Patient- and Hospital-Level Determinants of Rehabilitation for In-Patient Stroke Care: An Observation Analysis.
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ABSTRACT:
SUBMITTER: Chen TT
PROVIDER: S-EPMC4902513 | biostudies-literature | 2016 May
REPOSITORIES: biostudies-literature
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Patient- and Hospital-Level Determinants of Rehabilitation for In-Patient Stroke Care: An Observation Analysis.
Chen Tsung-Tai TT Chen Chia-Pei CP Kuang Shao-Hua SH Wang Vinchi V
Medicine 20160501 19
During acute stroke care, rehabilitation usage may be influenced by patient- and hospital-related factors. We would like to identify patient- and hospital-level determinants of population-level inpatient rehabilitation usage associated with acute stroke care.From data obtained from the claim information from the National Health Insurance Administration (NHIA) in Taiwan (2009-2011), we enrolled 82,886 stroke patients with intracerebral hemorrhage and cerebral infarction from 207 hospitals. A gene ...[more]
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Project description:BackgroundAction observation (AO) is a physical rehabilitation approach that facilitates the occurrence of neural plasticity through the activation of the mirror-neural system, promoting motor recovery in people with stroke.ObjectivesTo assess whether AO enhances upper limb motor function in people with stroke.Search methodsWe searched the Cochrane Stroke Group Trials Register (last searched 18 May 2021), the Cochrane Central Register of Controlled Trials (18 May 2021), MEDLINE (1946 to 18 May 2021), Embase (1974 to 18 May 2021), and five additional databases. We also searched trial registries and reference lists.Selection criteriaRandomized controlled trials (RCTs) of AO alone or associated with physical practice in adults after stroke. The primary outcome was upper limb (arm and hand) motor function. Secondary outcomes included dependence on activities of daily living (ADL), motor performance, cortical activation, quality of life, and adverse effects.Data collection and analysisTwo review authors independently selected trials according to the predefined inclusion criteria, extracted data, assessed risk of bias using RoB 1, and applied the GRADE approach to assess the certainty of the evidence. The reviews authors contacted trial authors for clarification and missing information.Main resultsWe included 16 trials involving 574 individuals. Most trials provided AO followed by the practice of motor actions. Training varied between 1 day and 8 weeks of therapy, 10 to 90 minutes per session. The time of AO ranged from 1 minute to 10 minutes for each motor action, task or movement observed. The total number of motor actions ranged from 1 to 3. Control comparisons included sham observation, physical therapy, and functional activity practice.Primary outcomesAO improved arm function (standardized mean difference (SMD) 0.39, 95% confidence interval (CI) 0.17 to 0.61; 11 trials, 373 participants; low-certainty evidence); and improved hand function (mean difference (MD) 2.76, 95% CI 1.04 to 4.49; 5 trials, 178 participants; low-certainty evidence).Secondary outcomesAO did not improve ADL performance (SMD 0.37, 95% CI -0.34 to 1.08; 7 trials, 302 participants; very low-certainty evidence), or quality of life (MD 5.52, 95% CI -30.74 to 41.78; 2 trials, 30 participants; very low-certainty evidence). We were unable to pool the other secondary outcomes (motor performance and cortical activation). Only two trials reported adverse events without significant adverse effects.Authors' conclusionsThe effects of AO are small for arm function compared to any control group; for hand function the effects are large, but not clinically significant. For both, the certainty of evidence is low. There is no evidence of benefit or detriment from AO on ADL and quality of life of people with stroke; however, the certainty of evidence is very low. As such, our confidence in the effect estimate is limited because it will likely change with future research.
| S-EPMC9354942 | biostudies-literature
Project description:Variation in the delivery of evidence-based care affects outcomes for patients with stroke. A range of hospital (organizational), patient, and clinical factors can affect care delivery. Clinical registries are widely used to monitor stroke care and guide quality improvement efforts within hospitals. However, hospital features are rarely collected. We aimed to explore the influence of hospital resources for stroke, in metropolitan and regional/rural hospitals, on the provision of evidence-based patient care and outcomes. The 2017 National Audit organizational survey (Australia) was linked to patient-level data from the Australian Stroke Clinical Registry (2016-2017 admissions). Regression models were used to assess the associations between hospital resources (based on the 2015 Australian National Acute Stroke Services Framework) and patient care (reflective of national guideline recommendations), as well as 90-180-day readmissions and health-related quality of life. Models were adjusted for patient factors, including the severity of stroke. Fifty-two out of 127 hospitals with organizational survey data were merged with 22 832 Australian Stroke Clinical Registry patients with an admission for a first-ever stroke or transient ischaemic attack (median age 75 years, 55% male, and 66% ischaemic). In metropolitan hospitals (n = 42, 20 977 patients, 1701 thrombolyzed, and 2395 readmitted between 90 and 180 days post stroke), a faster median door-to-needle time for thrombolysis was associated with ≥500 annual stroke admissions [-15.9 minutes, 95% confidence interval (CI) -27.2, -4.7], annual thrombolysis >20 patients (-20.2 minutes, 95% CI -32.0, -8.3), and having specialist stroke staff (dedicated medical lead and stroke coordinator; -12.7 minutes, 95% CI -25.0, -0.4). A reduced likelihood of all-cause readmissions between 90 and 180 days was evident in metropolitan hospitals using care pathways for stroke management (odds ratio 0.82, 95% CI 0.67-0.99). In regional/rural hospitals (n = 10, 1855 patients), being discharged with a care plan was also associated with the use of stroke clinical pathways (odds ratio 3.58, 95% CI 1.45-8.82). No specific hospital resources influenced 90-180-day health-related quality of life. Relevant to all international registries, integrating information about hospital resources with clinical registry data provides greater insights into factors that influence evidence-based care.
