Research Items (160)
- Jan 2019
Introduction: Increasing attention is being paid to interventions for cognitive impairment (CI) post-stroke, including for CI that does not meet dementia criteria. The aim of this paper was to conduct a systematic review and meta-analysis of the prevalence of cognitive impairment no dementia (CIND) within one year post-stroke. Patients and methods: Pubmed, EMBASE and PsychInfo were searched for papers published in English in 1995–2017. Included studies were population or hospital-based cohort studies for first-ever/recurrent stroke, assessing CIND using standardised criteria at 1–12 months post-stroke. Abstracts were screened, followed by full text review of potentially relevant articles. Data were extracted using a standard form, and study quality was appraised using the Crowe Critical Appraisal Tool. A pooled prevalence of CIND with 95% confidence intervals (CI) was estimated using random-effects meta-analysis. Heterogeneity was measured using the I² statistic. Results: A total of 7000 abstracts were screened, followed by 1028 full text articles. Twenty-three articles were included in the systematic review, and 21 in the meta-analysis. The pooled CIND prevalence was 38% [95% CI = 32–43%] (I²=92.5%, p < 0.01). Study quality emerged as one source of heterogeneity. The five studies with the highest quality scores had no heterogeneity (I²=0%, p = 0.99), with a similar pooled prevalence (39%, 95%CI = 35–42%). Other sources of heterogeneity were stroke type, inclusion of pre-stroke CI, and age at assessment time. Discussion and conclusion: Meta-analysis of available studies indicates that in the first year post-stroke, 4 in 10 patients display a level of cognitive impairment that does not meet the criteria for dementia.
- Dec 2018
Background: Point prevalence surveys (PPSs) collect data on hospital-acquired infections (HAIs) at one point in time but do not provide information on incidence over the entire admission or impact on patients or healthcare resources. Retrospective record review examines the entire admission to determine adverse event prevalence, incidence, preventability, physical impairment and additional length of stay. Aim: To establish whether European HAI surveillance definitions can be applied to the Irish National Adverse Events Study (INAES) retrospective record review data to determine HAI burden. Methods: In the INAES, 1574 admissions were reviewed using a two-stage methodology and 247 adverse events were found. These were examined against European HAI case definitions to determine whether the event was an HAI. Results were compared with the 2011/12 European PPS data for Ireland. Findings: The prevalence of HAI adverse events in INAES was 4.4% (95% confidence interval (CI) 3.1–6.1%) with an incidence of 3.8 (95% CI 2.5–5.2) HAI adverse events per 100 admissions. The PPS HAI prevalence for Ireland was 5.2%. HAI types and micro-organisms were similar in INAES and the PPS. Approximately three-quarters of INAES HAI adverse events were preventable, 7% caused permanent impairment and 7% contributed to death. A mean of 10 additional bed days were attributed to HAI adverse events, equivalent to €9400 per event. Conclusion: Retrospective record review is an accurate source of information on HAI incidence, preventability and impact that complements PPS prevalence rates. HAI adverse events result in higher costs to the healthcare system than other adverse events.
Background: Cognitive impairment is common post-stroke, and can increase disability and levels of dependency. This study explored the impact of cognitive impairment six-months post-stroke on outcomes at five years. Methods: This was a five-year follow-up of the Action on Secondary Prevention Interventions and Rehabilitation in Stroke cohort. Cognitive impairment was assessed using the Montreal Cognitive Assessment at six months post-stroke. Outcomes at five years included mortality, cognitive decline, quality of life, activities of daily living, and depressive symptoms. Mortality was ascertained from medical records and death notifications. Quality of life was assessed using the Stroke Specific Quality of Life Scale. Independence in activities of daily living was assessed using the Nottingham Extended Activities of Daily Living scale. Depressive symptoms was assessed using the Centre for Epidemiologic Studies Depression Scale. Data were analysed using regression models. Results: Of 256 patients assessed at six months post-stroke, 63 (24.6%) had died within five years. Cognitive impairment at six months was significantly associated with increased risk of mortality within five years, controlling for age, sex and stroke severity [HR (95% CI): 2.19 (1.42, 3.39)]. Cognitive impairment at six months was also associated with greater subsequent cognitive decline, poorer quality of life, lower levels of independence in activities of daily living, and increased likelihood of depressive symptoms five years post-stroke. Conclusion: Cognitive impairment post-stroke continues to be associated with poorer outcomes. There is a need for more effective interventions to improve outcomes for this patient group.
