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

Cadilhac, Dominique A.; Fisher, Rebecca J; Bernhardt, Julie

doi:10.1177/1747493017750924

Cited by 6 publications

(6 citation statements)

References 49 publications

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“…This maximised the availability of national registry data to conduct health services research and built on previous approaches to evaluate effectiveness of stroke unit care. 31,61,70,128 We developed an ESD consensus score based on our international consensus paper. This was successfully used to determine the degree to which evidence-based core components had been adopted in models of ESD operating in the real world.…”

Section: Length Of Hospital Staymentioning

confidence: 99%

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

Fisher

Chouliara

Byrne

et al. 2021

Health Serv Deliv Res

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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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Section: Length Of Hospital Staymentioning

confidence: 99%

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

Fisher

Chouliara

Byrne

et al. 2021

Health Serv Deliv Res

View full text Add to dashboard Cite

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“…Translating evidence from clinical trials into routine clinical practice is inherently difficult [26], which can detrimentally affect patient care and outcomes [27]. Often, implementation activities are focused on short-term actions and effects [28].…”

Section: Discussionmentioning

confidence: 99%

Inclusion of a care bundle for fever, hyperglycaemia and swallow management in a National Audit for acute stroke: evidence of upscale and spread

et al. 2019

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Background In the Quality in Acute Stroke Care (QASC) trial undertaken in stroke units (SUs) located in New South Wales (NSW), Australia (2005–2010), facilitated implementation of a nurse-led care bundle to manage fever, hyperglycaemia and swallowing (FeSS protocols) reduced death and disability for patients with stroke. We aimed to determine subsequent adherence to the bundled FeSS processes (reflective of the protocols) between 2013 and 2017 in Australian hospitals, and examine whether changes in adherence to these processes varied based on previous participation in the QASC trial or subsequent statewide scale-up (QASCIP—Quality in Acute Stroke Care Implementation Project) and presence of an SU. Methods Cross-sectional, observational study using self-reported organisational survey and retrospective clinical audit data from the National Acute Services Stroke Audit (2013, 2015, 2017). Mixed-effects logistic regression was performed with dependent variables: (1) composite outcome measure reflecting compliance with the FeSS protocols and (2) individual FeSS processes, including the year of audit as an independent variable, adjusted for correlation of outcomes within hospital. Separate models including interaction terms between the year of audit and previous participation in QASC/QASCIP and year of audit and SU were also generated. Results Hospital participation included the following: 2013—124 hospitals, 3741 cases; 2015—112 hospitals, 4087 cases; and 2017—117 hospitals, 4192 cases. An 80% increase in the odds of receiving the composite outcome in 2017 compared to 2013 was found (2013, 30%; 2017, 41%; OR 1.8; 95% CI 1.6, 2.0; p < 0.001). The odds of FeSS adherence from 2013 to 2017 was greater for hospitals that had participated in QASC/QASCIP relative to those that had not (participated OR 2.1; 95% CI 1.7, 2.7; not participated OR 1.6; 95% CI 1.4, 1.8; p = 0.03). Similar uptake in adherence was evident in hospitals with and without an SU between 2013 and 2017. Conclusion The use of the FeSS protocols within Australia increased from 2013 to 2017 with the inclusion of these care processes in the National Audit. Greater uptake in hospitals previously involved in QASC/QASCIP was evident. Our implementation methods may be useful for other national initiatives for improving access to evidence-based practice. Electronic supplementary material The online version of this article (10.1186/s13012-019-0934-y) contains supplementary material, which is available to authorized users.

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“…However, such trials are complex and challenging to carry out and it is frequently difficult to develop, describe, and measure the intervention satisfactorily. 9 We have used information from randomised trials, high quality cohort studies and recent clinical practice guidelines. Planners should be aware that lack of evidence of benefit is not the same as evidence of lack of benefit.…”

Section: Introductionmentioning

confidence: 99%

Stroke systems of care in high-income countries: what is optimal?

et al. 2020

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Stroke is a complex, time-sensitive, medical emergency that requires well-functioning systems of care to optimise treatment and improve patient outcomes. Education and training campaigns are needed to improve both the recognition of stroke among the general public and the response of emergency medical services. Specialised stroke ambulances (mobile stroke units) have been piloted in many cities to speed up the diagnosis, triage and emergency treatment of people with acute stroke symptoms. Hospital-based interdisciplinary stroke units remain the central feature of a modern stroke service. Many have now developed a role in the very early phase (hyperacute units) plus outreach for patients who return home (early supported discharge services). Different levels (comprehensive and primary) of stroke centre and telemedicine networks have been developed to coordinate the various service components with specialist investigations and interventions including rehabilitation. Major challenges include balancing the resources for stroke across the whole patient journey including the rapid, accurate triage of those patients who require highly specialised treatment in comprehensive stroke centres and developing technology to improve communication across different parts of a service. (178 words) A major focus of public health initiatives has been to improve the time to treatment for 91 patients with ischaemic stroke. There are several inter-related reasons that contribute to 92 patients with stroke experiencing delays with the provision of reperfusion therapies. In a 93 recent systematic review, 8 four categories of factors associated with delays were identified: 1) 94 patient-related factors, plus health system factors related to 2) training, 3) resources, and 4) 95 lack of coordination. In another similar systematic review, 10 the authors reported that 96 patients' attitudes, knowledge, and education were associated with time to presentation to 97 hospital after stroke. Visiting the primary care physician after stroke was associated with 98 delayed presentation. 99Various strategies directed at the public and emergency medical services appear to improve stroke recognition and time to presentation and treatment for people with stroke. A systematic review of 39 studies of stroke knowledge conducted in the UK, North America, Asia and Australia 11 provided an illustration of the wide variability between studies in terms of the ability of the public to name stroke risk factors, to name signs and symptoms of stroke, and the decision to call emergency medical services. In other studies it was also found that the general public would opt to contact or attend their primary care physician first, rather than emergency medical services following onset of their symptoms. 11 Public awareness campaigns are designed to improve time to diagnosis and treatment metrics.However, of the studies of educational campaigns and stroke awareness conducted in Europe, Asia, North America, and Australia, few have been found to be effective for improving resp...

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

Cited by 6 publications

References 49 publications

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

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

Inclusion of a care bundle for fever, hyperglycaemia and swallow management in a National Audit for acute stroke: evidence of upscale and spread

Stroke systems of care in high-income countries: what is optimal?

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