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Project description:ImportanceRacial disparities in treatment benchmarks have been documented among older patients with hip fractures. However, these studies were limited to patient-level evaluations.ObjectiveTo assess whether disparities in meeting fracture care time-to-surgery benchmarks exist at the patient level or at the hospital or institutional level using high-quality multicenter prospectively collected data; the study hypothesis was that disparities at the hospital-level reflecting structural health systems issues would be detected.Design, setting, and participantsThis cohort study was a secondary analysis of prospectively collected data in the PREP-IT (Program of Randomized trials to Evaluate Preoperative antiseptic skin solutions in orthopaedic Trauma) program from 23 sites throughout North America. The PREP-IT trials enrolled patients from 2018 to 2021, and patients were followed for 1-year. All patients with hip and femur fractures enrolled in the PREP-IT program were included in analysis. Data were analyzed April to September 2022.ExposuresPatient-level and hospital-level race, ethnicity, and insurance status.Main outcomes and measuresPrimary outcome measure was time to surgery based on 24-hour time-to-surgery benchmarks. Multilevel multivariate regression models were used to evaluate the association of race, ethnicity, and insurance status with time to surgery. The reported odds ratios (ORs) were per 10% change in insurance coverage or racial composition at the hospital level.ResultsA total of 2565 patients with a mean (SD) age of 64.5 (20.4) years (1129 [44.0%] men; mean [SD] body mass index, 27.3 [14.9]; 83 [3.2%] Asian, 343 [13.4%] Black, 2112 [82.3%] White, 28 [1.1%] other) were included in analysis. Of these patients, 834 (32.5%) were employed and 2367 (92.2%) had insurance; 1015 (39.6%) had sustained a femur fracture, with a mean (SD) injury severity score of 10.4 (5.8). Five hundred ninety-six patients (23.2%) did not meet the 24-hour time-to-operating-room benchmark. After controlling for patient-level characteristics, there was an independent association between missing the 24-hour benchmark and hospital population insurance coverage (OR, 0.94; 95% CI, 0.89-0.98; P = .005) and the interaction term between hospital population insurance coverage and racial composition (OR, 1.03; 95% CI, 1.01-1.05; P = .03). There was no association between patient race and delay beyond 24-hour benchmarks (OR, 0.96; 95% CI, 0.72-1.29; P = .79).Conclusions and relevanceIn this cohort study, patients who sought care from an institution with a greater proportion of patients with racial or ethnic minority status or who were uninsured were more likely to experience delays greater than the 24-hour benchmarks regardless of the individual patient race; institutions that treat a less diverse patient population appeared to be more resilient to the mix of insurance status in their patient population and were more likely to meet time-to-surgery benchmarks, regardless of patient insurance status or population-based insurance mix. While it is unsurprising that increased delays were associated with underfunded institutions, the association between institutional-level racial disparity and surgical delays implies structural health systems bias.