- Jun 2018
- 15th Annual Psychology, Health & Medicine Conference
Background: Cognitive impairment is common post-stroke, and can increase disability and levels of dependency. The aim of this study was to explore the impact of cognitive impairment at six-months post-stroke on outcomes at five years. Methods: This was a five-year follow-up of the Action on Secondary Prevention Interventions and Rehabilitation in Stroke (ASPIRE-S) cohort. Cognitive impairment was assessed using the Montreal Cognitive Assessment at six months post-stroke. Outcomes at five years included mortality, quality of life, independence in activities of daily living, and depressive symptoms. Mortality was ascertained from medical records, and a website of death notifications. Health-related quality of life was assessed using the Stroke Specific Quality of Life Scale, with higher scores indicating greater quality of life. Activities of daily living were assessed using the Nottingham Extended Activities of Daily Living scale, with higher scores indicating greater levels of independence. Depressive symptoms were assessed using the Centre for Epidemiologic Studies Depression Scale. Data were analysed using cox, logistic, and linear regression models. Results: Of 256 patients assessed at six months post-stroke, 63 (24.6%) had died within five years. Cognitive impairment at six months was significantly associated with increased risk of mortality within five years, controlling for age, sex and stroke severity [HR (95% CI): 2.19 (1.42, 3.39)]. Cognitive impairment at six months was also associated with poorer quality of life, lower levels of independence in activities of daily living, and increased likelihood of experiencing depressive symptoms at five years post-stroke. Conclusion: Cognitive impairment post-stroke continues to be associated with poorer prognoses across a range of outcomes. There is a need for more effective interventions to improve outcomes for this patient group.
- May 2018
Background The aim of this study was to examine predictors of mortality in patients 5 years after ischemic stroke, focusing on cognitive impairment, vulnerability, and vascular risk factors assessed at 6 months post stroke. Materials and Methods Patients from the Action on Secondary Prevention Interventions and Rehabilitation in Stroke (ASPIRE-S) cohort were followed up 5 years post ischemic stroke. Vascular risk factors, cognitive impairment, and vulnerability were assessed at 6 months post stroke. Cognitive impairment was assessed using a cutoff score lower than 26 on the Montreal Cognitive Assessment (MoCA). Vulnerability was defined as a score of 3 or higher on the Vulnerable Elders Scale (VES). Mortality and date of death were ascertained using hospital records, death notifications, and contact with general practitioners. Predictors of mortality were explored using multivariate Cox proportional hazards models. Adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) are presented. Results Sixty-three of 256 patients (24.6%) assessed at 6 months post stroke had died within 5 years. Cognitive impairment (HR [95% CI]: 2.19 [1.42-3.39]), vulnerability (HR [95% CI]: 5.23 [2.92-9.36]), atrial fibrillation (AF) (HR [95% CI]: 2.31 [1.80-2.96]), and dyslipidemia (HR [95% CI]: 1.90 [1.10-3.27]) were associated with increased risk of 5-year mortality. Discussion Vulnerability, cognitive impairment, AF, and dyslipidemia at 6 months were associated with increased risks of mortality 5 years post ischemic stroke. Conclusion Identification and management of these risk factors should be emphasized in poststroke care.
Background and Aims: The aim of this study was to profile cognitive decline 5 years post-stroke, and to explore associations with primary healthcare service use and informal care. Method: Patients from the Action on Secondary Prevention Interventions and Rehabilitation in Stroke (ASPIRE-S) cohort were followed up at 6 months and 5 years post-stroke. Cognitive impairment was assessed using the Montreal Cognitive Assessment (MoCA), with cognitive decline defined as a decrease of at least 2 points. Primary healthcare service use was defined as the number of general practitioner visits in the previous 12 months (0 to 4 or 5 or more visits). Informal care was defined as any unpaid care received by stroke patients from family members, neighbours or friends. Results: One hundred patients had cognitive assessment at both 6 months and five years post-stroke. Cognitive decline was evident in 66 (66.0%) patients at 5 years. Increasing age was significantly associated with cognitive decline [OR (95% CI): 1.05 (1.01, 1.09)]. Controlling for age, cognitive decline was associated with a greater number of GP visits in the previous 12 months [OR (95% CI)): 4.73 (1.27, 17.61)], but not with likelihood of receiving informal care [OR (95% CI): 1.20 (0.35, 4.07)]. Conclusion: Cognitive decline is evident in a significant number of patients five years post-stroke, and is associated with increased use of primary healthcare services. Further research is required to explore predictors and outcomes of cognitive decline post-stroke.
The aim of this study was to profile cognitive decline within 5 years post-stroke, and to explore associations with primary healthcare service use and receipt of informal care.
The aim of this study was to systematically review and meta-analyse the association between cognitive impairment and medication non-adherence in patients with stroke.
- Apr 2018
- Irish Heart Foundation 21st Annual Stroke Conference
The aim of this study was to explore the association between cognitive impairment in stroke patients and anxious or depressive symptoms in family members five years post-stroke.
Executive summary: Taking, or adhering to, prescribed medications is important after a stroke. Medications are used to control cardiovascular risk factors, such as high blood pressure and high cholesterol. Controlling these risk factors can reduce the risk of having a second stroke, and could also reduce the risk of developing cognitive impairment. Cognitive impairment is common after stroke and can affect ability to take medications as prescribed. Little research to date has explored the link between cognitive impairment and medication adherence after stroke. This review found nine studies that reported on the relationship between cognitive impairment and medication adherence, with contradictory results. When all nine studies were combined, there was no overall association between cognitive impairment and adherence. However, the nine studies differed greatly in how they defined and measured cognitive impairment and medication adherence. The overall quality of the evidence was low, with more research needed to fully understand the potential link between cognitive impairment and medication adherence after stroke.
