SLIDE 1 Assessing and managing rehabilitation needs of people with stroke in Australia
Elizabeth Lynch
Julie Luker Dominique Cadilhac Susan Hillier
SLIDE 2 Talk overview
Stroke rehabilitation in Australia Pre-intervention:
- How people assessed for stroke rehabilitation
Intervention: Education vs multifaceted intervention Post-intervention:
- Proportions of patients assessed
- Criteria used in rehabilitation assessments
- Barriers/enablers to improving practices
Pathway to impact:
- Dissemination
- Stroke Foundation audit
- Stroke Clinical Guidelines
Lessons learned
SLIDE 3 Stroke in Australia
Stroke affects 1 in 5 Australians1
- Leading cause of disability in adults
- One of leading causes of death
Nearly 2/3 of people living with stroke in community need help for daily activities 2
- 1. The GBD 2016 Lifetime Risk of Stroke Collaborators, N Eng J Med 2018
- 2. Deloitte Access Economics 2013
SLIDE 4 Assessment for rehabilitation after stroke
Marked inequity exists in access to stroke rehabilitation Global issue: In Canada, 37% patients with stroke need inpatient rehabilitation, 28% access inpatient rehabilitation1 In Australia, assessments vary between reviewers2
- 1. Willems et al, Healthcare Policy 2012
- 2. Kennedy et al, Arch Phys Med Rehabil, 2012
Country Proportions of patients assessed for rehabilitation Australia 49% (National Stroke Foundation 2013) Canada 58% (Willems et al, Arch Phys Med Rehabil, 2012) UK 85% (Royal College of Physicians SSNAP) USA 90% (Prvu-Bettger et al, Arch Phys Med Rehabil, 2013)
SLIDE 5
Stroke rehabilitation pathway
SLIDE 6 Stroke rehabilitation pathway
Stroke unit Variable referral rates 27-73%
SLIDE 7 Stroke rehabilitation pathway
Severe stroke Stroke unit Mild stroke Variable referral rates 27-73%
SLIDE 8 Stroke rehabilitation pathway
Invalid criteria Current rate 45% Severe stroke Stroke unit Family advocacy Assessor opinion Mild stroke Variable referral rates 27-73%
SLIDE 9 Stroke rehabilitation pathway
Relationship with acute hospital Rehabilitation centre priorities Invalid criteria Current rate 45% Severe stroke Stroke unit Family advocacy Assessor opinion Mild stroke Variable referral rates 27-73%
SLIDE 10 Assessment for Rehabilitation Tool
Developed in 2011
- Existing literature
- Survey of clinical practice
- Expert working group
- Pilot tested
Patient-centred, evidence- based decision-making tool Released in December 2012 Each person should receive the right rehabilitation in the right place at the right time
SLIDE 11 Domain Current level
Rehab indicated (y/n) Able to be managed at home
Swallowing Hydration, nutrition Continence Mobility – transfers, gait Activities of daily living Eating and drinking Communication Cognition, insight Level of alertness, engagement Vision, sensory systems, perception Behaviour Emotional, psychological Specialty needs eg IV, PEG
SLIDE 12 Participation (consistent with ICF framework) Role/s pre-stroke Need for rehabilitation/intervention Y/N? If Y, plan?
Domestic Vocational Recreational Social
Environment Pre-stroke (note barriers and facilitators) Need for intervention Y/N? If Y, plan?
Home Extended
Rehabilitation is indicated for every person with stroke unless:
- 1. Palliation
- 2. Persistently non-responsive (coma)
- 3. Refused
- 4. Full recovery
www.australianstrokecoalition.com.au
SLIDE 13 How were patients being assessed for rehabilitation on acute stroke units?