| S-EPMC9713603 | biostudies-literature
Project description:IntroductionStroke is one of the leading causes of mortality and disability. Improving patient outcomes can be achieved by improving stroke care and adherence to guidelines. Since wide variation in adherence rates for stroke guidelines still exists, we aimed to describe and compare stroke care variability within Belgian hospitals.Materials and methodsAn observational, multicenter study was performed in 29 Belgian hospitals. We retrospectively collected patient characteristics, quality indicators, and time metrics from the last 30 consecutive patients per hospital, diagnosed with ischemic stroke in 2019 with structured questionnaires. Mean adherence ratios (%) ± SD (minimum - maximum) were calculated.ResultsWe analyzed 870 patient records from 29 hospitals. Results showed large inter- and intrahospitals variations in adherence for various indicators. Almost all the patients received brain imaging (99.7%) followed by admission at a stroke unit in 82.9% of patients. Of patients not receiving thrombolysis, 92.5% of patients were started on antithrombotic drugs. Indicators with moderate median adherence but large interhospital variability were glycemia monitoring [82.3 ± 16.7% (26.7-100.0%)], performing clinical neurological examination and documentation of stroke severity [63.1 ± 36.8% (0-100%)], and screening for activities of daily living [51.1 ± 40.3% (0.0-100.0%)]. Other indicators lacked adequate adherence: swallowing function screening [37.0 ± 30.4% (0.0-93.3%)], depression screening [20.2 ± 35.8% (0.0-100%)], and timely body temperature measurement [15.1 ± 17.0% (0.0-60%)].ConclusionWe identified high adherence to guidelines for some indicators, but lower rates with large interhospital variability for other recommendations also based on robust evidence. Improvement strategies should be implemented to improve the latter.
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Project description:ObjectiveTo examine the association between hospital, patient, and local health system characteristics and the likelihood, prevalence, and duration of observation care among fee-for-service Medicare beneficiaries.Data sourcesThe 100 percent Medicare inpatient and outpatient claims and enrollment files for 2009, supplemented with 2007 American Hospital Association Survey and 2009 Area Resource File data.Study designUsing a lagged cross-sectional design, we model the likelihood of a hospital providing any observation care using logistic regression and the conditional prevalence and duration of observation care using linear regression, among 3,692 general hospitals in the United States.Principle findingsCritical access hospitals (CAHs) have 97 percent lower odds of providing observation care compared to other hospitals, and they conditionally provide three fewer observation stays per 1,000 visits. The provision of observation care is negatively associated with the proportion of racial minority patients, but positively associated with average patient age, proportion of outpatient visits occurring in the emergency room, and diagnostic case mix. Duration is between 1.5 and 2.8 hours shorter at government-owned, for-profit hospitals, and CAHs compared to other nonprofit hospitals.ConclusionsVariation in observation care depends primarily on hospital characteristics, patient characteristics, and geographic measures. By contrast, local health system characteristics are not a factor.
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Project description:ObjectivesTo understand the hospital-to-outpatient care transition and how the discharge process of stroke patients is managed; and to identify potential opportunities to improve these processes, while contrasting pre- and during COVID-19 experiences in Peru.MethodsA qualitative study was conducted between February and March 2021 consisting of in-depth interviews of patients with stroke, their caregivers and healthcare personnel regarding stroke care at a national tertiary referral center for stroke care in Lima, Peru. We explored the following phases of the patients' journeys: pre-hospitalization, emergency room, hospitalization, discharge process and post-discharge. For each phase, we explored experiences, feelings and expectations using thematic analysis.ResultsWe conducted a total of 11 interviews with patients or caregivers and 7 with health care personnel and found disruption in the continuity of care for patients with stroke. Mainly, caregivers and patients referred to problems related to communication with healthcare personnel and an absence of training to provide post-discharge care at home. Potential solutions included increasing human resources and caregiver participation in care, implementation of electronic healthcare records, improving the referral system and reinforcing telemedicine services.ConclusionThe continuity of care of patients with stroke was negatively affected during the COVID-19 pandemic. In LMICs, the impact was likely greater due to the already weak and fragmented healthcare systems. The COVID-19 pandemic presents an opportunity to improve post-stroke care services, and address patients' experiences and feelings by developing solutions in a participatory manner.
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Project description:BackgroundEvery minute, six indigenous Africans develop new strokes. Patient-level and system-level contributors to early stroke fatality in this region are yet to be delineated. We aimed to identify and quantify the contributions of patient-level and system-level determinants of inpatient stroke fatality across 16 hospitals in Ghana and Nigeria.MethodsThe Stroke Investigative Research and Educational Network (SIREN) is a multicentre study involving 16 sites in Ghana and Nigeria. Cases include adults (aged ≥18 years) with clinical and radiological evidence of an acute stroke. Data on stroke services and resources available at each study site were collected and analysed as system-level factors. A host of demographic and clinical variables of cases were analysed as patient-level factors. A mixed effect log-binomial model including both patient-level and system-level covariates was fitted. Results are presented as adjusted risk ratios (aRRs) with respective 95% CIs.FindingsOverall, 814 (21·8%) of the 3739 patients admitted with stroke died as inpatients: 476 (18·1%) of 2635 with ischaemic stroke and 338 (30·6%) of 1104 with intracerebral haemorrhage. The variability in the odds of stroke fatality that could be attributed to the system-level factors across study sites assessed using model intracluster correlation coefficient was substantial at 7·3% (above a 5% threshold). Stroke units were available at only five of 16 centres. The aRRs of six patient-level factors associated with stroke fatality were: low vegetable consumption, 1·19 (95% CI 1·07-1·33); systolic blood pressure, 1·02 (1·01-1·04) for each 10 mm Hg rise; stroke lesion volume more than 30 cm3, 1·48 (1·22-1·79); National Institutes of Health Stroke Scale (NIHSS) score, 1·20 (1·13-1·26) for each 5-unit rise; elevated intracranial pressure, 1·75 (1·31-2·33); and aspiration pneumonia, 1·79 (1·16-2·77).InterpretationStudies are needed to assess the efficacy of interventions targeting patient-level factors such as aspiration pneumonia in reducing acute stroke fatality in this region. Policy directives to improve stroke unit access are warranted.FundingUS National Institutes of Health.TranslationsFor the Twi, Yoruba and Hausa translations of the abstract see Supplementary Materials section.
