Using audit and feedback to increase clinician adherence to clinical practice guidelines in brain injury rehabilitation: v

ObjectiveThis study evaluated whether frequent (fortnightly) audit and feedback cycles over a sustained period of time (>12 months) increased clinician adherence to recommended guidelines in acquired brain injury rehabilitation.DesignA before and after study design.SettingA metropolitan inpatient brain injury rehabilitation unit.ParticipantsClinicians; medical, nursing and allied health staff.InterventionsFortnightly cycles of audit and feedback for 14 months. Each fortnight, medical file and observational audits were completed against 114 clinical indicators.Main outcome measureAdherence to guideline indicators before and after intervention, calculated by proportions, Mann-Whitney U and Chi square analysis.ResultsClinical and statistical significant improvements in median clinical indicator adherence were found immediately following the audit and feedback program from 38.8% (95% CI 34.3 to 44.4) to 83.6% (95% CI 81.8 to 88.5). Three months after cessation of the intervention, median adherence had decreased from 82.3% to 76.6% (95% CI 72.7 to 83.3, pConclusionA fortnightly audit and feedback program increased clinicians’ adherence to guideline recommendations in an inpatient acquired brain injury rehabilitation setting. We propose future studies build on the evidence-based method used in the present study to determine effectiveness and develop an implementation toolkit for scale-up.</div

Telerehabilitation services for stroke

Publisher version made available in accordance with the publisher's policy. This item is under embargo for a period of 12 months from the date of publication, in accordance with the publisher's policy. 'This review is published as a Cochrane Review in the Cochrane Database of Systematic Reviews 2013, Issue 12. Cochrane Reviews are regularly updated as new evidence emerges and in response to comments and criticisms, and the Cochrane Database of Systematic Reviews should be consulted for the most recent version of the Review.’Background Telerehabilitation is an alternative way of delivering rehabilitation services. Information and communication technologies are used to facilitate communication between the healthcare professional and the patient in a remote location. The use of telerehabilitation is becoming more viable as the speed and sophistication of communication technologies improve. However, it is currently unclear how effective this model of delivery is relative to rehabilitation delivered face-to-face. Objectives To determine whether the use of telerehabilitation leads to improved ability to perform activities of daily living amongst stroke survivors when compared with (1) in-person rehabilitation (when the clinician and the patient are at the same physical location and rehabilitation is provided face-to-face); or (2) no rehabilitation. Secondary objectives were to determine whether use of telerehabilitation leads to greater independence in self care and domestic life and improved mobility, health-related quality of life, upper limb function, cognitive function or functional communication when compared with in-person rehabilitation and no rehabilitation. Additionally, we aimed to report on the presence of adverse events, cost-effectiveness, feasibility and levels of user satisfaction associated with telerehabilitation interventions. Search methods We searched the Cochrane Stroke Group Trials Register (November 2012), the Cochrane Effective Practice and Organization of Care Group Trials Register (November 2012), the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 11, 2012), MEDLINE (1950 to November 2012), EMBASE (1980 to November 2012) and eight additional databases. We searched trial registries, conference proceedings and reference lists. Selection criteria Randomised controlled trials (RCTs) of telerehabilitation in stroke. We included studies that compared telerehabilitation with in-person rehabilitation or no rehabilitation. In addition, we synthesised and described the results of RCTs that compared two different methods of delivering telerehabilitation services without an alternative group. We included rehabilitation programmes that used a combination of telerehabilitation and in-person rehabilitation provided that the greater proportion of intervention was provided via telerehabilitation. Data collection and analysis Two review authors independently identified trials on the basis of prespecified inclusion criteria, extracted data and assessed risk of bias. A third review author moderated any disagreements. The review authors contacted investigators to ask for missing information. Main results We included in the review 10 trials involving a total of 933 participants. The studies were generally small, and reporting quality was often inadequate, particularly in relation to blinding of outcome assessors and concealment of allocation. Selective outcome reporting was apparent in several studies. Study interventions and comparisons varied, meaning that in most cases, it was inappropriate to pool studies. Intervention approaches included upper limb training, lower limb and mobility retraining, case management and caregiver support. Most studies were conducted with people in the chronic phase following stroke. Primary outcome: no statistically significant results for independence in activities of daily living (based on two studies with 661 participants) were noted when a case management intervention was evaluated. Secondary outcomes: no statistically significant results for upper limb function (based on two studies with 46 participants) were observed when a computer programme was used to remotely retrain upper limb function. Evidence was insufficient to draw conclusions on the effects of the intervention on mobility, health-related quality of life or participant satisfaction with the intervention. No studies evaluated the cost-effectiveness of telerehabilitation. No studies reported on the occurrence of adverse events within the studies. Authors' conclusions We found insufficient evidence to reach conclusions about the effectiveness of telerehabilitation after stroke. Moreover, we were unable to find any randomised trials that included an evaluation of cost-effectiveness. Which intervention approaches are most appropriately adapted to a telerehabilitation approach remain unclear, as does the best way to utilise this approach