Observations
- Observed team meetings at 2 stroke units
- ver 4 weeks
- Field notes taken, medical records reviewed
- Inductive content analysis by 2 reviewers
SLIDE 14 Observations: How rehabilitation discussed, how referrals affected
Rehab mentioned (n=50, 78%) For rehab referral (n=47, 94%) Not for referral (n=3)
Patient refused (n=1) Full recovery (n=1) Residential care (n=1)
24 team meetings observed (5 case conferences at each stroke unit), providing data on 64 patients
SLIDE 15 Observations: How rehabilitation discussed, how referrals affected
Plan unclear (n=1) Home, no rehab (n=7) Residential care (n=4) Palliation (n=2)
Not referred (n=14) Rehab not mentioned (n=14, 22%) Rehab mentioned (n=50, 78%) For rehab referral (n=47, 94%) Not for referral (n=3)
Patient refused (n=1) Full recovery (n=1) Residential care (n=1)
24 team meetings observed (5 case conferences at each stroke unit), providing data on 64 patients
SLIDE 16 Observations: How rehabilitation discussed, how referrals affected
Plan unclear (n=1) Home, no rehab (n=7) Residential care (n=4) Palliation (n=2)
Not referred (n=14) Rehab not mentioned (n=14, 22%) Rehab mentioned (n=50, 78%) For rehab referral (n=47, 94%) Not for referral (n=3)
Patient refused (n=1) Full recovery (n=1) Residential care (n=1)
24 team meetings observed (5 case conferences at each stroke unit), providing data on 64 patients
Note: effect of non-English speaking background
SLIDE 17 Observations: factors affecting whether rehabilitation discussed
Rehabilitation consistently discussed
Obvious symptoms, alert, improving speech and/or mobility Anticipated discharge home or low level residential care Active input by PT, OT and or SP
Rehabilitation not discussed
Very mild stroke- related symptoms or none apparent Anticipated discharge home Discharged from/ not assessed by PT, OT, SP
Rehabilitation not discussed unless family request referral
Reduced alertness, severe hemiplegia, dysphagia Anticipated palliation
level residential care SP and PT ‘monitor’ function, no OT input
SLIDE 18 Observations: factors affecting whether rehabilitation discussed
Rehabilitation consistently discussed
Obvious symptoms, alert, improving speech and/or mobility Anticipated discharge home or low level residential care Active input by PT, OT and or SP
Rehabilitation not discussed
Very mild stroke- related symptoms or none apparent Anticipated discharge home Discharged from/ not assessed by PT, OT, SP
Rehabilitation not discussed unless family request referral
Reduced alertness, severe hemiplegia, dysphagia Anticipated palliation
level residential care SP and PT ‘monitor’ function, no OT input
SLIDE 19 Observations: factors affecting whether rehabilitation discussed
Rehabilitation consistently discussed
Obvious symptoms, alert, improving speech and/or mobility Anticipated discharge home or low level residential care Active input by PT, OT and or SP
Rehabilitation not discussed
Very mild stroke- related symptoms or none apparent Anticipated discharge home Discharged from/ not assessed by PT, OT, SP
Rehabilitation not discussed unless family request referral
Reduced alertness, severe hemiplegia, dysphagia Anticipated palliation
level residential care SP and PT ‘monitor’ function, no OT input
SLIDE 20 Observations: factors affecting whether rehabilitation discussed
Rehabilitation consistently discussed
Obvious symptoms, alert, improving speech and/or mobility Anticipated discharge home or low level residential care Active input by PT, OT and or SP
Rehabilitation not discussed
Very mild stroke- related symptoms or none apparent Anticipated discharge home Discharged from/ not assessed by PT, OT, SP
Rehabilitation not discussed unless family request referral
Reduced alertness, severe hemiplegia, dysphagia Anticipated palliation
level residential care SP and PT ‘monitor’ function, no OT input
SLIDE 21 Observations: factors affecting whether rehabilitation discussed
Rehabilitation consistently discussed
Obvious symptoms, alert, improving speech and/or mobility Anticipated discharge home or low level residential care Active input by PT, OT and or SP
Rehabilitation not discussed
Very mild stroke- related symptoms or none apparent Anticipated discharge home Discharged from/ not assessed by PT, OT, SP
Rehabilitation not discussed unless family request referral
Reduced alertness, severe hemiplegia, dysphagia Anticipated palliation
level residential care SP and PT ‘monitor’ function, no OT input