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Project description:BackgroundHospital investments in care coordination services and innovative delivery models represent an important source for improving care efficiency and population health.ObjectiveThe aim of this study was to explore variation of hospital-initiated care coordination services and participation in Accountable Care Organizations (ACOs) by community characteristics within an organizational theory framework.MethodsOur main data sets included the 2015 American Hospital Association Annual Survey, Survey of Care Systems and Payment, American Community Survey, and Area Health Resource File. Two main outcomes were (a) hospital-reported initiation of care coordination practices (such as chronic disease management, post-hospital discharge continuity of care, and predictive analytics) and (b) participation in ACO models. State fixed-effects models were used to test the association between the adoption of care coordination practices and hospital characteristics, community-level sociodemographic characteristics, and health policies.ResultsHospitals with large bed size, located in urban areas, and/or with high volume of operations were more likely to adopt care coordination practices and participate in the ACO models. Hospitals serving communities with high uninsurance rates and/or poverty rates were significantly less likely to provide care coordination practices. More stringent Community Benefit Laws (CBLs) were positively associated with the implementation of care coordination practices suggesting strong normative impacts of CBLs.ConclusionGreater hospital-initiated care coordination practices and innovative ACO models were available in well-resourced areas. Policymakers may consider increasing resources for care coordination practices in rural, underserved, and high-poverty-high-uninsured areas to ensure that vulnerable populations can benefit from these services.
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Project description: Not available
| S-EPMC7068824 | biostudies-literature
Project description:Background:The health care industry is undergoing a rapid transformation to meet the ever-increasing needs and demands of its patient population. Level of patients' satisfaction is an important health outcome, which is regarded as a determinant measure for quality of care. This study was performed with the aim of assessing the level of patient satisfaction with inpatient services and its determinants in Black Lion Specialized Hospital, Addis Ababa, Ethiopia. Methods:A facility-based cross-sectional study was conducted from November 25th to December 20th, 2015, using 398 randomly selected patients. Ethical clearance was obtained from the Jimma University research review board, and verbal consent was also received from the study participants during data collection time. A pretested structured interview questionnaire was used to collect data from study participants. The collected data were handled by using SPSS statistical software. Before analysis, relevant explanatory variables were identified using factor analysis with varimax rotation, and bivariate analysis was carried out using linear regression for every independent variable with the outcome variable independently. Explanatory variables scoring p value <-0.05 were used for the final model after checking the assumption. Study findings are presented by using tables, graphs, and description. Results:A total of 398 patients were participated in the study, yielding a response rate of 100%. A total of 46.2% (95% CI: 41.2%-51.1%) patients were satisfied by the services they received in the hospital. Patient and health care provider interaction and general facility amenity-related domains were found to explain 96.4% of the variability in the net overall satisfaction score. Good quality services provided by hospital physicians, availability of laboratory and radiology services, pain management services, and inpatient pharmacy services of the hospital had positive influences. Besides toilet cleanliness, availability of rooms for accommodation and dietary service had significant relation with level of patient satisfaction. Quality of the inpatient pharmacy service had a great influence on satisfaction; a unit increase in it resulted in 2.3 (95% CI: 2.1-2.5) times increment in patient satisfaction level at p ? 0.001. For final predictors, regression estimates for level of satisfaction moved from very dissatisfied to very satisfied when service improves by a unit. Conclusion:Overall patients' satisfaction is lower than other studies in the nation. A great opportunity is there to improve patient's satisfaction level if the service quality is improved around the time of patient and health care provider interaction and facility amenity services. Besides, improving the health literacy of service providers and devising a strategy to routinely assess satisfaction level of patients in the facility is critical. On top of this, providing tailored on-the-job training for health care workers in the facility is a crucial step in order to improve their knowledge and skills to render patient-centered quality service to improve their patients' satisfaction. Using a checklist during service delivery may improve client patient interaction and ensure the standard. Facility design dimension can be considered for future research activities.
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