Inability to identify stroke warning signs accurately is an important cause of delay in seeking medical attention, leading to potential ineligibility for acute intervention. We report on post-campaign findings (wave 2) of national surveys to estimate changes in population knowledge following a media-based Face, Arm, Speech, Time stroke awareness campaign, comparing findings to those of a pre-campaign population survey (wave 1).
Introduction Stroke is one of the primary causes of death and disability worldwide, leaving a considerable proportion of survivors with persistent cognitive and functional deficits. Despite the prevalence of poststroke cognitive impairment, there is no established treatment aimed at improving cognitive function following a stroke. Therefore, the aims of this systematic review are to identify psychological interventions intended to improve poststroke cognitive function and establish their efficacy. Methods and analysis A systematic review of non-randomised controlled studies that investigated the efficacy of psychological interventions aimed at improving cognitive function in stroke survivors will be conducted. Electronic searches will be performed in the PubMed, Embase and PsycINFO databases, the search dating from the beginning of the index to February 2017. Reference lists of all identified relevant articles will be reviewed to identify additional studies not previously identified by the electronic search. Potential grey literature will be reviewed using Google Scholar. Titles and abstracts will be assessed for eligibility by one reviewer, with a random sample of 50% independently double-screened by second reviewers. Any discrepancies will be resolved through discussion, with referral to a third reviewer where necessary. Risk of bias will be assessed with the Risk of Bias in Non-randomized Studies of Interventions tool. Meta-analyses will be performed if studies are sufficiently homogeneous. This review will follow the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. The quality of the evidence regarding cognitive function will be assessed according to the Grading of Recommendations Assessment, Development and Evaluation. Ethics and dissemination This systematic review will collect secondary data only and as such ethical approval is not required. Findings will be disseminated through presentations and peer-reviewed publication. This review will provide information on the effectiveness of psychological interventions for poststroke cognitive impairment, identifying which psychological interventions are effective for improving poststroke cognitive function. PROSPERO registration number CRD42017069714.
Background While medication adherence is essential for the secondary prevention of stroke, it is often sub-optimal, and can be compromised by cognitive impairment. This study aimed to systematically review and meta-analyse the association between cognitive impairment and medication non-adherence in stroke. Methods A systematic literature search of longitudinal and cross-sectional studies of adults with any stroke type, which reported on the association between any measure of non-adherence and cognitive impairment, was carried out according to PRISMA guidelines. Odds ratios and 95% confidence intervals were the primary measure of effect. Risk of bias was assessed using the Cochrane Bias Methods Group's Tool to Assess Risk of Bias in Cohort Studies, with evidence quality assessed according to the GRADE approach. We conducted sensitivity analyses according to measure of cognitive impairment, measure of medication adherence, population, risk of bias and adjustment for covariates. The protocol was registered with PROSPERO. Results From 1,760 titles and abstracts, we identified 9 studies for inclusion. Measures of cognitive impairment varied from dementia diagnosis to standardised cognitive assessments. Medication adherence was assessed through self-report or administrative databases. The majority of studies were of medium risk of bias (n = 6); two studies had low risk of bias. Findings were mixed; when all studies were pooled, there was no evidence of an association between cognitive impairment and medication non-adherence post-stroke [OR (95% CI): 0.85 (0.66, 1.03)]. However, heterogeneity was substantial [I2 = 90.9%, p < .001], and the overall evidence quality was low. Conclusions Few studies have explored associations between cognitive impairment and medication adherence post-stroke, with substantial heterogeneity in study populations, and definitions and assessments of non-adherence and cognitive impairment. Further research using clear, standardised and objective assessments is needed to clarify the association between cognitive impairment and medication non-adherence in stroke.
- Dec 2017
This is a protocol for a Cochrane Review (Intervention). The objectives are as follows: This review aims to look at the benefits and harms of using interventions for improving adherence to immunosuppressant therapies in solid organ transplant recipients, including paediatric and adult heart, lung, kidney, liver and pancreas transplant recipients.
Background: Although brief cessation advice from healthcare professionals increases quit rates, smokers typically do not get this advice during hospitalisation, possibly due to resource issues, lack of training and professionals' own attitudes to providing such counselling. Medical students are a potentially untapped resource who could deliver cessation counselling, while upskilling themselves and changing their own attitudes to delivering such advice in the future; however, no studies have investigated this. We aimed to determine if brief student-led counselling could enhance motivation to quit and smoking cessation behaviours among hospitalised patients. Methods: A mixed-methods, 2-arm pilot feasibility randomised controlled trial with qualitative process evaluation enrolled 67 hospitalised adult smokers, who were recruited and randomized to receive a brief medical student-delivered cessation intervention (n = 33) or usual care (n = 34); 61 medical students received standardised cessation training and 33 were randomly assigned to provide a brief in-hospital consultation and follow-up support by phone or in-person one week post-discharge. Telephone follow-up at 3- and 6-months assessed scores on the Motivation to Stop Smoking Scale (MTSS; primary outcome) and several other outcomes, including 7-day point prevalent abstinence, quit attempts, use of cessation medication, and ratings of student's knowledge and efficacy. Data were analysed as intention to treat (ITT) using penalised imputation, per protocol, and random effects repeated measures. Focus group interviews were conducted with students post-intervention to elicit their views on the training and intervention process. Results: Analyses for primary and most secondary outcomes favoured the intervention group, although results were not statistically significant. Point prevalence abstinence rates were significantly higher for the intervention group during follow-up for all analyses except 6-month ITT analysis. Fidelity was variable. Patients rated students as being "very" knowledgeable about quitting and "somewhat" helpful. Qualitative results showed students were glad to deliver the intervention; were critical of current cessation care; felt constrained by their inability to prescribe cessation medications and wanted to include cessation and other behavioural counselling in their normal history taking. Conclusions: It appears feasible for medical students to be smoking cessation interventionists during their training, although their fidelity to the intervention requires further investigation. A definitive trial is needed to determine if medical students are effective cessation counsellors and if student-led intervention could be tailored for other health behaviours. Trial registration: NCT02601599 (retrospectively registered 1 day after first participant recruited on November 3rd 2015).