SLIDE 22 Observations: factors affecting whether rehabilitation discussed
Rehabilitation consistently discussed
Obvious symptoms, alert, improving speech and/or mobility Anticipated discharge home or low level residential care Active input by PT, OT and or SP
Rehabilitation not discussed
Very mild stroke- related symptoms or none apparent Anticipated discharge home Discharged from/ not assessed by PT, OT, SP
Rehabilitation not discussed unless family request referral
Reduced alertness, severe hemiplegia, dysphagia Anticipated palliation
level residential care SP and PT ‘monitor’ function, no OT input
SLIDE 23 Observations: factors affecting whether rehabilitation discussed
Rehabilitation consistently discussed
Obvious symptoms, alert, improving speech and/or mobility Anticipated discharge home or low level residential care Active input by PT, OT and or SP
Rehabilitation not discussed
Very mild stroke- related symptoms or none apparent Anticipated discharge home Discharged from/ not assessed by PT, OT, SP
Rehabilitation not discussed unless family request referral
Reduced alertness, severe hemiplegia, dysphagia Anticipated palliation
level residential care SP and PT ‘monitor’ function, no OT input
SLIDE 24 Observations: factors affecting whether rehabilitation discussed
Rehabilitation consistently discussed
Obvious symptoms, alert, improving speech and/or mobility Anticipated discharge home or low level residential care Active input by PT, OT and or SP
Rehabilitation not discussed
Very mild stroke- related symptoms or none apparent Anticipated discharge home Discharged from/ not assessed by PT, OT, SP
Rehabilitation not discussed unless family request referral
Reduced alertness, severe hemiplegia, dysphagia Anticipated palliation
level residential care SP and PT ‘monitor’ function, no OT input
SLIDE 25 Observations: factors affecting whether rehabilitation discussed
Rehabilitation consistently discussed
Obvious symptoms, alert, improving speech and/or mobility Anticipated discharge home or low level residential care Active input by PT, OT and or SP
Rehabilitation not discussed
Very mild stroke- related symptoms or none apparent Anticipated discharge home Discharged from/ not assessed by PT, OT, SP
Rehabilitation not discussed unless family request referral
Reduced alertness, severe hemiplegia, dysphagia Anticipated palliation
level residential care SP and PT ‘monitor’ function, no OT input
SLIDE 26 Behaviour change interventions
Multifaceted intervention (5 hospitals)
- Education and provision of Assessment Tool
- Audit and feedback
- Barrier identification
- Strategy development workshop
- Site champion
- Reminders
Education-only (5 hospitals)
- Education and provision of Assessment Tool
SLIDE 27
Evaluation of interventions
Were the interventions effective for improving rehabilitation assessment practices? Was multifaceted intervention more effective than education alone? What were the barriers and enablers to improving rehabilitation assessment practices?
SLIDE 28 Post-intervention focus groups – reported use of Assessment Tool
Acute stroke units only - 8 focus groups, 32 participants 4 sites reported that when Assessment Tool not used, domains such as continence or mood tended not to be documented Recommended criteria did not guide rehabilitation referrals at 4 sites
Sections of Assessment Tool used
- All functional domains and summary only
- Summary re rehabilitation indication only
- No sections used
3 4 1 Frequency of use
- Every patient
- Most patients (some forgotten)
- Never
5 2 1
SLIDE 29
Focus groups: factors considered when assessing for rehabilitation
Perceived likelihood of admission to the rehabilitation service
[Rehabilitation assessments are] based on what we know the rehab facilities require
Anticipated discharge destination Stroke severity Advocacy by families Medical stability Age Participation/motivation Progress in therapy sessions
SLIDE 30 Influencing change in practice: Social and professional role
Perceived usefulness to guide professional decisions I think [the Tool] … highlights areas that we wouldn’t have always discussed previously … the cognition and … the emotional sort of things vs If I thought, or if any of the clinicians thought, that [use
- f the Tool] would have been …
valuable in terms of lifting our game and … benefiting our patients, I have no doubt we would have adopted it
SLIDE 31
Influencing change in practice: Social and professional role
