Stroke Event 13 Sep - First morning presentations

Emerging Evidence -Findings from the four stroke theme

projects.

Chair: Prof Marion Walker

A partnership between

Nottinghamshire Healthcare NHS Trust

and the University of Nottingham

Collaboration for Leadership in Applied Health Research and Care for Nottinghamshire, Derbyshire and Lincolnshire

CLAHRC NDL

Leading Change in Early Supported Discharge

Dr Rebecca Fisher & Professor Marion Walker





CLAHRC NDL

• Overview of the Stroke Early Supported Discharge research programme

• Are the benefits of ESD still evident in practice? Results from a 3 year evaluation– Christine Cobley, Research Associate

What to expect


CLAHRC NDL

Thanks to the Team


CLAHRC NDL

• Marion Walker• Christine Cobley• Fiona Nouri• Nikki Chouliara• Iskra Potgieter• Amy Moody• Brian Crosbie• Meghan Thurston• Catherine Gaynor

• Jo James• Rebecca Larder

• UK Policy context: National Stroke Strategy 2007, Royal College Physicians Clinical Guideline for Stroke

• Clinical trial data: demonstrated effectiveness of Early Supported Discharge

• Large variation in quality of service provision across the UK (Care quality commission 2011)

Why ESD?


CLAHRC NDL

Rehab

Support

Hospital

Home

Acute

Rehab Rehab

SupportESD

• “In performing the research we aim to (a) gain clarity around how an ESD service might be organised (b) test methods to facilitate the implementation of ESD services and report on successes and challenges associated with implementation (c) test methods to measure the effectiveness of ESD services”

Our Remit


CLAHRC NDL

• Stroke Rehabilitation Implementation Research• (A) What is the evidence?: Consensus on the core components

of evidence based Early Supported Discharge services• (B) What is the context?: qualitative mapping used to describe

models of services operating in practice (how & why?)• (C) Implementing change: facilitate evidence based practice

Educational programme: measuring effectiveness & team working

• (D) Evaluation: Are the benefits of ESD still evident in practice?

ESD research programme


CLAHRC NDL





CLAHRC NDL

Are the benefits of stroke Early Supported

Discharge still evident in practice?

• Participants admitted to SU at NUH & SFH: Nov’10- Feb’12• Eligibility criteria informed by international ESD Consensus• Study differs to original trials: Evaluating ESD operating in real

world practice• Both patients and carers eligible for ESD (whether or not they

were referred to service)• Formation of Non-ESD cohort• Baseline assessment within 14days stroke onset; participants

followed period of 12 months

Methods : Participants & Intervention


CLAHRC NDL

• Baseline & scheduled follow-up home visits (6, 26, 52 wk F/U)• Choice determined by previous trials & meta-analyses investigating ESD• Primary: BI• Secondary:SF36; EQ5D;*NEADL;GHQ-28; Satisfaction Qu*• Carer Outcomes: *GHQ-28; *SF-36; *Satisfaction Qu *Assessments not completed at baseline, but 6w, 6m & 12m f/u stages

• Hospital data from Hospital Trust, Primary Care Trust & Local Authority databases– Admission & discharge to SU– Place of residence on admission & discharge– Service discharge to (if any)– BI admission & discharge– HRG code– LOS on acute & rehab wards– Readmissions at 28days & 1yr post baseline assessment

Methods : Data Collected


CLAHRC NDL

• LOS used to calculate associated hospital based costs patient by patient basis

• Using HRG & Trim-points translated LOS into associated costs• Used model of tariff unbundling that could be used to

generate savings from ESD related reduction LOS to fund ESD services

• To compare with annual staffing of ESD services information used:– ESD Team Structure– Banding & Whole Time Equivalent figures

Methods : Statistical Analysis


CLAHRC NDL

Flow of participants through study

Table 1

Participants enrolled into study n=293

ESD n=135

Non ESD n=158

Six week evaluation n=128

Exclusion 1 Lost to follow-up 1 No longer wish to continue 2 Illness 0 Change in diagnosis 1 Death Total 5 2 Unable to complete at just this time point

Six week evaluation n=130


Six month evaluation n=123

Exclusion 1 Lost to follow-up 2 No longer wish to continue 0 Illness 0 Change in diagnosis 4 Death Total 7