Introduction: The Integrated care Programme in Ireland aims to integrate prevention and management of chronic disease into clinical practice. It will require changes in service delivery to make every clinical consultation count to: 1) Routinely assess patients for their lifestyle risk factors for chronic disease, 2) Support patients in changing their lifestyle related health behavior, and 3) Encourage self-management for patients with existing chronic disease. Changing this culture and practice to Make Every Contact Count will require upskilling of our existing healthcare staff and teaching the skills and knowledge required in undergraduate training programmes for all health professionals as outlined in the National Implementation plan for Healthy Ireland in the Health Services (2015-2017). Short description of practice change implemented: All new staff in the Irish health service will “Make Every Contact Count” by routinely assessing patients risk factors for chronic disease and carrying out a lifestyle behavior change intervention as part of all clinical interactions. Aim and theory of change: In 2015, the Health and Wellbeing Division, HSE established a collaborative between the Higher Education Institutions in Ireland to develop a competency based national standard undergraduate curriculum for medical, nursing and allied health professionals to support the integration of chronic disease prevention into clinical practice by Making Every Contact Count through brief interventions. Targeted population and stakeholders: Targeted population: All undergraduate students on health professional degree programmes. Key stakeholders are: HSE, HEI’s, all service users including those at risk of chronic disease and who have chronic diseases. Timeline: The curriculum will be delivered in relevant courses in HEI’s in Ireland from September 2017. Highlights: This is the first time that a collaborative standard competency based national curriculum for healthcare professionals has been developed in Ireland. Collaborative health service and education initiative Shifts the emphasis towards chronic disease prevention in training healthcare professionals Evidence informed curriculum: The curriculum includes lifestyle choices and personal wellness, communicating with patients for chronic disease prevention and health behaviour change interventions to Make Every Contact Count. Comments on sustainability: Supports sustainable change in the routine delivery of lifestyle behaviour change interventions as part of all clinical consultations. Comments on transferability: Internationally transferable into other undergraduate training programmes for healthcare professionals. Conclusions: A nationally directed, collaborative approach was useful in: 1) Creating leadership and commitment to the curriculum across all HEI’s, 2) Providing a multidisciplinary approach to its development, 3) Supporting the collective exchange of knowledge and resources, and 4) Supporting the implementation across all HEI’s in Ireland. Discussions: New staff recruited in the HSE will have the skills and knowledge to carry out brief interventions as a routine part of all their clinical consultations. Lessons learned: The importance of champions within positions of influence in each HEI was crucial to support the curriculum development and implementation. Progress to date: Curriculum has been developed and plans for implementation in each HEI are being developed.
- Oct 2017
Objectives The influence of healthcare system factors on long-term care admissions has received relatively little attention. We address this by examining how inadequacies in the healthcare system impact on long-term care admissions of people with dementia. This is done in the context of the Irish healthcare system. Methods Thirty-eight qualitative in-depth interviews with healthcare professionals and family carers were conducted. Interviews focused on participants’ perceptions of the main factors which influence admission to long-term care. Interviews were analysed thematically. Results The findings suggest that long-term care admissions of people with dementia may be affected by inadequacies in the healthcare system in three ways. Firstly, participants regarded the economic crisis in Ireland to have exacerbated the under-resourcing of community care services. These services were also reported to be inequitable. Consequently, the effectiveness of community care was seen to be limited. Secondly, such limits in community care appear to increase acute hospital admissions. Finally, admission of people with dementia to acute hospitals was believed to accelerate the journey towards long-term care. Conclusions Inadequacies in the healthcare system are reported to have a substantial impact on the threshold for long-term care admissions. The findings indicate that we cannot fully understand the factors that predict long-term care admission of people with dementia without accounting for healthcare system factors on the continuation of homecare.