How closely the recommended criteria align with professional values Everybody is… considered for rehabilitation on an ideal basis rather than on the basis of perceived system constraints vs If you’re not dead and you’re not in a coma theoretically you should be for rehab [but people with severe strokes].… they’re really not a rehab candidate
SLIDE 32
Influencing change in practice: Beliefs about consequences
Highlight service shortages
I think the Tool … [is] … going to show the gap between who can access rehab and who should access rehab
vs
They deserve rehab, however, they’re never going to get it because we don’t have services. That creates problems with families There were some medico-legal questions … if we were recommending [rehabilitation] … and then that couldn’t be provided … it was … something that could come back to us
SLIDE 33 Influencing change in practice: Social influences
Acute stroke unit group Rehabilitation team I’d say [the Tool] is also not taken
- n board by rehab … I think what
would help us … is if the rehab team were using this or asking for it Any patient that wasn't at their baseline would be indicated for rehab… but they might have dementia… so I wouldn’t refer them, because that would just destroy my relationship with the rehab facility
SLIDE 34
Behavioural regulation
We do it as part of our meeting vs We’ve got our procedures in place … we didn’t want to double up on what we’re already doing
SLIDE 35 Post-intervention medical record audit
Demographic variable Multifaceted intervention (n=152) Education (n=150) P value Males (%) Age (median) Pre-stroke living status Community Residential care Stroke severity (NIHSS) 8< 8-16 16> Stroke type TACI PACI POCI LACI ICH 57% 77 129 (85%) 22 (15%) 117 (77%) 28 (18%) 7 (5%) 13 (9%) 46 (30%) 23 (15%) 58 (38%) 12 (8%) 56% 78 118 (79%) 12 (8%) 118 (79%) 29 (19%) 3 (2%) 8 (5%) 39 (26%) 28 (18%) 51 (34%) 24 (16%) 0.98 0.75 0.20 0.45 0.15
SLIDE 36 Changes in rehabilitation assessments over time
Rehabilitation assessment Pre-intervention (n=284) Post-intervention (n=302) Test of proportion
Assessed by anyone 182 (64%) 219 (73%) 0.01 Assessed by hospital clinician 122 (43%) 214 (71%) <0.001 Assessed by rehabilitation specialist 125 (44%) 114 (38%) 0.93 Accessed rehabilitation 152 (54%) 172 (57%) 0.20
SLIDE 37 Changes in rehabilitation assessments over time
Rehabilitation assessment Pre-intervention (n=284) Post-intervention (n=302) Test of proportion
Assessed by anyone 182 (64%) 219 (73%) 0.01 Assessed by hospital clinician 122 (43%) 214 (71%) <0.001 Assessed by rehabilitation specialist 125 (44%) 114 (38%) 0.93 Accessed rehabilitation 152 (54%) 172 (57%) 0.20
SLIDE 38 Effectiveness of implementation interventions
Rehabilitation assessment Intervention received P Difference in absolute change (95% CI) Multifaceted (n=152) Education (n=150)
Assessment conducted 112 (74%) 108 (72%) 0.51 -24% (-0.94-0.47) By hospital clinician 112 (74%) 102 (68%) 0.21 44% (-0.25-1.13) By rehabilitation specialist 57 (38%) 58 (39%) 0.12 -54% (-1.22-0.13) Accessed rehabilitation 77 (51%) 95 (63%) 0.13 -41% (-1.17-0.15)
SLIDE 39
Post-intervention rehabilitation assessments and access
Records of 302 people with stroke included in analysis 214 (71%) assessed by treating team 175 (82%) recommended for rehabilitation 159 (91%) of those recommended accessed rehabilitation
SLIDE 40
Post-intervention rehabilitation assessments and access
Records of 302 people with stroke included in analysis 214 (71%) assessed by treating team 175 (82%) recommended for rehabilitation 159 (91%) of those recommended accessed rehabilitation 115 (38%) assessed by rehabilitation service 93 (81%) recommended for rehabilitation 93 (100%) of those recommended accessed rehabilitation
SLIDE 41
Post-intervention rehabilitation assessments and access
Records of 302 people with stroke included in analysis 214 (71%) assessed by treating team 175 (82%) recommended for rehabilitation 159 (91%) of those recommended accessed rehabilitation 115 (38%) assessed by rehabilitation service 93 (81%) recommended for rehabilitation 93 (100%) of those recommended accessed rehabilitation 82 (27%) not assessed by anyone 0 recommended for rehabilitation 7 (9%) of those not assessed, accessed rehabilitation
SLIDE 42
Post-intervention rehabilitation assessments and access