Six month evaluation n=114


Twelve month evaluation n=112


Twelve month evaluation n=114


Baseline Characteristics of Participants


CLAHRC NDL

Variable ESD (n=135) Non ESD (n=158) Comparison P

Age, median (IQR) †††

71(62-79) 76(65.75-82) 0.005*

N days between stroke onset & baseline assessment, mean (SD) ††

7(7) 6(6) 0.503

Gender †

Women, N (%)

45(33.3%) 56 (35.4%) 0.705

Male, N (%) 90(66.6%) 102(64.6%)

Baseline BI, median (IQR) †††

80 (65-95)

85 (70-95)

0.174

Ethnicity†

White, N(%)

127(94%) 155 (98.1%) 0.068

Other, N(%)

8 (6%) 3 (1.9%)

†Groups were compared using χ2 for Ethnicity & Gender. ††Groups were compared using t-test for N days between stroke onset and baseline assessment. †††Groups were compared using Mann Whitney U Test for Age and Baseline Barthel score. *Significant at P<0.05.

https://en.wikipedia.org/wiki/Chi_(letter)

Clinical Hospital Data


CLAHRC NDL

Variable ESD (n=135) NESD (n=158) Comparison* PBI adm, mean (SD)

11.4 (5.5) 10.7 (5.6) 0.326

BI disch, mean (SD)

18 (6) 18 (4.75) 0.749

Total LOS acute, median (IQR)

4(2-7) 3(2-5.75) 0.061

Total LOS rehab, median (IQR)

0(0-12) 6.5(0-15.75) 0.018*

Total LOS (rehab + acute stay), median (IQR)

9(4-18.25) 11(5-21.0) 0.029*

Readmitted to SU within 28 days hospital discharge N (%)

2(1.5%) 1(0.7%) 0.606

Readmitted to Gen ward within 28 days of hospital discharge, N (%)

12(9.2%) 11(7.7%) 0.669

Readmitted to SU within 1 year baseline assessment, N (%)

18(13.8%) 10 (7.0%) 0.073

Readmitted to Gen ward within 1 year baseline assessment, N (%)

47 (36.0%) 62 (43.4%) 0.266

Case fatality, N (%)

11 (8.5%) 16 (11.2%) 0.544

†Groups were compared using χ2 for Readmissions and Case Fatality. †† t-test for BI †††Mann Whitney U Test for LOS. *Significant at P<0.05.

https://en.wikipedia.org/wiki/Chi_(letter)

• ESD group significantly more knowledgeable– Risk & practical help at 6 weeks (P<0.05) – Community services & emotional support at 6weeks, 6 &

12months (P<0.05) – Higher level overall satisfaction services received 6 weeks

& 6 months (P<0.01)

• No other differences on outcomes between groups at individual time points

Comparison of patient outcomes: Between Group Comparison


CLAHRC NDL

Comparison of patient outcomes: Within Group Comparison


CLAHRC NDL

ESD (n=110)

Non ESD (n=109)

Variable Baseline

6 Weeks

6 Months

12 Months

P

Baseline

6 Weeks

6 Months

12 Months

P

BI 80(65-91) 95(84-100) 95(80-100) 90(75-100) 0.000* 85(70-95) 90(80-100) 95(80-100) 95(75-100) 0.000*

NEADL Q 35(24-49) 39(27-50) 31.5(18-46) 0.146 Q 35(24-52) 36(24.5-54) 36(20-50.5) 0.037

GHQ-28 25(18-35) 22(16-34) 19(12-30) 18.5(13-29) 0.000* 23(17-31) 22(16-29) 19.5(14-25) 20(13-26) 0.001*

PCS 32.9(24.3-39.9)

32.4(25.4-42.4)

33.9(22.9-47.1)

31.7(21.3-43.1)

0.010* 35.1(28.3-43.3)

34.5(26.3-42.9) 33.3(24.8-43.9)

35.3(24.1-45.8)

0.413

MCS

50.3(38.8-58.7)

47.1(35.7-55.3)

52.4(43.9-58.1)

53.3(44.2-60.2)

0.000*

51.3(43.6-58.0)

47.9(34.4-57.1)

54.1(45.8-58.5)

53.5(48.1-59.1)

0.006*

EuroQol Index

0.74(0.65-0.84)

0.78(0.7-0.88)

0.77(0.68-1.00)

0.77(0.65-0.88)

0.001*

0.75(0.68-0.88)

0.77(0.69-0.88)

0.77(0.68-0.88)

0.77(0.69-0.88)

0.711

EuroQol Imaginable Health

55(45-70)

60(50-80)

65(50-80)

70(50-80)

0.000*

60(50-80)

65(50-80)

70(50-80)

75(50-85)

0.002*

†Median (interquartile range in parentheses). Groups were compared using Friedman Test. *Significant at P<0.05.


