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

Abstract

BackgroundIn 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.MethodsTen 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.ResultsData 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.ConclusionsA 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 registrationANZCTR (Australian New Zealand Clinical Trials Registry), ACTRN12616000340437 Electronic supplementary materialThe online version of this article (doi:10.1186/s13012-016-0487-2) contains supplementary material, which is available to authorized users.

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“…The learnings on CHP brought about by the operational program (4) may be instrumental to its success, since low CHP competencies of staff may hinder implementation in practice (82,85). This latter point corresponds well with findings on implementation strategies that introduce learning and practice facilitation (96,180,181). Interestingly, some studies have shown that staff and managers with own SNAP risks are less positive towards CHP (83,84), less prone to implement CHP (82,85), and less prone to implement supportive policies (84).…”

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“…This indicates the importance of understanding the context when conducing implementation research, as shown in other implementation studies (e.g., Lynch et al . ). Recommendations for future work are that other key stakeholder groups (such as multidisciplinary team members and healthcare consumers) are involved in the implementation interventions, to develop a shared understanding of the importance of implementing these behaviours consistently.…”

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“…The use of knowledge brokers (KBs) is considered as one of the promising KT strategies, [11,21,22] that can enhance success and sustainability of the whole KT process [23], and consequently help reduce research-practice gaps [11,17,[24][25][26][27][28][29][30]. Evidence from multiple studies suggests that KBs have an impact on behaviour change [31] in many healthcare sectors [32][33][34][35][36][37][38][39], including rehabilitation [40][41][42][43][44][45][46][47]. For instance, Baskerville et al showed that primary care practitioners who work with knowledge brokers are 2.76 (95% CI, 2.18-3.43) times more likely to adopt evidence-based guidelines [48].…”

“…collecting information, sharing information, and adopting information) and those resulting from being positioned between individuals with different perspectives (i.e., between clinicians and researchers). In Canada and elsewhere the interest in the utilization of KBs as a promising strategy is growing, knowledge on how the brokering role is mediated by different facilitators and barriers is limited [40][41][42][43][44][45][46][47]61]. To date, no previous research has identi ed potential barriers associated with using KBs as a means to promote the uptake of research evidence in rehabilitation settings.…”