A systematic review of measures of adherence to physical exercise recommendations in people with stroke

© The Author(s) 2018 Creative Commons Attribution-NonCommercial 4.0 International (CC BY-NC 4.0)Objective: To review methods for measuring adherence to exercise or physical activity practice recommendations in the stroke population and evaluate measurement properties of identified tools. Data sources: Two systematic searches were conducted in eight databases (MEDLINE, CINAHL, PsycINFO, Cochrane Library of Systematic Reviews, Sports Discus, PEDro, PubMed and EMBASE). Phase 1 was conducted to identify measures. Phase 2 was conducted to identify studies investigating properties of these measures. Review methods: Phase 1 articles were selected if they were published in English, included participants with stroke, quantified adherence to exercise or physical activity recommendations, were patient or clinician reported, were defined and reproducible measures and included patients >18 years old. In phase 2, articles were included if they explored psychometric properties of the identified tools. Included articles were screened based on title/abstract and full-text review by two independent reviewers. Results: In phase 1, seven methods of adherence measurement were identified, including logbooks (n = 16), diaries (n = 18), ‘record of practice’ (n = 3), journals (n = 1), surveys (n = 2) and questionnaires (n = 4). One measurement tool was identified, the Physical Activity Scale for Individuals with Physical Disabilities (n = 4). In phase 2, no eligible studies were identified. Conclusion: There is not a consistent measure of adherence that is currently utilized. Diaries and logbooks are the most frequently utilized tools

Activity, participation, and goal awareness after acquired brain injury : A prospective observational study of inpatient rehabilitation

Objective To examine the frequency and timing of inpatient engagement in meaningful activities within rehabilitation (within and outside of structured therapy times) and determine the associations between activity type, goal awareness, and patient affect. Methods This prospective observational study performed behavioral mapping in a 42-bed inpatient brain injury rehabilitation unit by recording patient activity every 15 minutes (total 42 hours). The participants were randomly selected rehabilitation inpatients with acquired brain injury; all completed the study. The main outcome measures included patient demographics, observation of activity, participation, goal awareness, and affect. Results The inpatients spent 61% of the therapeutic day (8:30 to 16:30) in their single room and were alone 49% of the time. They were physically socially inactive for 76% and 74% of their awake time, respectively, with neutral affect observed for about half of this time. Goal-related activities were recorded for only 25% of the inpatients’ awake time. The odds of physical activity were 10.3-fold higher among in patients receiving support to address their goals within their rehabilitation program (odds ratio=10.3; 95% confidence interval, 5.02–21.16). Conclusion Inpatients in a mixed brain injury rehabilitation unit spent a large amount of their awake hours inactive and only participated in goal-related activities for a quarter of their awake time. Rehabilitation models that increase opportunities for physical, cognitive, and social activities outside of allied health sessions are recommended to increase overall activity levels during inpatient rehabilitation

Predicting fitness-to-drive following stroke using the Occupational Therapy – Driver Off Road Assessment Battery

Introduction: It is difficult to determine if, or when, individuals with stroke are ready to undergo on-road fitness-to-drive assessment. The Occupational Therapy - Driver Off Road Assessment Battery was developed to determine client suitability to resume driving. The predictive validity of the Battery needs to be verified for people with stroke. Aim: Examine the predictive validity of the Occupational Therapy - Driver Off Road Assessment Battery for on-road performance among people with stroke. Method: Off-road data were collected from 148 people post stroke on the Battery and the outcome of their on-road assessment was recorded as: fit-to-drive or not fit-to-drive. Results: The majority of participants (76%) were able to resume driving. A classification and regression tree (CART) analysis using four subtests (three cognitive and one physical) from the Battery demonstrated an area under the curve (AUC) of 0.8311. Using a threshold of 0.5, the model correctly predicted 98/112 fit-to-drive (87.5%) and 26/36 people not fit-to-drive (72.2%). Conclusion: The three cognitive subtests from the Occupational Therapy - Driver Off Road Assessment Battery and potentially one of the physical tests have good predictive validity for client fitness-to-drive. These tests can be used to screen client suitability for proceeding to an on-road test following stroke. Implications for Rehabilitation: Following stroke, drivers should be counseled (including consideration of local legislation) concerning return to driving. The Occupational Therapy - Driver Off Road Assessment Battery can be used in the clinic to screen people for suitability to undertake on road assessment. Scores on four of the Occupational Therapy - Driver Off Road Assessment Battery subtests are predictive of resumption of driving following stroke

