Increasing delivery of an outdoor journey intervention to people with stroke: A feasibility study involving five community rehabilitation teams

<p>Abstract</p> <p>Background</p> <p>Contrary to recommendations in a national clinical guideline, baseline audits from five community-based stroke rehabilitation teams demonstrated an evidence-practice gap; only 17% of eligible people with stroke were receiving targeted rehabilitation by occupational therapists and physiotherapists to increase outdoor journeys. The primary aim of this feasibility study was to design, test, and evaluate the impact of an implementation program intended to change the behaviour of community rehabilitation teams. A secondary aim was to measure the impact of this change on client outcomes.</p> <p>Methods</p> <p>A before-and-after study design was used. The primary data collection method was a medical record audit. Five community rehabilitation teams and a total of 12 professionals were recruited, including occupational therapists, physiotherapists, and a therapy assistant. A medical record audit was conducted twice over 12 months (total of 77 records pre-intervention, 53 records post-intervention) against a guideline recommendation about delivering outdoor journey sessions to people with stroke. A behavioural intervention (the 'Out-and-About Implementation Program') was used to help change team practice. Active components of the intervention included feedback about the audit, barrier identification, and tailored education to target known barriers. The primary outcome measure was the proportion of medical records containing evidence of multiple outdoor journey sessions. Other outcomes of interest included the proportion of medical records that contained evidence of screening for outdoor journeys and driving by team members, and changes in patient outcomes. A small sample of community-dwelling people with stroke (n = 23) provided pre-post outcome data over three months. Data were analysed using descriptive statistics and t-tests.</p> <p>Results</p> <p>Medical record audits found that teams were delivering six or more outdoor journeys to 17% of people with stroke pre-intervention, rising to 32% by 12 months post-intervention. This change represents a modest increase in practice behaviour (15%) across teams. More people with stroke (57%) reported getting out of the house as often as they wanted after receiving the outdoor journey intervention compared to 35% one year earlier; other quality of life outcomes also improved.</p> <p>Conclusions</p> <p>The 'Out-and-About Implementation Program' helped rehabilitation teams to change their practice, implement evidence, and improve client outcomes. This behavioural intervention requires more rigorous evaluation using a cluster randomised trial design.</p

Compliance with Australian stroke guideline recommendations for outdoor mobility and transport training by post-inpatient rehabilitation services: an observational cohort study

Background: Community participation is often restricted after stroke, due to reduced confidence and outdoor mobility. Australian clinical guidelines recommend that specific evidence-based interventions be delivered to target these restrictions, such as multiple escorted outdoor journeys. The aim of this study was to describe post-inpatient outdoor mobility and transport training delivered to stroke survivors in New South Wales, Australia and whether therapy differed according to type, sector or location of service provider. Methods: Using an observational retrospective cohort study design, 24 rehabilitation service providers were audited. Provider types included outpatient (n = 8), day therapy (n = 9), home-based rehabilitation (n = 5) and transitional aged care services (TAC, n = 2). Records of 15 stroke survivors who had received post-hospital rehabilitation were audited per service, for wait time, duration, amount of therapy and outdoor-related therapy. Results: A total of 311 records were audited. Median wait time for post-hospital therapy was 13 days (IQR, 5–35). Median duration of therapy was 68 days (IQR, 35–109), consisting of 11 sessions (IQR 4–19). Overall, a median of one session (IQR 0–3) was conducted outdoors per person. Outdoor-related therapy was similar across service providers,except that TAC delivered an average of 5.4 more outdoor-related sessions (95 % CI 4.4 to 6.4), and 3.5 more outings into public streets (95 % CI 2.8 to 4.3) per person, compared to outpatient services. Conclusion: The majority of service providers in the sample delivered little evidence-based outdoor mobility and travel training per stroke participant, as recommended in national stroke guidelines