Background: As part of the StrokeCog research programme, this study built on previous research from the research group by analysing acute care utilisation patterns post-stroke in Ireland, with a specific focus on healthcare utilisation by those with post-stroke cognitive impairment. Methods: Secondary data analysis of the Irish Hospital Inpatient Enquiry (HIPE) dataset. Bivariate and multivariate statistics were conducted to compare acute care utilisation and discharge destinations (death, home, rehabilitation or nursing home) as well as length of stay (LOS) post-stroke. The implications of cognitive impairment for all of these parameters was also examined. Findings: Findings from previous research from this research group indicated that the mean length of hospital stay for those with stroke in Ireland was 24 days (SD: 47). Those discharged to a nursing home had a considerably longer length of stay (M: 50; SD: 82) compared to those discharged home (M:17; SD 32). In total, fifteen per cent of stroke discharges were discharged to a nursing home. The current study builds on these findings by comparing hospital utilisation and discharge pathways for those with a long LOS with and without post-stroke cognitive impairment. Discussion: The research findings from this analysis will inform the estimation of costs of cognitive impairment post-stroke in Ireland as part of an overall programme of work focussed on developing and delivering effective interventions for post-stroke cognitive impairment.
- Aug 2017
Aim: To explore the association between cardiovascular medication use and cognitive impairment in adults aged 50 years and over. Method: This cross-sectional linked database study involved secondary quantitative analysis of 1,903 participants from wave 1 of the Irish Longitudinal Study on Ageing with available pharmacy claims data. Cognitive impairment was assessed using a cut-off of ≤23 on the Montreal Cognitive Assessment. Cardiovascular medication use was calculated using the proportion of days covered for antihypertensive, antithrombotic, and lipid-modifying medications. For each class of cardiovascular medication, participants were categorised as belonging to one of three medication use groups: 1) not dispensed any medications (reference); 2) poor adherence (proportion of days covered <80%); and 3) good adherence (proportion of days covered ≥80%). Results: Controlling for demographic and health variables, there was no evidence of an independent association between impaired cognitive function and use of antihypertensives [good adherence OR (95% CI): 1.16 (0.88, 1.52), poor adherence OR (95% CI): 1.39 (0.95, 2.04)]; antithrombotics [good adherence OR (95% CI): 1.26 (0.93, 1.70), poor adherence OR 95% CI): 1.13 (0.80, 1.59)]; or lipid-modifying agents [good adherence OR (95% CI): 0.95 (0.71, 1.25), poor adherence OR (95% CI): 0.88 (0.64, 1.22)]. Conclusion: We found no evidence of an association between cardiovascular medication use and cognitive function. Future studies should investigate the prospective associations between cognition and use of cardiovascular medications using longitudinal data.
Background: In the setting of a national audit of acute stroke services, we examined the delivery of thrombolytic therapy for ischaemic stroke and whether current practice was achieving safe outcomes and consistent delivery for patients. Method: Data obtained from the recent national stroke audit was compared against previous Irish audit, the most recent SSNAP UK stroke audit and the Safe Implementation of Thrombolysis in Stroke-Monitoring Study (SITS-MOST) study. Results: Thrombolysis was provided in 27 acute hospitals throughout Ireland during the period assessed with 82% (22/27) providing 24/7 access, the remaining sites using redirect policies. Decision to thrombolyse was made by stroke trained consultants in 63% (17/27) of units, with general physicians and emergency medicine consultants covering the other units. Thrombolysis rate for non-haemorrhagic stroke was 11% (n = 80/742, CI 95% ±2.23) versus a 1% rate in the 2008 audit. Sites receiving patients through a redirect policy had the highest thrombolysis rate, an average of 24%. Nearly 30% of cases were thrombolysed on the weekend. Eighty-three percent of cases were managed in a stroke unit at some time during admission versus 54% of the national total cases. Thirty-seven percent of patients were ≥80 years old. The mortality rate was 11.3% versus the national mortality rate for non-thrombolysed ischaemic strokes of 10% (p > 0.5), and this is comparable to the SITS-MOST 2007 study 3-month mortality rate of 11.3% (p > 0.5). Conclusion: Stroke thrombolysis is being effectively and safely provided in acute stroke services in Ireland despite regular involvement of non-specialist staff. There is still potential to improve thrombolysis rate.
Background: There are few studies concentrating on the influence of health system factors on long-term care admissions of people with dementia. We address this absence by examining how inadequacies in the healthcare system impact on long-term care admissions of people with dementia. This is in the context of the Irish healthcare system which has been greatly impacted by the economic crisis and austerity. Methods: Thirty-eight qualitative in-depth interviews with healthcare professionals and family carers were conducted. Interviews focused on participants’ perceptions of the main factors which influence admission to long-term care. Interviews were analysed thematically. Results: Long-term care admissions of people with dementia are affected by inadequacies in the healthcare system in three ways. Firstly, the economic crisis in Ireland appears to have exacerbated the under-resourcing of community care services. These services are also inequitable. Consequently, the effectiveness of community care is limited. Secondly, such limits in community care increase acute care admissions. Finally, admission of people with dementia to acute care can accelerate the journey towards long-term care. Conclusions: Inadequacies in the healthcare system have a substantial impact on the threshold for long-term care admissions. This suggests that we cannot fully understand the factors that predict long-term care admission of people with dementia without accounting for healthcare system factors on the continuation of homecare.