A tailored occupational therapist-led vocational intervention for people with stroke: Protocol for a pilot randomized controlled trial

Background: Resuming work after stroke is a common goal of working-age adults, yet there are few vocational rehabilitation programs designed to address the unique challenges faced following stroke. The Work intervention was developed to address these gaps. Objective: This paper presents a protocol that outlines the steps that will be undertaken to pilot both the intervention and trial processes for the Work trial. Methods: The Work trial is a 2-arm, prospective, randomized, blinded-assessor study with intention-to-treat analysis. A total of 54 adults of working age who have experienced a stroke \u3c4 months prior will be randomized 1:1 to either (1) an experimental group who will receive a 12-week early vocational intervention (Work intervention) plus usual clinical rehabilitation or (2) a control group who will receive only their usual clinical rehabilitation. Results: Outcomes include study and intervention feasibility and intervention benefit. In addition to evaluating the feasibility of delivering vocational intervention early after stroke, benefit will be assessed by measuring rates of vocational participation and quality-of-life improvements at the 3- and 6-month follow-ups. Process evaluation using data collected during the study, as well as postintervention individual interviews with participants and surveys with trial therapists, will complement quantitative data. Conclusions: The results of the trial will provide details on the feasibility of delivering the Work intervention embedded within the clinical rehabilitation context and inform future trial processes. Pilot data will enable a future definitive trial to determine the clinical effectiveness of vocational rehabilitation when delivered in the early subacute phase of stroke recovery

Organising health care services for people with an acquired brain injury: an overview of systematic reviews and randomised controlled trials

This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.Background Acquired brain injury (ABI) is the leading cause of disability worldwide yet there is little information regarding the most effective way to organise ABI health care services. The aim of this review was to identify the most up-to-date high quality evidence to answer specific questions regarding the organisation of health care services for people with an ABI. Methods We conducted a systematic review of English papers using MEDLINE, EMBASE, PsycINFO, CINAHL and the Cochrane Library. We included the most recently published high quality systematic reviews and any randomised controlled trials, non-randomised controlled trials, controlled before after studies or interrupted time series studies published subsequent to the systematic review. We searched for papers that evaluated pre-defined organisational interventions for adults with an ABI. Organisational interventions of interest included fee-for-service care, integrated care, integrated care pathways, continuity of care, consumer engagement in governance and quality monitoring interventions. Data extraction and appraisal of included reviews and studies was completed independently by two reviewers. Results A total of five systematic reviews and 21 studies were included in the review; eight of the papers (31%) included people with a traumatic brain injury (TBI) or ABI and the remaining papers (69%) included only participants with a diagnosis of stroke. We found evidence supporting the use of integrated care to improve functional outcome and reduce length of stay and evidence supporting early supported discharge teams for reducing morbidity and mortality and reducing length of stay for stroke survivors. There was little evidence to support case management or the use of integrated care pathways for people with ABI. We found evidence that a quality monitoring intervention can lead to improvements in process outcomes in acute and rehabilitation settings. We were unable to find any studies meeting our inclusion criteria regarding fee-for-service care or engaging consumers in the governance of the health care organisation. Conclusions The review found evidence to support integrated care, early supported discharge and quality monitoring interventions however, this evidence was based on studies conducted with people following stroke and may not be appropriate for all people with an ABI

Implementation interventions to promote the uptake of evidence-based practices in stroke rehabilitation (Review)