CLAHRC NDL

Parameter β Std. Error P value

Model A: Main Effects

Gender 0.206 0.2015 0.306

Ethnicity 0.170 0.4322 0.695

Age -0.661 0.1974 0.001*

ESD -0.065 0.1910 0.734

Time6Weeks 1.103 0.1492 0.000*

Time26Weeks 1.202 0.1575 0.000*

Time52Weeks 0.918 0.1556 0.000*

Model B: Interaction Effects

ESD*Gender

-0.035

0.2730

0.898

ESD*Ethnicity -0.590 0.3127 0.059

ESD*Age -0.587 0.3030 0.053

ESD*Time6Weeks 1.569 0.2270 0.000*

ESD*Time26Weeks 1.500 0.2262 0.000*

ESD*Time52Weeks 1.057 0.2183 0.000*

*Significant at P<0.05

Generalised Estimating Equations analysis of Barthel Index scores at 6, 26, and 52 weeks

• Interaction Model: explore between group differences whilst adjusting for possible covariates– Descriptive analyses age significantly different, model age insignificant in

relation to BI performance over time– No differences between groups ethnic & sex variables– Findings favoured ESD group: at 6weeks: 4.7 times likely BI ≥ 90– Findings favoured ESD group: at 6months: 4.5 times likely BI ≥ 90– Findings favoured ESD group: at 12 months: 2.9 times likely BI ≥ 90

• Sensitivity Analyses: Robustness of model explored adjusting BI threshold values (85, 93, and 95) Findings remained consistent

Results: GEE Modelling findings


CLAHRC NDL


CLAHRC NDL

Results: Carer Outcomes

• No Between Group differences– Physical, mental & psychological well-being– Satisfaction & knowledge stroke related services

• Within Group differences– Significant improvement in mental health of carers

receiving ESD (χ2(2)=13.000, p = 0.002)– Post-hoc analysis showed difference between 6weeks & 6

months (Z=-3.646, p=0.000)


CLAHRC NDL

Results: Unbundling National Stroke Tariff

• Using Payment by Results scheme & stroke tariffs for each patient, associated hospital based care costs calculated

• Used proposed model of unbundling National Stroke Tariff to calculate potential savings could be associated with ESD

• Unbundling model involved splitting total LOS into discrete segments attributing appropriate amounts of tariff to each

HRG Code

Best Practice tariff (£)

Trim-point (days)

Day 0 to 3

Day 4 to 9

Day 10 to Trim-point

Daily cost exceeding trim-point

LOS Hospital Receives Commissioner saving

AA22z £4,570 57 £1,500 £1064 £2,006 £179 17 £4,570 £0.00

3 £1,500 £3,070

8 £2,564 £2,006

73 £4,570 + £2,864 -£2,864

AA23z £4,633 51 £1,500 £1088 £2,045 £181 17 £4,633 £0.00

3 £1,500 £3,133

8 £2,588 £2,045

73 £4,570 + £3,982 -£3,982


CLAHRC NDL

Results: Unbundling National Stroke Tariff

• Of Study Sample, 237 assigned HRG AA22z or AA23z

• Total saving of £245,217 calculated based on total LOS

• Average Annual cost of ESD service involved in study based on team composition: £350,000


CLAHRC NDL

Summary of Findings & Concluding Remarks

• Study has measured effectiveness ESD in practice, for 1st time • When adopting evidence based model, ESD services can

– Significantly reduce LOS– Result in equivalent or better outcomes for patients & their

carers• Presented quantitative methodology: evaluating effectiveness of

ESD services, using BI as measure of patient recovery• Distinction to trials important

– Participants not randomised, groups compared formed naturally

– ESD intervention investigated are services operating outside strict, protocol driven trial environment


CLAHRC NDL

Summary of Findings & Concluding Remarks

• Present model of tariff unbundling for use within English Payment by Results Scheme, would ensure ESD related cost savings associated with reduction in LOS were realised

• Findings in addition to policy & national guideline recommendations, difficult to believe why ESD services are not accessible to all eligible

Thank you for listening

[email protected]

www.clahrc-ndl.nihr.ac.uk

Twitter: @CLAHRC_NDL


CLAHRC NDL

Concern that it would be unethical to withdraw such an established and accepted treatment.