Searches and content of the OTseeker database: Informing research priorities

BACKGROUND. A strategic and prioritized approach to occupational therapy research is needed, particularly given the limited research funding available. Comparing occupational therapists' information needs with the research evidence available can potentially inform research debate within the profession. This study aimed to identify research topics most often sought by users of the OTseeker database and to compare these with the quantity of topics available in the database. METHOD. A random sample of keyword search terms submitted to OTseeker (n = 4,500) was coded according to diagnostic and intervention categories, and compared with the amount of research contained in OTseeker in 2004. RESULTS. Most frequently sought topics were relevant to the diagnostic categories of pediatric conditions (19%), neurology and neuromuscular disorders (17%), and mental health (17%). Most frequently sought intervention topics included modes of service delivery, sensory interventions, and physical modalities. Although many frequently sought topics had a correspondingly high volume of research in OTseeker, a few areas had very little content (e.g., fine motor skill acquisition, autistic spectrum disorder). This information is offered to inform discussions about research priorities and resource allocation for research within occupational therapy

Digitally enabled aged care and neurological rehabilitation to enhance outcomes with Activity and MObility UsiNg Technology (AMOUNT) in Australia: A randomised controlled trial

Background: Digitally enabled rehabilitation may lead to better outcomes but has not been tested in large pragmatic trials. We aimed to evaluate a tailored prescription of affordable digital devices in addition to usual care for people with mobility limitations admitted to aged care and neurological rehabilitation. Methods and findings: We conducted a pragmatic, outcome-assessor-blinded, parallel-group randomised trial in 3 Australian hospitals in Sydney and Adelaide recruiting adults 18 to 101 years old with mobility limitations undertaking aged care and neurological inpatient rehabilitation. Both the intervention and control groups received usual multidisciplinary inpatient and post-hospital rehabilitation care as determined by the treating rehabilitation clinicians. In addition to usual care, the intervention group used devices to target mobility and physical activity problems, individually prescribed by a physiotherapist according to an intervention protocol, including virtual reality video games, activity monitors, and handheld computer devices for 6 months in hospital and at home. Co-primary outcomes were mobility (performance-based Short Physical Performance Battery [SPPB]; continuous version; range 0 to 3; higher score indicates better mobility) and upright time as a proxy measure of physical activity (proportion of the day upright measured with activPAL) at 6 months. The dataset was analysed using intention-to-treat principles. The trial was prospectively registered with the Australian New Zealand Clinical Trials Registry (ACTRN12614000936628). Between 22 September 2014 and 10 November 2016, 300 patients (mean age 74 years, SD 14; 50% female; 54% neurological condition causing activity limitation) were randomly assigned to intervention (n = 149) or control (n = 151) using a secure online database (REDCap) to achieve allocation concealment. Six-month assessments were completed by 258 participants (129 intervention, 129 control). Intervention participants received on average 12 (SD 11) supervised inpatient sessions using 4 (SD 1) different devices and 15 (SD 5) physiotherapy contacts supporting device use after hospital discharge. Changes in mobility scores were higher in the intervention group compared to the control group from baseline (SPPB [continuous, 0–3] mean [SD]: intervention group, 1.5 [0.7]; control group, 1.5 [0.8]) to 6 months (SPPB [continuous, 0–3] mean [SD]: intervention group, 2.3 [0.6]; control group, 2.1 [0.8]; mean between-group difference 0.2 points, 95% CI 0.1 to 0.3; p = 0.006). However, there was no evidence of a difference between groups for upright time at 6 months (mean [SD] proportion of the day spent upright at 6 months: intervention group, 18.2 [9.8]; control group, 18.4 [10.2]; mean between-group difference −0.2, 95% CI −2.7 to 2.3; p = 0.87). Scores were higher in the intervention group compared to the control group across most secondary mobility outcomes, but there was no evidence of a difference between groups for most other secondary outcomes including self-reported balance confidence and quality of life. No adverse events were reported in the intervention group. Thirteen participants died while in the trial (intervention group: 9; control group: 4) due to unrelated causes, and there was no evidence of a difference between groups in fall rates (unadjusted incidence rate ratio 1.19, 95% CI 0.78 to 1.83; p = 0.43). Study limitations include 15%–19% loss to follow-up at 6 months on the co-primary outcomes, as anticipated; the number of secondary outcome measures in our trial, which may increase the risk of a type I error; and potential low statistical power to demonstrate significant between-group differences on important secondary patient-reported outcomes. Conclusions: In this study, we observed improved mobility in people with a wide range of health conditions making use of digitally enabled rehabilitation, whereas time spent upright was not impacted. Trial registration: The trial was prospectively registered with the Australian New Zealand Clinical Trials Register; ACTRN1261400093662

