Out of sight, out of mind: long-term outcomes for people discharged home, to inpatient rehabilitation and to residential aged care after stroke

OnlinePubl.Purpose: The aim of this study was to describe differences in long-term outcomes for patients discharged to inpatient rehabilitation facilities (IRFs) following stroke compared to patients discharged directly home or to residential aged care facilities (RACFs). Materials and Methods: Cohort study. Data from the Australian Stroke Clinical Registry were linked to hospital admissions records and the national death index. Main outcomes: death and hospital readmissions up to 12 months post-admission, Health-related Quality of Life (HRQoL) 90-180 days post-admission. Results: Of 8,555 included patients (median age 75, 55% male, 83% ischemic stroke), 4,405 (51.5%) were discharged home, 3,442 (40.2%) to IRFs, and 708 (8.3%) to RACFs. No between-group differences were observed in hazard of death between patients discharged to IRFs versus home. Fewer patients discharged to IRFs were readmitted to hospital within 90, 180 or 365-days compared to patients discharged home (adjusted subhazard ratio [aSHR]:90-days 0.54, 95%CI 0.49, 0.61; aSHR:180-days 0.74, 95%CI 0.67, 0.82; aSHR:365-days 0.85, 95%CI 0.78, 0.93). Fewer patients discharged to IRFs reported problems with mobility compared to those discharged home (adjusted OR 0.54, 95%CI 0.47, 0.63), or to RACFs (aOR 0.35, 95%CI 0.25, 0.48). Overall HRQoL between 90-180 days was worse for people discharged to IRFs versus those discharged home and better than those discharged to RACFs. Conclusions: Several long-term outcomes differed significantly for patients discharged to different settings after stroke. Patients discharged to IRFs reported some better outcomes than people discharge directly home despite having markers of more severe stroke. Implications for rehabilitation: People with mild strokes are usually discharged directly home, people with moderate severity strokes to inpatient rehabilitation, and people with very severe strokes are usually discharged to residential aged care facilities. People discharged to inpatient rehabilitation reported fewer problems with mobility and had a reduced risk of hospital readmission in the first year post-stroke compared to people discharged directly home after stroke. The median self-reported health-related quality of life for people discharged to residential aged care equated to 'worst health state imaginable'.Elizabeth A. Lynch, Angela S. Labberton, Joosup Kim, Monique F. Kilkenny, Nadine E. Andrew, Natasha A. Lannin, Rohan Grimley, Steven G. Faux and Dominique A. Cadilhac; on behalf of the Stroke123 Investigators and AuSCR Consortiu

Effect of adding upper limb rehabilitation to botulinum toxin-A on upper limb activity after stroke: Protocol for the InTENSE trial

Rationale: Although clinical practice guidelines recommend that management of moderate to severe spasticity include the use of botulinum toxin-A in conjunction with therapy, there is currently no evidence to support the addition of therapy. Aims: To determine the effect and cost-benefit of adding evidence-based movement training to botulinum toxin-A. Sample size estimate: A total of 136 participants will be recruited in order to be able to detect a between-group difference of seven points on the Goal Attainment Scale T-score with 80% power at a two-tailed significance level of 0.05. Methods and design: The InTENSE trial is a national, multicenter, Phase III randomized trial with concealed allocation, blinded assessment and intention-to-treat analysis. Stroke survivors who are 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 three months ago, who have completed formal rehabilitation and have no significant cognitive impairment will be randomly allocated to receive botulinum toxin-A plus evidence-based movement training or botulinum toxin-A alone. Study outcomes: The primary outcomes are goal attainment (Goal Attainment Scaling) and upper limb activity (Box and Block Test) at three months (end of intervention) and at 12 months (beyond the intervention). Secondary outcomes are spasticity, range of motion, strength, pain, burden of care and health-related quality of life. Direct costs, personal costs and health system costs will be collected at 12 months. Discussion: The results of the InTENSE trial are anticipated to directly influence intervention for moderate to severe spasticity after stroke. Trial Registration: ANZCTR12615000616572.Natasha A Lannin, Louise Ada, Coralie English, Julie Ratcliffe and Maria Crott

Effect of the coronavirus disease 2019 pandemic on the quality of stroke care in stroke units and alternative wards: a national comparative analysis