Concern that it would be unethical to withdraw such an established and accepted treatment.

A pilot study of home visits in Australia recruited only ten participants in 3m despite admission records suggesting more people should have been available.

1. National survey 184 questionnaire posted

2. Opinions and perceptions 42 interviews;

17 with patients/staff involved in trial 20 senior OT interviews; 6 expert interviews

3. Feasibility RCT 126 trial patients recruited

1. National survey of practice

What is routine occupational therapy practice when

conducting pre-discharge home visits for patients with a

stroke?

How many visits?

Pre discharge assessment visitApril and May 2011 mean 7 (sd 6.93) 0- 27 Access visitApril and May 2011 mean 7 (sd 8.39) 0- 38

74% knew number of visits; 26% did not87% policy to have 2 members of staff attending

Reason for home visitReason Frequency Percentage

Assess/practice activities of daily living in home environment

79 96%

Identify/address safety issues 78 95%

Assess/practice mobility/transfers in home environment

75 92%

As part of discharge planning 66 81%

Carer concerns 63 77%Assess access to and within property

63 76%

Increase patient’s confidence and mood

59 72%

Equipment provision 49 60%Inform ongoing rehabilitation goals

42 51%

Obtain measurements 31 38%Stroke unit policy 4 5%Missing (respondents who did not complete this question)

3 3%

Time on visits

Time at home on visits. Range 10-135 mins

Mean 63 mins (SD 20) i.e. just over an hour

Time on travel. Range 15-180 minsMean 49 mins (SD 25.41)

Time on…

Time to organise visits.Range 10-240 mins Mean 50 mins (SD 34.58)

Time writing up report. Range 2-210 minsMean 61 mins (SD 33.13)

Overall time

Mean time 223 minutes i.e. almost 3 ¾ hours

to undertake the ‘average’ home visit

What is in your visiting bag?

Summary

National picture of home visits Reasons for visits Time/workload involved National links for interviews/further

research

2. Opinions and perceptions; experts,

OTs, patients.


OTs, patients. Differing purposes of visits Effective use of resources ‘Entrenched practice’ Perceptions of patients Implementation aspects


OTs, patients. Differing purposes of visits Effective use of resources ‘Entrenched practice’ Perceptions of patients Implementation aspects

Should it be an OT?

YES‘Unique still to OT … should be protected … and not become generic’ (042).

Should it be an OT?

YES‘Unique still to OT … should be protected … and not become generic’ (042).

NO‘It is always assumed to be an OT role … there may be some instances when it could be more appropriate for another profession to lead the visit’ (039).

Visiting

There are often requests for visits which I feel are inappropriate(127).

Visiting


I don’t think they [home visits] need to be carried out as a routine task (106).

Visiting


I don’t think they [home visits] need to be carried out as a routine task (106).

I believe it should be made a policy that all patients that have had a stroke have a pre-discharge OT home visit (132).

Resource issues

They are popular with patient and staff however they lack some understanding of how much time and effort they take (088).

Resource issues

They are popular with patient and staff however they lack some understanding of how much time and effort they take (088).

They’re extraordinarily expensive in terms of time and resource ….’(Expert 1)

“…..they do not cost a lot, compared to a lot of other interventions… if they then are reducing the hospital stay by even one or two nights... OT time isn't that expensive compared to a lot of things, to a lot of other interventions…that go on in hospital” (Expert 4)

Realistic?

‘They get observed in a very artificial situation for an hour and then the occupational therapist makes a judgment on the basis of that as to whether somebody’s going to be able to manage, you know, safely or not. And I think that that is unrealistic’ (Expert 1)

Realistic?

‘They get observed in a very artificial situation for an hour and then the occupational therapist makes a judgment on the basis of that as to whether somebody’s going to be able to manage, you know, safely or not. And I think that that is unrealistic’ (Expert 1)‘Home visits are an essential part of practice as patients can present very differently in their own environment’ (039).