Feasibility and results of a randomised pilot-study of pre-discharge occupational therapy home visits

BACKGROUND: Pre-discharge home visits aim to maximise independence in the community. These visits involve assessment of a person in their own home prior to discharge from hospital, typically by an occupational therapist. The therapist may provide equipment, adapt the home environment and/or provide education. The aims of this study were to investigate the feasibility of a randomised controlled trial in a clinical setting and the effect of pre-discharge home visits on functional performance in older people undergoing rehabilitation. METHODS: Ten patients participating in an inpatient rehabilitation program were randomly assigned to receive either a pre-discharge home visit (intervention), or standard practice in-hospital assessment and education (control), both conducted by an occupational therapist. The pre-discharge home visit involved assessment of the older person's function and environment, and education, and took an average of 1.5 hours. The hospital-based interview took an average of 40 minutes. Outcome data were collected by a blinded assessor at 0, 2, 4, 8 and 12 weeks. Outcomes included performance of activities of daily living, reintegration to community living, quality of life, readmission and fall rates. RESULTS: Recruitment of 10 participants was slow and took three months. Observed performance of functional abilities did not differ between groups due to the small sample size. Difference in activities of daily living participation, as recorded by the Nottingham Extended Activities of Daily Living scale, was statistically significant but wide confidence intervals and low statistical power limit interpretation of results. CONCLUSION: Evaluation of pre-discharge home visits by occupational therapists in a rehabilitation setting is feasible, but a more effective recruitment strategy for a main study is favored by application of a multi-centre setting

Market-dependent production set

A country’s production possibility frontier or PPF is defined as the boundary of its economy’s production set in the net output space for a given technology and fixed quantities of primary factors of production. In general equilibrium theory, exogenous changes in technology or primary-factor supplies alter equilibrium prices; however, government-policy induced domestic relative commodity price changes do not alter the shape of an economy’s production set. We show that, under international capital mobility, which is empirically significant, the shape of a country’s production set does, in fact, depend on market forces and this shape can be manipulated by government policy

Increasing response rates to lifestyle surveys: a review of methodology and 'good practice'.

Background Lifestyle surveys are traditionally used for collecting detailed population information about individual behaviours that impact on health. However, declining response rates and the under-representation of certain population groups in lifestyle survey data has led to uncertainty over the accuracy of any findings. In order to maximise response rates, a mixed-methods approach is now recommended. This review was carried out in order to examine the methodological literature related to the administration of lifestyle surveys and the implications for response rates. It was envisaged that the results of this review could provide a valuable resource for those involved in undertaking lifestyle surveys. Methods A review of the empirical evidence and published literature on the methodological considerations associated with administration of lifestyle surveys, specifically in relation to maximising response rates, was carried out. A search for ‘grey literature’ was also conducted using the internet, and citation tracking was performed on all retrieved articles. A request for examples of relevant lifestyle survey work, particularly those incorporating mixed-methods designs and/or strategies to increase response rates, was distributed to several Primary Care Trusts (PCTs) across England. The responses are illustrated as ‘good practice’ case studies. Results The postal questionnaire remains an important lifestyle survey tool, but response rates have decreased rapidly in recent years. Interviews and telephone surveys are recommended in order to supplement data from postal questionnaires to overcome any literacy and language barriers. These approaches are advocated to increase response rates in some population groups, but costs may be prohibitive. Electronic surveys are a cheaper alternative, but the evidence seems to suggest that the use of the internet does not appear to increase overall response rates to surveys. Evidence on the use of incentives suggests they can be effective at increasing response rates, but only if their use is tailored to the design of the survey and to the characteristics of target populations. Conclusions The empirical evidence was not robust enough to make definitive recommendations, but information from the published literature, along with examples of ‘good practice’ in lifestyle survey work suggests that supplementing, or offering different survey modes, alongside targeted maximisation strategies can increase coverage and also, with careful planning, can prove to be cost-effective

