Analysis ◽

Patient Outcomes ◽

International Study ◽

Stroke Care ◽

Evidence Based

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Evolution of Evidence-Based Medicine in Stroke

Cerebrovascular Diseases ◽

10.1159/000517679 ◽

2021 ◽

pp. 1-12

Author(s):

Graeme J. Hankey

Keyword(s):

Medical Research ◽

Patient Care ◽

Patient Outcomes ◽

Evidence Based Medicine ◽

Stroke Care ◽

The State ◽

Evidence Based ◽

Empirical Testing ◽

Based Medicine ◽

Scientific Endeavour

The introduction and evolution of evidence-based stroke medicine has realized major advances in our knowledge about stroke, methods of medical research, and patient outcomes that continue to complement traditional individual patient care. It is humbling to recall the state of knowledge and scientific endeavour of our forebears who were unaware of what we know now and yet pursued the highest standards for evaluating and delivering effective stroke care. The science of stroke medicine has evolved from pathophysiological theory to empirical testing. Progress has been steady, despite inevitable disappointments and cul-de-sacs, and has occasionally been punctuated by sensational breakthroughs, such as the advent of reperfusion therapies guided by imaging.

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How to do health services research in stroke: A focus on performance measurement and quality improvement

International Journal of Stroke ◽

10.1177/1747493017750924 ◽

2018 ◽

Vol 13 (2) ◽

pp. 166-174 ◽

Cited By ~ 4

Author(s):

Dominique A Cadilhac ◽

Rebecca Fisher ◽

Julie Bernhardt

Keyword(s):

Health Services Research ◽

Health Services ◽

Patient Outcomes ◽

Stroke Care ◽

Evidence Based ◽

Clinical Services ◽

Policy And Practice ◽

Services Research ◽

Inadequate Knowledge ◽

Improve Health

The objective of this “How to” research series article is to provide guidance on getting started in Health Services Research. The purpose of health services research is to contribute knowledge that can be used to help improve health systems and clinical services through influencing policy and practice. The methods used are broad, have varying levels of rigor, and may require different specialist skills. This paper sets out practical steps for undertaking health services research. Importantly, use of the highlighted techniques can identify solutions to address inadequate knowledge translation or promote greater access to evidence-based stroke care to optimize patient outcomes.

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ASSESSING ORGANISATIONAL CONTEXT IN EMERGENCY DEPARTMENTS PRIOR TO IMPLEMENTING EVIDENCE-BASED STROKE CARE PROTOCOLS – THE T3 TRIAL CONTEXT ANALYSIS

10.26226/morressier.5ab8f565d462b8029238d5f3 ◽

2018 ◽

Author(s):

Sandy Middleton

Keyword(s):

Emergency Departments ◽

Stroke Care ◽

Evidence Based ◽

Context Analysis ◽

Organisational Context

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Engaging primary care providers in managing pediatric eating disorders: a mixed methods study

Journal of Eating Disorders ◽

10.1186/s40337-020-00363-8 ◽

2021 ◽

Vol 9 (1) ◽

Author(s):

Jocelyn Lebow ◽

Cassandra Narr ◽

Angela Mattke ◽

Janna R. Gewirtz O’Brien ◽

Marcie Billings ◽

...

Keyword(s):

Primary Care ◽

Eating Disorders ◽

Mixed Methods ◽

Care Setting ◽

Primary Care Setting ◽

Primary Care Providers ◽

Mixed Methods Study ◽

Evidence Based ◽

Care Providers ◽

Evidence Based Treatment

Abstract Background The primary care setting offers an attractive opportunity for, not only the identification of pediatric eating disorders, but also the delivery of evidence-based treatment. However, constraints of this setting pose barriers for implementing treatment. For interventions to be successful, they need to take into consideration the perspectives of stakeholders. As such, the purpose of this study was to examine in-depth primary care providers’ perspective of challenges to identifying and managing eating disorders in the primary care setting. Methods This mixed methods study surveyed 60 Pediatric and Family Medicine providers across 6 primary care practices. Sixteen of these providers were further interviewed using a qualitative, semi-structured interview. Results Providers (n = 60, response rate of 45%) acknowledged the potential of primary care as a point of contact for early identification and treatment of pediatric eating disorders. They also expressed that this was an area of need in their practices. They identified numerous barriers to successful implementation of evidence-based treatment in this setting including scarcity of time, knowledge, and resources. Conclusions Investigations seeking to build capacities in primary care settings to address eating disorders must address these barriers.

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Retrospective Review and Proof of Concept of Asia’s First Mobile Stroke Unit Experience in Kovai Medical Center and Hospital

Journal of Stroke Medicine ◽

10.1177/2516608520968418 ◽

2020 ◽

Vol 3 (2) ◽

pp. 116-123

Author(s):

Mathew Cherian ◽

Pankaj Mehta ◽

Shriram Varadharajan ◽

Santosh Poyyamozhi ◽

Elango Swamiappan ◽

...

Keyword(s):

Acute Stroke ◽

Retrospective Review ◽

Stroke Unit ◽

Care Pathway ◽

Clinical Care ◽

Stroke Care ◽

First Year ◽

Proof Of Concept ◽

Mobile Stroke Unit ◽

Clinical Care Pathway

Background: We review our initial experience of India’s and Asia’s first mobile stroke unit (MSU) following the completion of its first year of operation. We outline the clinical care pathway integrating the MSU services using a case example taking readers along our clinical care workflow while highlighting the challenges faced in organizing and optimizing such services in India. Methods: Retrospective review of data collected for all patients from March 2018 to February 2019 transported and treated within the MSU during the first year of its operation. Recent case example is reviewed highlighting complete comprehensive acute clinical care pathway from prehospital MSU services to advanced endovascular treatment with focus on challenges faced in developing nation for stroke care. Results: The MSU was dispatched and utilized for 14 patients with clinical symptoms of acute stroke. These patients were predominantly males (64%) with median age of 59 years. Ischemic stroke was seen in 7 patients, hemorrhagic in 6, and 1 patient was classified as stroke mimic. Intravenous tissue plasminogen activator was administered to 3 patients within MSU. Most of the patients’ treatment was initiated within 2 h of symptom onset and with the median time of patient contact (rendezvous) following stroke being 55 mins. Conclusion: Retrospective review of Asia’s first MSU reveals its proof of concept in India. Although the number of patients availing treatment in MSU is low as compared to elsewhere in the world, increased public awareness with active government support including subsidizing treatment costs could accelerate development of optimal prehospital acute stroke care policy in India.

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