Clinical guideline adherence by physiotherapists working in acute stroke care.

The publication of the Irish Clinical Guidelines for Stroke in 2009 provided healthcare professionals with an essential tool for improving stroke services. The aim of this study was to identify the degree to which Senior Physiotherapists in acute stroke care adhered to the Irish Clinical Guidelines for Stroke. This was a cross-sectional study, a postal or online survey was distributed to 31 Senior Physiotherapists working in acute stroke care, 23 responded, achieving a 74% response rate. There was excellent compliance with guidelines for the completion and documentation of full assessment within 5 working days of admission 19 respondents (82.6%), and the involvement of the patient in goal setting 19 (82.6%). Poor compliance was reported in relation to the provision of early assessment 10 (43.5%) and adequate rehabilitation intensity 9 (39%). The main barriers to compliance in these areas were organisational in nature.</p

The experience of recurrent fallers in the first year after stroke

Purpose: Understanding the experiences of fallers after stroke could inform falls-prevention interventions, which have not yet shown effectiveness in this population. The aim of this study was to explore the experience of recurrent fallers post-stroke in relation to recovery and living with falls. Methods: Participants who had more than one fall in the first year after stroke were identified from a prospective cohort study. The methods of grounded theory informed data collection and analysis. Semi-structured interviews were conducted, audio-recorded and transcribed. Coding was conducted and categories were developed inductively. Results: Nine stroke survivors aged 53-85 were interviewed 18-22 months post-discharge. Participants had experienced between 2 and 9 falls and one participant suffered a fracture. Three inter-linked categories were identified: (i) Judging the importance of falls by exploring cause and consequence, (ii) getting back up, and (iii) being careful. Conclusions: Stroke survivors' assessment of their own falls-risk and their individual priorities contribute to their decisions around activity participation. "Being careful" could be described as a form of self-managing falls-risk. The inclusion of self-management principles, peer-educators, and education to rise from the floor in falls-management programmes warrants investigation. Not all falls were considered equally important by participants. This could be considered when defining falls-related outcomes. Implications for Rehabilitation Healthcare professionals may be able to offer an increased sense of control to stroke survivors through education about how to avoid particular causes and consequences of falls. Falls-related advice should be specific, relevant to the individual, and respectful of their sense of identity. Being able to rise from the floor appears to be important for coping with falls and falls-risk. Professionals should be cognisant of the potential differences of opinion between stroke survivors and their families around management of falls-risk.</p

Falls related EvEnts in the first year after StrokE in Ireland: results of the multi-centre prospective FREESE cohort study

Introduction: Falls are common post-stroke adverse events. This study aimed to describe the first-year falls incidence, circumstances and consequences among persons discharged home after stroke in Ireland, and to examine the association between potential risk factors and recurrent falls. Patients and Methods: Patients with acute stroke and planned home-discharge were recruited consecutively from five hospitals. Variables recorded pre-discharge included: age, stroke severity, comorbidities, fall history, prescribed medications, hemi-neglect, cognition, and functional independence (Barthel Index). Falls were recorded with monthly diaries, and six and 12-month interviews. The association of pre-discharge factors with recurrent falls (>1 fall) was examined using univariable logistic regression. Results: 128 participants (mean age=68.6, SD=13.3) were recruited. 110 completed 12-month follow-up. The first-year falls-incidence was 44.5% (95%CI=35.1-53.6) with 25.6% falling repeatedly (95%CI=18.5- 34.4). Fallers experienced 1-18 falls (median=2) and five reported fractures. 47% of fallers experienced at least one fall outdoors. Only 10% of recurrent fallers had bone health medication prescribed at discharge. Lower Barthel Index scores (<75/100, RR=4.38, 1.64-11.72) and psychotropic medication prescription (RR=2.10, 1.13-3.91) were associated with recurrent falls. Discussion: This study presents prospectively collected information about falls circumstances. It was not powered for multivariable analysis of risk factors. Conclusion: One quarter of stroke survivors discharged to the community fall repeatedly and mostly indoors in the first year. Specific attention may be required for individuals with poor functional independence or those on psychotropic medication. Future falls-management research in this population should explore falls in younger individuals, outdoor as well as indoor falls and post-stroke bone health status

First year post-stroke healthcare costs and fall-status among those discharged to the community