Patients

“I was quite happy in as much as I know that the fact I’d got a home visit they were considering me, releasing me from hospital so I was quite happy to conform with anything that would encourage them to say, you can go home” (Patient 1)

“Without a doubt, it was things that I haven’t even thought about, the height of the bed the amount of steps from the stairs…would I be able to use the stair lift…if there hadn’t been a home visit things could have gone disastrously wrong” (Patient 5)

3. Feasibility RCT

Worked with clinical colleagues to agree the methodology

Clinicians had power as gate keepers in process

3. Feasibility RCT

Worked with clinical colleagues to agree the methodology

Clinicians had power as gate keepers in process

‘New’ methodology in rehab research;

RCT arm (clinical uncertainty)

Cohort arm (‘Sure’)- but asked to define

3. Feasibility RCT

RCT- 93 patients randomly allocated;

47 to intervention arm (home visit) and

46 to control (interview) arm.

Cohort -33

Feasibility RCT

RCT -93 patients randomly allocated;

47 to intervention arm 46 to control

Parallel -33

Recruitment

Systematic collection of data

Mean cost of home visit £208 (SD £107).

Mean cost of a hospital interview £75 (SD£40).

Trial Issues for future

Measures Protocol adherence Safety- more falls in in home visit

arm- more confident? Chance? Control group- too much

intervention?

Relevant?

Data shows interesting differences /RCT feasible

Main paper was 10th most read article in Clinical Rehabilitation

Pump Priming award from NUH for virtual reality project based on interviews→

The Senior Stroke Association Fellowship.

HOVIS 2?

http://www.google.co.uk/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&docid=gyPGF1fak86AIM&tbnid=Pb8alqlEnyoQRM:&ved=0CAUQjRw&url=http://www.thechurchfarmer.com/tag/church-2/&ei=Bk8fUurnEKWd0QXd-4GABA&bvm=bv.51495398,d.d2k&psig=AFQjCNGkbK7vQ09KxUB71EWdD6mcgNL9pQ&ust=1377869921870818

Thanks to…TEAM HOVISPhillip WhiteheadKaren FellowsNikki SpriggClaire EdwardsSTEERING GROUPProf Nadina LincolnChris SampsonCecily PalmerOswald NewoldDr Nicola BrainDr Guo Boliang

Dr Daniel SimpkinsDr Lyn Legg Prof Marion WalkerDr Kate RadfordDr Annie McCluskey Prof Marilyn JamesDr Amanda CromptonProf Cath Sackley Dr Ruth ParryDr Karen StainerDr Tracy Sachand of course the Ward

Staff and Patients

Wii STAR: Wii Stroke Therapy for Arm Rehabilitation

PJ Standen, Kate Threapleton, Louise Connell, Andy Richardson, David Brown, Steven Battersby,

Fran Platts





CLAHRC NDL

Background


CLAHRC NDL

• Need new approach to provide the necessary rehabilitation of upper limb following stroke.

• Patients have decreasing access to appropriate therapy and even if sent home with exercises, adherence to treatment is poor.

• Exercise plans can appear rigid and inflexible. Their effectiveness is irrelevant if they exhaust patients’ capabilities and motivation (Clay and Hopps, 2003).

• Adherence could be improved if treatments are designed that are amenable or adaptable to more appropriately fit into the lifestyles and limitations of patients and their families.

Background


CLAHRC NDL

• Virtual reality and interactive video gaming have emerged as new treatment approaches in stroke rehabilitation (Laver et al, 2011).

• Commercial gaming consoles already used in clinical settings (eg Saposnik et al 2010): advantages of being widely acceptable, providing easily perceived feedback and their low cost facilitates unrestricted home use.

• But games not designed for therapeutic use and current systems do not capture movement of fingers.

Development of equipment


CLAHRC NDL

• In conjunction with users we developed a low cost intervention for home use that was flexible and motivating in order to improve adherence.

• After several iterations we produced the virtual glove which allows capture of position of thumb and three fingers and translates into game play.

• Designed to facilitate practice of movements that underlie everyday tasks such as grasp and release.

Development of games


CLAHRC NDL

• Four games each with different levels of challenge to keep the participants motivated to continue to use the system, but to ensure that they can achieve some success.

• Scores displayed on the screen at the end of a game.

• A log of when the system is in use is collected by the computer as well as what games are being played and what scores the user obtains.

Feasibility trial


CLAHRC NDL

We approached patients who • were aged 18 or over who• were recovering from a stroke • were no longer receiving any other intensive rehabilitation • still experiencing problems with their upper limb

• Recruited from stroke wards City Hospital, ESD and Community Support Team and Stroke Outreach Service.