Records of 302 people with stroke included in analysis 214 (71%) assessed by treating team 175 (82%) recommended for rehabilitation 159 (91%) of those recommended accessed rehabilitation 115 (38%) assessed by rehabilitation service 93 (81%) recommended for rehabilitation 93 (100%) of those recommended accessed rehabilitation 82 (27%) not assessed by anyone 0 recommended for rehabilitation 7 (9%) of those not assessed, accessed rehabilitation
SLIDE 43
Post-intervention: patients who did not access recommended rehabilitation (n=16)
Rehabilitation not recommended at time of discharge n=10 Patient refused n=6 Fully recovered n=1 Not recommended by rehabilitation specialists n=3 6 patients with stroke symptoms not referred to rehabilitation Discharged to nursing home n=2 Discharged home n=3 Overseas resident n=1
SLIDE 44
Post-intervention rehabilitation assessments and access
Records of 302 people with stroke included in analysis 214 (71%) assessed by treating team 175 (82%) recommended for rehabilitation 159 (91%) of those recommended accessed rehabilitation 115 (38%) assessed by rehabilitation service 93 (81%) recommended for rehabilitation 93 (100%) of those recommended accessed rehabilitation 82 (27%) not assessed by anyone 0 recommended for rehabilitation 7 (9%) of those not assessed, accessed rehabilitation
SLIDE 45 Post-intervention reasons rehabilitation not recommended
Acute hospital Rehabilitation Assessment for Rehabilitation Tool criteria 21 6 Fully recovered 20 4 Patient or family refused 2 2 Other reasons 17 14 For residential care placement 3 6 Poor motivation/participation 3 4 Unwell/medically unstable 2 1 Not following instructions 2 Dementia 2 Reason not given 3 1 From residential care 1 Other 3
SLIDE 46 Triangulation of results: factors affecting whether assessed as needing rehabilitation
Factor Focus groups Audit Anticipated discharge destination ✓ ✓ Unwell, medically unstable (negative) ✓ ✓ Poor motivation/participation (negative) ✓ ✓ Severity of symptoms (negative) ✓ Perceived likelihood of being accepted by rehabilitation ✓ Advocacy by families ✓ Age ✓ Expected recovery ✓ Cognitive or language problems (negative) ✓
SLIDE 47 Discussion
People with severe stroke can make significant gains in quality
- f life and reduced carer burden
with rehabilitation 1 Motivation and participation after stroke can be influenced by therapists’ attitudes 2 Medical instability should not rule a patient out of rehabilitation
1 Pereira et al 2012, 2 Luker et al 2015
SLIDE 48 Discussion
Both interventions improved proportions of patients assessed for rehabilitation BUT: more than 25% of patients were not assessed Important new evidence regarding behaviour change interventions
- Multifaceted intervention was not more effective
than education
- Likely cost benefits associated with education
intervention
SLIDE 49 Discussion
Rehabilitation referral practices were unchanged Rehabilitation assessment and referral practices
- Appeared to be driven in part by rehabilitation
service availability
- Did not identify any unmet rehabilitation needs
for patients with stroke in Australia
- Provided no data to support anecdotal reports of
limited rehabilitation service availability
- Provided no data with which to advocate for
increased rehabilitation services
SLIDE 50 Next steps
A change in assessment practices was required to provide accurate data regarding rehabilitation needs after stroke
- Liaised with Stroke Foundation and advised on wording
- f new data point:
SLIDE 51 Next steps
A change in assessment practices was required to provide accurate data regarding rehabilitation needs after stroke
- Involved in update of Clinical Guidelines for Stroke
Management (2017)
SLIDE 52
Impact
Proportions being assessed for rehabilitation steadily improving (2013:49%; 2015:57%; 2017:59%) Use of Assessment for Rehabilitation Tool still needs work (2015: 11%, not presented in 2017
report) – highlighted in interview on Radio National 21st January 2019
The impact of the new Stroke Clinical Guidelines has yet to be evaluated.
SLIDE 53
Lessons for others
Involvement of different groups – rehabilitation teams Partnering and communicating often with key stakeholders – Stroke Foundation, clinical networks Presenting at variety of fora – Clinical network meetings, academic meetings (medical, allied health, nursing) Publishing in different journals – rehabilitation, implementation science, medical journals Opportunities to discuss on mainstream media – Health Report (Radio national 21st January 2019)
SLIDE 54
Acknowledgements
Thank you to all the patient and clinicians who participated in this study