Effectiveness of interventions to improve the uptake of immunisation in primary care, with specific focus on Mumps, Measles and Rubella (MMR)

Background: There has been a decade of MMR vaccine uptake which is below the threshold for herd immunity for measles and large numbers of children are unprotected. The number of measles cases in England is now rising (DH, 2008). The Department of Health has issued a letter about the urgent action needed to reduce the risk of a measles epidemic. PCTs are following DH guidance in conducting MMR catch up programmes to increase uptake to 95% to gain herd immunity for the population, as well as increasing the overall immunisation coverage. Objectives: We carried out a rapid review of published studies to assess the evidence of the effectiveness of interventions to promote uptake of immunisation, with a particular emphasis on MMR. We also included studies which assessed healthcare professionals’ issues relating to immunisation and studies which examined parents’ concerns and issues that influenced decision making associated with vaccination

Healthy Halifax Lifestyle Survey

Background For the period 2009 to 2011, NHS Calderdale, in partnership with Calderdale Metropolitan Borough Council, was awarded £2 million for ‘Healthy Halifax’ as part of the UK government’s Healthy Towns Programme. The overall aim of 'Healthy Halifax' was to target initiatives on facilitating healthier lifestyles in local populations living in four Calderdale wards with the greatest health inequalities and poorest health outcomes. As part of understanding 'what works' and how best to meet the health needs of these target populations, a lifestyle survey was undertaken across the four wards. Method The Healthy Halifax lifestyle survey was designed and distributed based on the most up-to-date evidence-based recommendations, and sought to elicit population data on health-related attitudes and behaviours, physical activity, diet, alcohol consumption, smoking, and perceptions of community. Demographic and anthropometric information was also collected. Surveys were distributed in two phases, March to May 2011 and October to November 2011. A random sample of postcodes from the target wards was generated using a Royal Mail address database, and survey booklets were distributed to all domestic addresses within each randomly selected postcode. The main method of survey distribution was door-to-door, either conducted by a bilingual member of the community to overcome language and/or literacy barriers, or by a trained interviewer familiar with the local area. The target response rate was 250 completed surveys per ward, and following completion of Phase 1, under-represented groups based on gender, ethnicity and age (working age or retired) were identified by comparison of respondents with ward profile proportions, and a target quota sample was calculated. In Phase 2, target respondents were identified on-street or door-to-door by a market research team, and the surveys were completed using face-to-face Interview methods. Results The Healthy Halifax lifestyle survey sample (n=1339) was found to be representative of the target wards when compared with ward profile demographics. This resulted in an accurate and rich source of health data collected from traditionally under-represented, hard to reach groups. Findings suggest that poor health behaviours constitute predominant social norms within these wards, but differences in health behaviours were observed both within and between the target wards, indicating that generalised area interventions informed by local and national policy may not be accurate (and therefore not effective) as they do not reflect the complexities of individual populations. However, findings also suggest that there is clear potential to invest and build on existing community assets in order to increase social capital and create more sustainable changes in order to reduce health inequalities. Conclusions Findings from the Healthy Halifax lifestyle survey appear to recommend a bottom-up community development approach alongside a top-down commissioner approach to target resources where they are most needed. More detailed, longitudinal research and evaluation within target populations is needed in order to increase knowledge of health behaviours and attitudes in such communities and measure changes over time