• Randomly allocated to either the intervention (virtual glove) group or the control group (usual care).

• Intervention group had the virtual glove, games and a PC in their homes for a period of 8 weeks.

• They were advised to use the system for 20 mins 3x day (max 56 hours).

Feasibility trial


CLAHRC NDL

Measures of upper limb function were taken at baseline, 4 weeks and 8 weeks

• Wolf Motor Functions Test - a measure of upper limb functioning

• 9 Hole Peg Test - a test of fine motor co-ordination

• Nottingham Extended Activities of Daily Living

• Motor Activity Log - how well and how much they use their more impaired arm to accomplish each of a range of ADL

• For intervention group only: frequency and type of requests for help; duration and type of support provided; frequency of using the equipment

Feasibility trial


CLAHRC NDL

Three sets of results

• Adherence: did participants use the equipment as frequently as we had recommended?

• Did the outcome measures show any difference between the groups?

• How much time did the research team spend supporting home use of the intervention?

Adherence Data


CLAHRC NDL

1 2 3 4 8 9 13 17 22 23 24 260

10

20

30

40

50

60

70

80

90

100

Percentage of Recommended Use

Recommended time used %

Recommended days used %

Participant ID

%

Barriers to use


CLAHRC NDL

• Equipment outages. • Needing someone to help them set up equipment or put on the glove. • If the participant is computer literate the games are likely to become boring:

“I would say the first few weeks was brilliant. But as I say, then as it got going longer on, it was sort of, well, some days I couldn't be bothered and then some days, if you've got something else to do, it was just sort of missing it out. But at first, yes, it was really good.” (P8).

• Other health problems and fatigue• Competing commitments: “And what time the family came, if the family

came just when I had started it – I had to then leave it” (P4) , and more passive pastimes: “I admit it depended what was on the telly” (P4).

• Getting back to pre stroke life especially once mobile

Facilitators


CLAHRC NDL

• Flexibility: “Whereas with a computer, you could say four o'clock/five o'clock, if you felt all right, you could do it sort of any time you wanted to. You're not set to a time all the time, which was quite good.” (P8)

• Immersion in games: “You just forget what – you sort of look at the time and, say it was ten o'clock, you're playing and then the next time you look up you think, crikey, it's half-past eleven, sort of thing.” (P8)

• Belief in its therapeutic nature: “Oh yeah, of course, because it helps – well, it helps you a lot in your movement. First and fore, with the position, you know, then you enjoy the games.” (P9)

• Support and encouragement from relatives

Outcome measures


CLAHRC NDL

• 22 participants completed outcome measures at 4 weeks and 18 at 8 weeks.

• The only significant (p<0.05) difference was a higher reported use in the intervention group of the affected limb on the MAL at 8 weeks when compared to the control group .

• The lack of differences between the two groups was probably due to the considerable variation in how much the equipment was used.

– Looking at the intervention group only, there was a significantly (p<0.05) higher change from baseline on WOLF grip strength in those with a higher use of the equipment, when compared to those with a lower use.

Therapist Time - Participant Visits


CLAHRC NDL

• Intervention group only– Total number of visits = 118 (mean = 9.83; SD = 3.97)– Includes visits to complete baselines, outcome measures and all visits related to

delivering the intervention

1 2 3 4 8 9 13 17 22 23 24 260

2

4

6

8

10

12

14

16

18

Total Number of Visits

Participant ID

Visit

s

Therapist Time – Duration of Visits


CLAHRC NDL

• 146 hours was spent delivering the intervention in total

Baseline Midpoint OM Final OM Int Training Technical Other Comms Other Research0

5

10

15

20

25

30

35

40

45

50

55

1922

14

52

21

15

3

Total Hours Delivering Intervention

Research Activity

Hour

s

Therapist time - conclusions


CLAHRC NDL

• Mean number of visits (9.83) over approximately 8 weeks, duration is not extraordinary.

• The complexities of delivering a novel intervention in a community setting probably account for above average amount of visits.

• Some participants with complex stroke pathology (cognitive issues, profound sensory disturbance) demanded more ‘one to one’ therapy time.

• After an initial OT/PT assessment, there may be an argument for trained support staff to deliver this intervention which could have cost-benefits to a service.