Background and purpose Changes to hospital systems were implemented from March 2020 in Australia in response to the coronavirus disease 2019 pandemic, including decreased resources allocated to stroke units. We investigate changes in the quality of acute care for patients with stroke or transient ischemic attack during the pandemic according to patients' treatment setting (stroke unit or alternate ward). Methods We conducted a retrospective cohort study of patients admitted with stroke or transient ischemic attack between January 2019 and June 2020 in the Australian Stroke Clinical Registry (AuSCR). The AuSCR monitors patients' treatment setting, provision of allied health and nursing interventions, prescription of secondary prevention medications, and discharge destination. Weekly trends in the quality of care before and during the pandemic period were assessed using interrupted time series analyses. Results In total, 18,662 patients in 2019 and 8,850 patients in 2020 were included. Overall, 75% were treated in stroke units. Before the pandemic, treatment in a stroke unit was superior to alternate wards for the provision of all evidence-based therapies assessed. During the pandemic period, the proportion of patients receiving a swallow screen or assessment, being discharged to rehabilitation, and being prescribed secondary prevention medications decreased by 0.58% to 1.08% per week in patients treated in other ward settings relative to patients treated in stroke units. This change represented a 9% to 17% increase in the care gap between these treatment settings during the period of the pandemic that was evaluated (16 weeks). Conclusions During the first 6 months of the pandemic, widening care disparities between stroke units and alternate wards have occurred.Dominique A. Cadilhaca, Joosup Kima, Geoffrey Cloudc, Craig S. Andersone, Emma K. Tod ... et al

A systematic review of upper extremity casting for children and adults with central nervous system motor disorders

Objective: To summarize evidence on the use of upper extremity casting designed to achieve reductions in contracture, tone, pain, function, oedema or spasticity in the elbow, wrist or hand of adults and children with neurological conditions. Data sources: A search was conducted of the Cochrane Database of Systematic Reviews; the electronic databases MEDLINE, EMBASE, CINAHL, PEDro, OT-Seeker; Google Scholar; reference lists of retrieved trial reports and review articles. Review methods: Two independent reviewers determined whether retrieved study abstracts met inclusion criteria: human subjects; \u3e50% of participants children or adults described as having brain injury, cerebral palsy or stroke. Methodological quality of randomized controlled trials was rated using the PEDro scale (1—10 highest). Results: Thirty-one papers were retrieved and 23 studies appraised: three were randomized controlled trials and four were systematic reviews. Over three-quarters of the studies, excluding systematic reviews, were lower level evidence (n = 4 level V; n = 4 level IV; n = 1 level III). Methodological quality of randomized controlled trials was high (PEDro 8, 8 and 9) and there were modest positive short-term outcomes for two trials, although they did not include no-stretch comparison conditions. Safety issues typically included pain or skin breakdown; two adverse events were not cast related. Conclusion: While theoretical rationales suggest upper limb casting should be effective there is insufficient high-quality evidence regarding impact or long-term effects to either support or abandon this practice. High variability in casting protocols indicates little consistency or consensus in practice. As maximum or low-load stretch are rationales for cast application, the absence of no-stretch conditions in existing trials is a major weakness in current evidence

Supplementary Material for: Treatment and Outcomes of Working Aged Adults with Stroke: Results from a National Prospective Registry

<b><i>Background:</i></b> Given the potential differences in etiology and impact, the treatment and outcome of younger patients (aged 18–64 years) require examination separately to older adults (aged ≥65 years) who experience acute stroke. <b><i>Methods:</i></b><i></i> Data from the Australian Stroke Clinical Registry (2010–2015) including demographic and clinical characteristics, provision of evidence-based therapies and health-related quality of life (HRQoL) post-stroke was used. Descriptive statistics and multilevel regression models were used for group comparisons. <b><i>Results:</i></b> Compared to older patients (age ≥65 years) among 26,220 registrants, 6,526 (25%) younger patients (age 18–64 years) were more often male (63 vs. 51%; <i>p</i> < 0.001), born in Australia (70 vs. 63%; <i>p</i> < 0.001), more often discharged home from acute care (56 vs. 38%; <i>p</i> < 0.001), and less likely to receive antihypertensive medication (61 vs. 73%; <i>p</i> < 0.001). Younger patients had a 74% greater odds of having lower HRQoL compared to an equivalent aged-matched general population (adjusted OR 1.74, 95% CI 1.56–1.93, <i>p</i> < 0.001). <b><i>Conclusions:</i></b><i></i> Younger stroke patients exhibited distinct differences from their older counterparts with respect to demographic and clinical characteristics, prescription of antihypertensive medications and residual health status

Insights into accuracy of social scientists' forecasts of societal change

How well can social scientists predict societal change, and what processes underlie their predictions? To answer these questions, we ran two forecasting tournaments testing accuracy of predictions of societal change in domains commonly studied in the social sciences: ideological preferences, political polarization, life satisfaction, sentiment on social media, and gender-career and racial bias. Following provision of historical trend data on the domain, social scientists submitted pre-registered monthly forecasts for a year (Tournament 1; N=86 teams/359 forecasts), with an opportunity to update forecasts based on new data six months later (Tournament 2; N=120 teams/546 forecasts). Benchmarking forecasting accuracy revealed that social scientists’ forecasts were on average no more accurate than simple statistical models (historical means, random walk, or linear regressions) or the aggregate forecasts of a sample from the general public (N=802). However, scientists were more accurate if they had scientific expertise in a prediction domain, were interdisciplinary, used simpler models, and based predictions on prior data