Background Rehabilitation based upon research evidence gives stroke survivors the best chance of recovery. There is substantial research to guide practice in stroke rehabilitation, yet uptake of evidence by healthcare professionals is typically slow and patients often do not receive evidence‐based care. Implementation interventions are an important means to translate knowledge from research to practice and thus optimise the care and outcomes for stroke survivors. A synthesis of research evidence is required to guide the selection and use of implementation interventions in stroke rehabilitation. Objectives To assess the effects of implementation interventions to promote the uptake of evidence‐based practices (including clinical assessments and treatments recommended in evidence‐based guidelines) in stroke rehabilitation and to assess the effects of implementation interventions tailored to address identified barriers to change compared to non‐tailored interventions in stroke rehabilitation. Search methods We searched CENTRAL, MEDLINE, Embase, and eight other databases to 17 October 2019. We searched OpenGrey, performed citation tracking and reference checking for included studies and contacted authors of included studies to obtain further information and identify potentially relevant studies. Selection criteria We included individual and cluster randomised trials, non‐randomised trials, interrupted time series studies and controlled before‐after studies comparing an implementation intervention to no intervention or to another implementation approach in stroke rehabilitation. Participants were qualified healthcare professionals working in stroke rehabilitation and the patients they cared for. Studies were considered for inclusion regardless of date, language or publication status. Main outcomes were healthcare professional adherence to recommended treatment, patient adherence to recommended treatment, patient health status and well‐being, healthcare professional intention and satisfaction, resource use outcomes and adverse effects. Data collection and analysis Two review authors independently selected studies for inclusion, extracted data, and assessed risk of bias and certainty of evidence using GRADE. The primary comparison was any implementation intervention compared to no intervention. Main results Nine cluster randomised trials (12,428 patient participants) and three ongoing trials met our selection criteria. Five trials (8865 participants) compared an implementation intervention to no intervention, three trials (3150 participants) compared one implementation intervention to another implementation intervention, and one three‐arm trial (413 participants) compared two different implementation interventions to no intervention. Eight trials investigated multifaceted interventions; educational meetings and educational materials were the most common components. Six trials described tailoring the intervention content to identified barriers to change. Two trials focused on evidence‐based stroke rehabilitation in the acute setting, four focused on the subacute inpatient setting and three trials focused on stroke rehabilitation in the community setting. We are uncertain if implementation interventions improve healthcare professional adherence to evidence‐based practice in stroke rehabilitation compared with no intervention as the certainty of the evidence was very low (risk ratio (RR) 1.19, 95% confidence interval (CI) 0.53 to 2.64; 2 trials, 39 clusters, 1455 patient participants; I2 = 0%). Low‐certainty evidence indicates implementation interventions in stroke rehabilitation may lead to little or no difference in patient adherence to recommended treatment (number of recommended performed outdoor journeys adjusted mean difference (MD) 0.5, 95% CI –1.8 to 2.8; 1 trial, 21 clusters, 100 participants) and patient psychological well‐being (standardised mean difference (SMD) –0.02, 95% CI –0.54 to 0.50; 2 trials, 65 clusters, 1273 participants; I2 = 0%) compared with no intervention. Moderate‐certainty evidence indicates implementation interventions in stroke rehabilitation probably lead to little or no difference in patient health‐related quality of life (MD 0.01, 95% CI –0.02 to 0.05; 2 trials, 65 clusters, 1242 participants; I2 = 0%) and activities of daily living (MD 0.29, 95% CI –0.16 to 0.73; 2 trials, 65 clusters, 1272 participants; I2 = 0%) compared with no intervention. No studies reported the effects of implementation interventions in stroke rehabilitation on healthcare professional intention to change behaviour or satisfaction. Five studies reported economic outcomes, with one study reporting cost‐effectiveness of the implementation intervention. However, this was assessed at high risk of bias. The other four studies did not demonstrate the cost‐effectiveness of interventions. Tailoring interventions to identified barriers did not alter results. We are uncertain of the effect of one implementation intervention versus another given the limited very low‐certainty evidence. Authors' conclusions We are uncertain if implementation interventions improve healthcare professional adherence to evidence‐based practice in stroke rehabilitation compared with no intervention as the certainty of the evidence is very low

Effect of occupational therapy home visit discharge planning on participation after stroke: Protocol for the HOME Rehab trial

Introduction: After first stroke, the transition from rehabilitation to home can be confronting and fraught with challenges. Although stroke clinical practice guidelines recommend predischarge occupational therapy home visits to ensure safe discharge and provision of appropriate equipment, there is currently limited evidence to support this recommendation. Methods and analysis: The HOME Rehab trial is a national, multicentre, phase III randomised controlled trial with concealed allocation, blinded assessment and intention-to-treat analysis being conducted in Australia. The trial aim is to determine the effect and potential cost-effectiveness of an enhanced occupational therapy discharge planning intervention that involves pre and postdischarge home visits, goal setting and occupational therapy in the home (the HOME programme) in comparison to an in-hospital predischarge planning intervention. Stroke survivors aged ≥ 45 years, admitted to a rehabilitation ward, expected to return to a community (private) dwelling after discharge, with no significant prestroke disability will be randomly allocated 1:1 to receive a standardised discharge planning intervention and the HOME programme or the standardised discharge planning intervention alone. The primary outcome is participation measured using the Nottingham Extended Activities of Daily Living. Secondary outcome areas include hospital readmission, disability, performance of instrumental activities of daily living, health-related quality of life, quality of care transition and carer burden. Resources used/costs will be collected for the cost-effectiveness analysis and hospital readmission. Recruitment commenced in 2019. Allowing for potential attrition, 360 participants will be recruited to detect a clinically important treatment difference with 80% power at a two-tailed significance level of 0.05. Ethics and dissemination: This study is approved by the Alfred Health Human Research Ethics Committee and site-specific ethics approval has been obtained at all participating sites. Results of the main trial and the secondary endpoint of cost-effectiveness will be submitted for publication in peer-reviewed journals Trial registration number: ACTRN1261800136020