What we have learnt


CLAHRC NDL

• Identifying potential participants difficult and time consuming. • Once identified, recruitment reasonable (62% of 47 consented). • Huge variation in adherence and outcomes but inclusion criteria

deliberately wide. • Adherence low but it’s low for other unsupervised rehabilitation. • Eight weeks is a long time to ask people to use kit especially if they are

trying to return to their pre stroke life.• No reason to drop any of the outcome measures if going for definitive

trial, although baseline measures sometimes required two visits. • We provided a high level of support perhaps because it was a novel

intervention in a community setting.


[email protected]

[email protected]

www.clahrc-ndl.nihr.ac.uk

Twitter: @CLAHRC_NDL


CLAHRC NDL

mailto:[email protected]


Return to Work after Stroke:A Feasibility Randomised Controlled Trial

Mary GrantOn behalf of:

KA Radford, EJ Sinclair, J Terry, MF Walker, NB Lincoln, A Drummond, J Phillips, C Coole, L Watkins, E Rowley, B Guo,

N Brain, K Muhiddin, M Jarvis, M Jenkinson, C Sampson, C Edwards





CLAHRC NDL


CLAHRC NDL

• 110,000 strokes annually a quarter of which occur in working age adults, less than half of stroke survivors resume work (Daniel et al., 2009)

• Health risks - greater than heart disease (Waddell and Aylwood, 2005)

• Reduced quality of life

• Dramatic societal costs of £8.9 billion a year (Saka et al., 2009)

Background

• Vocational Rehabilitation: a process whereby those disadvantaged by illness or disability can access, maintain or return to employment (Tyerman and Meehan, 2004)

• Work is a recognised health outcome (NHS Outcomes Framework, 2010)

• Rehabilitation frequently fails to address work needs (Playford et al., 2011)

• Lack of evidence for stroke-specific vocational rehabilitation (SSVR)

Background continued


CLAHRC NDL


CLAHRC NDL

1. Interview and mapping study of current provision

2. Intervention development phase (case study design)

3. Feasibility trial with economic and intervention analysis

4. Qualitative study with stroke survivors and employers to explore usefulness and acceptability of the intervention

Four stage project

Aim of study

To test the feasibility of designing and delivering occupational therapy-led stroke-specific vocational rehabilitation (SSVR) and measuring it’s effectiveness in a pilot randomised controlled trial (RCT)


CLAHRC NDL

Method

Stroke survivors recruited from acute and stroke rehab stroke wards

OT-led stroke-specific vocational

rehabilitation (SSVR)Usual Care (UC)

Postal follow-up: 3, 6 and 12

months


CLAHRC NDL

Intervention

• Best practice guidelines (Tyerman and Meehan, 2004)

• Mapping work (Sinclair et al., 2013)

• Assessment, information, education, work preparation and phased return to work (Grant et al., 2012)

• Case co-ordination model (Fadyl and McPherson, 2009)


CLAHRC NDL

Inclusion Criteria

• Confirmed stroke diagnosis

• Aged 16+

• In paid/voluntary work, education, >1 hour per week

Exclusion Criteria

• Not intending to RTW

• Unable to give informed consent


CLAHRC NDL

Participants

Gender: n (%)MaleFemale

17 (73.9%)6 (26.1%)

19 (82.6%)4 (17.4%)

AgeMean (SD)Range

58.3 (12.7)24-78

53.8 (12.6)18-77

Length of Hospital StayMean days (SD) 19.6 (21.6) 27.1 (26.9)

Occupation: n (%)Non-ProfessionalProfessional

4 (17.4%)19 (82.6%)

12 (52.2%)11 (47.8)

Characteristic SSVR (n=23) Control (n=23)


CLAHRC NDL

Min

or

Mod

erat

e

Mod

erat

e...