- Jul 2017
- Innovation in Aging
Background: Controversy exists in the literature about whether carer stress is a risk factor for institutional care use by care recipients, or just an epiphenomenon. We tested competing models of the contribution of carer stress to institutional care utilisation by community-dwelling older people. Methods: Secondary analysis of The Irish Longitudinal Study on Aging (TILDA). A structural path analysis tested theoretically informed models of the relationship between carer stress and institutional care utilisation by community-dwelling older people. Results: Two competing models were tested. One in which carer stress was found to be an independent predictor of institutional care utilisation by care recipients (OR: 1.47; 95% CI: 1.05–2.06; AIC: 2813.67 BIC: 2866.83) and one in which stress was an epiphenomenon of the process of institutional care utilisation (coefficient: 0.37; 95% CI: 0.06–0.68; AIC: 2860.56 BIC: 2913.73). Both models appear equally valid, suggesting a bi-directional relationship between carer stress and utilisation of institutional care by community-dwelling older people. Conclusions: Results suggest the effects of institutional care utilisation on carer stress are as convincing as the effect of carer stress on institutional care utilisation, which has implications for current theories of the role of carer stress in institutional care utilisation.
Background An increased inter-arm systolic blood pressure difference of >10mmHg is associated with increased cardiovascular risk and a difference of >15mmHg with increased cerebrovascular risk. The stroke population presents a high-risk group for future cardiovascular and cerebrovascular events and therefore estimation of inter-arm SBP difference as a predictive tool may assist with further secondary stroke prevention. Objective To determine the prevalence of inter-arm systolic and diastolic blood pressure difference in a post stroke population. Methods A comprehensive assessment of secondary risk factors along with blood pressure measurements were taken 6-months’ post ischaemic stroke from the ASPIRE-S (Action on Secondary Prevention Interventions and Rehabilitation in Stroke cohort). Descriptive and logistic regression analyses were performed. Odds ratios and 95% Confidence intervals are presented Results 238 (M: F,139:99, mean age 68.4yrs) of 256 patients followed up at 6 months post stroke had suitable BP readings from both arms.40.3% (n=96) had an inter-arm systolic blood pressure difference of >10mmHg and 20.6% (n=49) had a difference of >15mmHg. A history of hypertension, diabetes, smoking and obesity was not significantly associated with an increased risk of inter-arm systolic blood pressure difference. After multivariate logistic analysis, a history of alcohol excess was associated with an increased IASBP >15mmHg (OR 2.32, 95% CI 1.03-5.22). Conclusion We have demonstrated that inter-arm systolic blood pressure difference is commonly seen in a post stroke population.
Introduction Older people experience greater morbidity with a corresponding increase in medication use resulting in a potentially higher risk of adverse drug reactions (ADRs). The aim of this study is to determine the prevalence and characteristics of ADR-related hospital admissions among older patients (≥65 years) and their associated health and cost outcomes. Methods and analysis The proposed study will include a cross-sectional study of ADR prevalence in all patients aged ≥65 years admitted acutely to a large tertiary referral hospital in Ireland over a 9-month period (2016–2017) and a prospective cohort study of patient-reported health outcomes and costs associated with ADR-related hospital admissions. All acute medical admissions will be screened for a suspected ADR-related hospital admission. A number of validated algorithms will be applied to assess the type, causative medications, preventability and severity of each ADR. ADRs will be determined, using a consensus method, by an expert panel. Patients who provide consent will be followed up 3 months post-discharge to establish patient-reported health outcomes (health service use, health-related quality of life, adherence) and costs associated with ADR-related hospital admissions. A random sample of patients admitted to hospital without a suspected ADR will be invited to take part in the study as a control group. Ethics and dissemination Ethical approval was obtained from Beaumont Hospital Ethics Committee. Findings will be disseminated through presentations and peer-reviewed publications.
- May 2017
- 3rd European Stroke Organisation Conference (ESOC 2017)
Aims: Cognitive impairment (CI) is a pervasive outcome of ischaemic stroke, reported in over half of patients six months post-stroke. However, cognitive rehabilitation has received considerably less research attention than physical rehabilitation. The aim of the StrokeCog study is to 1) model the progression, costs and outcomes of post-stroke CI, 2) develop and pilot-test a post-stroke cognitive intervention, and 3) evaluate the cost-effectiveness of alternative hypothetical interventions. Methods: Data will be collected on the epidemiology and costs of post-stroke CI using literature review, secondary data analysis and patient-level surveys, and analysed using regression and survival analysis. The pilot intervention design will be informed by systematic review of existing interventions and a qualitative study with patients, caregivers and healthcare professionals, and will be tested using a pilot feasibility randomised controlled trial (RCT). Decision-analytic modelling will be applied to findings from the RCT, and epidemiological and economic analyses, to evaluate the potential cost-effectiveness of hypothetical interventions. Results: An epidemiological modelling platform and meta-dataset will be produced and available for evaluation of alternative treatment strategies for post-stroke CI. Evidence for the feasibility, effectiveness and cost-effectiveness of a pilot intervention for post-stroke CI will be generated. Conclusions: The research findings will support the planning of cost-effective treatment strategies addressing post-stroke CI in hospital and community settings in Ireland.