  Introduction: Falls are common post-stroke events but their relationship with healthcare costs is unclear. The aim of this study was to examine the relationship between healthcare costs in the first year after stroke and falls among survivors discharged to the community. Patients and methods: Survivors of acute stroke with planned home discharges from five large hospitals in Ireland were recruited. Falls and healthcare utilisation data were recorded using inpatient records, monthly calendars and post-discharge interviews. Cost of stroke was estimated for each participant from hospital admission for one year. The association of fall-status with overall cost was tested with multivariable linear regression analysis adjusting for pre-stroke function, stroke severity, age and living situation. Results: A total of 109 stroke survivors with complete follow-up data (mean age = 68.5 years (SD = 13.5 years)) were included. Fifty-three participants (49%) fell following stroke, of whom 28 (26%) had recurrent falls. Estimated mean total healthcare cost was €20,244 (SD=€23,456). The experience of one fall and recurrent falls was independently associated with higher costs of care (p = 0.02 and p Discussion: The observed relationship between falls and cost is likely to be underestimated as aids and adaptions, productivity losses, and nursing home care were not included. Conclusion: This study points at differences across fall-status in several healthcare costs categories, namely the index admission, secondary/tertiary care (including inpatient re-admissions) and allied healthcare. Future research could compare the cost-effectiveness of inpatient versus community-based fall-prevention after stroke. Further studies are also required to inform post-stroke bone-health management and fracture-risk reduction.</p

First year post-stroke healthcare costs and fall-status among those discharged in the community

Introduction: Falls are common post-stroke events but their relationship with healthcare costs is unclear. The aim of this study was to examine the relationship between healthcare costs in the first year after stroke and falls among survivors discharged to the community. Patients and Methods: Survivors of acute stroke with planned home-discharges from five large hospitals in Ireland were recruited. Falls and healthcare utilisation data were recorded using inpatient records, monthly calendars and post-discharge interviews. Cost of stroke was estimated for each participant from hospital admission for one year. The association of fall-status with overall cost was tested with multivariable linear regression analysis adjusting for pre-stroke function, stroke severity, age and living situation. Results: 109 stroke survivors with complete follow-up data (mean age=68.5 years (SD=13.5 years)) were included. 53 participants (49%) fell following stroke, of whom 28 (26%) had recurrent falls. Estimated mean total healthcare cost was €20,244 (SD=€23,456). The experience of one fall and recurrent falls was independently associated with higher costs of care (p=0.02 and p<0.01, respectively). Discussion: The observed relationship between falls and cost is likely to be underestimated as aids and adaptions, productivity losses, and nursing home care were not included. Conclusion: This study points at differences across fall-status in several healthcare costs categories, namely the index admission, secondary/ tertiary care (including inpatient re-admissions) and allied health care. Future research could compare the cost-effectiveness of inpatient versus communitybased fall-prevention after stroke. Further studies are also required to inform post-stroke bone-health management and fracture-risk reduction

Validation of two risk-prediction models for recurrent falls in the first year after stroke: a prospective cohort study

Background: Several multivariable models have been derived to predict post-stroke falls. These require validation before integration into clinical practice. The aim of this study was to externally validate two prediction models for recurrent falls in the first year post-stroke using an Irish prospective cohort study. Methodology: Stroke patients with planned home-discharges from five hospitals were recruited. Falls were recorded with monthly diaries and interviews six and 12 months post-discharge. Predictors for falls included in two risk-prediction models were assessed at discharge. Participants were classified into risk-groups using these models. Model 1, incorporating inpatient falls-history and balance, had a six-month outcome. Model 2, incorporating inpatient near-falls history and upper limb function, had a twelve-month outcome. Measures of calibration, discrimination (area under the curve (AUC)) and clinical utility (sensitivity/ specificity) were calculated. Results: 128 participants (mean age=68.6 years, SD=13.3) were recruited. The fall status of 117 and 110 participants was available at six and 12 months respectively. Seventeen and 28 participants experienced recurrent falls by these respective timepoints. Model 1 achieved an AUC=0.56 (95% CI 0.46–0.67), sensitivity=18.8% and specificity=93.6%. Model 2 achieved AUC=0.55 (95% CI 0.44–0.66), sensitivity=51.9% and specificity=58.7%. Model 1 showed no significant difference between predicted and observed events (Risk Ratio (RR)=0.87, 95% CI 0.16–4.62). In contrast, model 2 significantly over-predicted fall events in the validation cohort (RR=1.61, 95% CI 1.04–2.48). Conclusions: Both models showed poor discrimination for predicting recurrent falls. A further large prospective cohort study would be required to derive a clinicallyuseful falls-risk prediction model for a similar population

Supplemental material for First year post-stroke healthcare costs and fall-status among those discharged to the community

<p>Supplemental material for First year post-stroke healthcare costs and fall-status among those discharged to the community by Mary E Walsh, Jan Sorensen, Rose Galvin, David JP Williams, Joseph A Harbison, Sean Murphy, Ronan Collins, Dominick JH McCabe, Morgan Crowe and N Frances Horgan: Central Statistics Office in European Stroke Journal</p