Seve

re

Mis

sing

05

101520253035

NIHSS; Stroke Severity (%) SSVR

Control

LACS PACS TACS POCS Missing05

101520253035

Bamford Classification (%) SSVR

Control


CLAHRC NDL

Participants

Hemianopia

Blurred Visi

on

Nystagmus

Quadrantanopia

Double Vision

Other0123456 Visual Impairments (n) SSVR

Control

Not affected Aphasia Dysarthria Dysarthria and aphasia

05

1015202530354045

Speech and Language Impairments (%)

SSVRControl


CLAHRC NDL

Primary Outcome

• Returned to work: yes/no

Secondary Outcomes

• Mood: Hospital Anxiety and Depression Scale (HADS)• Work Productivity: Work Productivity and Activity Impairment

Instrument (WPAI) and Work Limitations Questionnaire (WLQ)• Social Participation: Sydney Psychosocial Reintegration Scale

(SPRS)• Activities of Daily Living: Nottingham Extended Activities of Daily

Living (NEADL)• Health Status: EQ-5D


CLAHRC NDL

Results: Participants


CLAHRC NDL

Feasibility

3m 6m 12m0

102030405060708090

100Questionnaire Response Rates (%)

SSVRControl


CLAHRC NDL

Primary Outcome

3m 6m 12m0

20

40

60

80

100Participants in Work (%) SSVR

Control


CLAHRC NDL

3m 6m 12m0

4

8

12

16

20

Nottingham Extended Activities of Daily Living: Median Score SSVR

Control

3m 6m 12m 3m 6m 12mAnxiety Depression

012345678

Hospital Anxiety and Depression Scale: Median Scores SSVR

Control


CLAHRC NDL

Secondary Outcomes

3m 6m 12m0

2

4

6

8WLQ: % Productivity Loss SSVR

Control


CLAHRC NDL

Secondary Outcomes

3m 6m 12m0

15

30

45

60

Sydney Psychosocial Reintegration Scale: Median Score SSVR

Control

3m 6m 12m.00

.20

.40

.60

.80

1.00

EQ5D: Average of Scaled ScoresSSVRControl


CLAHRC NDL

Discussion

• Primary outcome: More intervention group participants were in work at 12 months

• Secondary outcomes: Relatively little variation between the two groups.

• Feasibility: Feasible to recruit, deliver and measure early SSVR - overall response rate of 73.9% - only one person withdrew from intervention


CLAHRC NDL

Limitations

• More information known about the intervention group

• Fixed time period

• Descriptive comparisons


CLAHRC NDL

Conclusions

• Early OT-led SSVR can be effectively delivered and measured using standardised and bespoke questionnaires

• SSVR can potentially influence return to work rates

• Knowledge from this feasibility study useful in planning future research: larger scale studies needed to demonstrate effect

• Impact of research: dissemination of new knowledge and new SSVR OT post commissioned in Nottingham


CLAHRC NDL

References

• Daniel K, Wolfe CDA, Busch MA, McKevitt C (2009) What are the social consequences of stroke in working aged adults? A systematic review. Stroke, 40, 431-440

• Fadyl JK, McPherson KM (2009) Approaches to vocational rehabilitation after traumatic brain injury: a review of the evidence. Journal of Head Trauma Rehabilitation, 24(3), 195-212.

• Grant M, Sinclair E, Walker MF, Radford KA. Vocational rehabilitation following stroke: describing intervention. International Journal of Stroke. 2012; 7 (Suppl 2):29.

• Department of Health (2010) The NHS Outcomes Framework 2011/12, London: Department of Health.

• Playford ED, Radford K, Burton C, Gibson A, Jellie B, Sweetland J, Watkins C. (2011) Mapping Vocational Rehabilitation Services for people with Long term neurological conditions: Summary report. Department of Health. Available at: http://www.ltnc.org.uk/ Accessed 10.12.12.


CLAHRC NDL

References

• Saka O, McGuire A, Wolfe C (2009) Cost of stroke in the United Kingdom. Age and Ageing, 38(1), 27–32

• Sinclair E, Radford K, Grant M, Terry J (2013) Developing stroke specific vocational rehabilitation: a soft systems analysis of current service provision. Disability and Rehabilitation. Published online, May 2013. DOI:10.3109/09638288.2013.793410

• Tyerman A, Meehan M J (eds) (2004) Vocational assessment and rehabilitation after acquired brain injury: Interagency guidelines. London: British Society of Rehabilitation Medicine/ Job Centre Plus/ Royal College of Physicians

• Wadell G, Aylward AK (2005) The scientific and conceptual basis of incapacity benefits. London: HMSO


CLAHRC NDL



CLAHRC NDL

[email protected] Grant – [email protected]

www.clahrc-ndl.nihr.ac.ukTwitter: @CLAHRC_NDL



Stroke Event 13 Sep - First morning presentations

Health & Medicine

applied health research

benefits of esd

esd primary

research associate

effectiveness of esd

implementation of esd

team collaboration

remit collaboration