Introduction: Outcomes in stroke patients are improved by a co-ordinated organisation of stroke services and provision of evidence-based care. We studied the organisation of care and application of guidelines in two neighbouring health care systems with similar characteristics. Methods: Organisational elements of the 2015 National Stroke Audit (NSA) from the Republic of Ireland (ROI) were compared with the Sentinel Stroke National Audit Programme (SSNAP) in Northern Ireland (NI) and the United Kingdom (UK). Compliance was compared with UK and European guidelines. Results: Twenty-one of 28 ROI hospitals (78%) reported having a stroke unit (SU) compared with all 10 in NI. Average SU size was smaller in ROI (6 beds vs. 15 beds) and bed availability per head of population was lower (1:30,633 vs. 1:12,037 p < 0.0001 Chi Sq). Fifty-four percent of ROI patients were admitted to SU care compared with 96% of UK patients (p < 0.0001). Twenty-four–hour physiological monitoring was available in 54% of ROI SUs compared to 91% of UK units (p < 0.0001). There was no significant difference between ROI and NI in access to senior specialist physicians or nurses or in SU nurse staffing (3.9/10 beds weekday mornings) but there was a higher proportion of trained nurses in ROI units (2.9/10 beds vs. 2.3/10 beds (p = 0.02 Chi Sq). Conclusion: Whilst the majority of hospitals in both jurisdictions met key criteria for organised stroke care the small size and underdevelopment of the ROI units meant a substantial proportion of patients were unable to access this specialised care.
Abstract Introduction Cognitive impairment is common following stroke and can increase disability and levels of dependency of patients, potentially leading to greater burden on carers and the healthcare system. Effective cardiovascular risk factor control through secondary preventive medications may reduce the risk of cognitive decline. However, adherence to medications is often poor and can be adversely affected by cognitive deficits. Suboptimal medication adherence negatively impacts secondary prevention targets, increasing the risk of recurrent stroke and further cognitive decline. The aim of this study is to profile cognitive function and secondary prevention, including adherence to secondary preventive medications and healthcare usage, 5 years post-stroke. The prospective associations between cognition, cardiovascular risk factors, adherence to secondary preventive medications, and rates of recurrent stroke or other cardiovascular events will also be explored. Methods and analysis This is a 5-year follow-up of a prospective study of the Action on Secondary Prevention Interventions and Rehabilitation in Stroke (ASPIRE-S) cohort of patients with stroke. This cohort will have a detailed assessment of cognitive function, adherence to secondary preventive medications and cardiovascular risk factor control. Ethics and dissemination Ethical approval for this study was granted by the Research Ethics Committees at Beaumont Hospital, Dublin and Connolly Hospital, Dublin, Mater Misericordiae University Hospital, Dublin, and the Royal College of Surgeons in Ireland. Findings will be disseminated through presentations and peer-reviewed publications.
Abstract Aims: The aim of this study is to profile cognitive function and secondary prevention, including adherence to secondary preventive medications and healthcare utilisation, five-years post-stroke. The prospective associations between cognition, cardiovascular risk factors, adherence to secondary preventive medications, and rates of recurrent stroke or other cardiovascular events will also be explored. Methods: This is a 5-year follow-up of a prospective study of the ASPIRE-S (Action on Secondary Prevention Interventions and Rehabilitation in Stroke) cohort of stroke patients. This cohort will have a detailed assessment of cognitive function, adherence to secondary preventive medications, healthcare utilisation and cardiovascular risk factor control. Results: Data collection for this study commenced in December 2016. Conclusion: Given the potential public health burden of cognitive impairment after stroke, identification of modifiable risk and protective factors to avert or delay cognitive decline is paramount. Delaying cognitive impairment could allow many individuals to reach the end of their natural lifespan before crossing the threshold for dementia. This study will provide valuable information on the trajectories of cognitive impairment, medication adherence and cardiovascular risk factors post-stroke, and will indicate how cognitive function and secondary prevention are related to each other, as well as to stroke or other cardiovascular event recurrence and healthcare utilisation, over time. These findings can help inform future health policy and service planning regarding the longer-term management of patients with stroke.
Introduction The Stroke and Cognition consortium (STROKOG) aims to facilitate a better understanding of the determinants of vascular contributions to cognitive disorders and help improve the diagnosis and treatment of vascular cognitive disorders (VCD). Methods Longitudinal studies with ≥75 participants who had suffered or were at risk of stroke or TIA and which evaluated cognitive function were invited to join STROKOG. The consortium will facilitate projects investigating rates and patterns of cognitive decline, risk factors for VCD, and biomarkers of vascular dementia. Results Currently, STROKOG includes 25 (21 published) studies, with 12,092 participants from five continents. The duration of follow-up ranges from 3 months to 21 years. Discussion Although data harmonization will be a key challenge, STROKOG is in a unique position to reuse and combine international cohort data and fully explore patient level characteristics and outcomes. STROKOG could potentially transform our understanding of VCD and have a worldwide impact on promoting better vascular cognitive outcomes.
- Sep 2016
- Age and Ageing
Background: The provision of homecare takes place within the context of the wider healthcare system. However, there is a notable absence of studies concentrating on healthcare system factors in long-term care admissions. We address this absence by examining how inadequacies in the healthcare system impact on long-term care admissions of people with dementia. This is done in the context of the Irish healthcare system. Methods: Thirty-eight qualitative in-depth interviews with healthcare professionals and family carers were conducted. Interviews focused on healthcare professionals and family carers perceptions of the main factors which influence admission to long-term care. Interviews were analysed thematically. Results: Long-term care admissions of people with dementia are affected by inadequacies in the Irish healthcare system in three ways. Firstly, community care services appear to be insufficient and inequitable, which limits their effectiveness. Secondly, such limitations in community care increase acute care admissions. Finally, admissions of people with dementia to acute care can accelerate the long-term care journey. Conclusions: Inadequacies in the Irish healthcare system have a substantial impact on the threshold for long-term care admissions. This study demonstrates that we cannot fully understand the factors that predict long-term care admission of people with dementia without taking into account how healthcare system factors impact on the continuation of homecare.
- May 2016
Background and purpose: Stroke is the third leading cause of death and disability. Few studies have assessed the profile and adequacy of access to rehabilitation services after ischaemic stroke both in the inpatient and community setting. The objectives of the Action on Secondary Prevention Interventions and Rehabilitation in Stroke (ASPIRE-S) study were to assess the disability and rehabilitation profile, adherence with rehabilitation recommendations and needs of patients 6 months following hospital admission for stroke. Methods: A rehabilitation prescription was completed before hospital discharge for each participant, and adherence to this prescription was assessed at 6 months to determine whether patients received their recommended rehabilitation needs. Results: Two hundred and fifty six patients were recruited to ASPIRE-S. The average age was 69 (SD 12.8). A majority (n = 221, 86%) were referred to the hospital multidisciplinary team, 59% (n = 132) were referred to all services (physiotherapy (PT), occupational therapy (OT), speech and language therapy (SLT)). Fifty-four percent (n = 119) of patients (seen by the multidisciplinary team) were referred for further rehabilitation in the community on discharge. Of these 119 patients, 112 (95%) recalled receiving community rehabilitation services. However, while most (68%) patients were referred for several disciplines (PT, OT, SLT), the most commonly recalled therapy (55%) was from a single discipline. The most commonly recommended frequency of therapy required was on a weekly basis. Sixty-one patients (51%) reported a delay in services, with some still awaiting services at 6 months. Conclusion: Results from this prospective study revealed that a significant number of patients (57%) did not receive the therapy recommended on discharge. Future initiatives should include the development of policies, which support more effective, equitable multidisciplinary rehabilitation for stroke patients in the community.
Background: Stroke is one of the leading causes of death and disability worldwide, and is associated with an increased risk of cognitive impairment. Cardiovascular risk factors appear to increase the risk of cognitive impairment, while effective risk factor control may reduce this risk. However, adherence to cardiovascular medications is often poor, and can be adversely affected by cognitive impairment. While use of cardiovascular medications may be related to a reduced risk of cognitive impairment, it is unclear how sub-optimal adherence affects the risk of cognitive impairment in stroke patients. Methods: The aim of this PhD thesis is to investigate the bidirectional association between cognitive impairment and medication adherence in stroke, through three studies. Results: Study 1 will systematically review the current evidence on the association between cognitive impairment and medication adherence in stroke. Study 2 will examine the prospective associations between cognitive impairment and medication adherence, and their impact on stroke recurrence, through recall of the ASPIRE-S (Action on Secondary Prevention Interventions and Rehabilitation in Stroke) cohort of stroke patients. Study 3 will explore these associations, and their impact on incident stroke, through secondary analysis of data from The Irish Longitudinal Study on Ageing. Conclusions: Findings from these three studies will help to elucidate the bidirectional association between cardiovascular medication adherence and cognitive impairment, and will indicate whether improving medication adherence presents a potential strategy to prevent or delay cognitive impairment.
Introduction Irish healthcare has undergone extensive change recently with spending cuts and a focus on quality initiatives; however, little is known about adverse event occurrence. Objective To assess the frequency and nature of adverse events in Irish hospitals. Methods 1574 (53% women, mean age 54 years) randomly selected adult inpatient admissions from a sample of eight hospitals, stratified by region and size, across the Republic of Ireland in 2009 were reviewed using two-stage (nurse review of patient charts, followed by physician review of triggered charts) retrospective chart review with electronic data capture. Results were weighted to reflect the sampling strategy. The impact on adverse event rate of differing application of international adverse event criteria was also examined. Results 45% of charts were triggered. The prevalence of adverse events in admissions was 12.2% (95% CI 9.5% to 15.5%), with an incidence of 10.3 events per 100 admissions (95% CI 7.5 to 13.1). Over 70% of events were considered preventable. Two-thirds were rated as having a mild-to-moderate impact on the patient, 9.9% causing permanent impairment and 6.7% contributing to death. A mean of 6.1 added bed days was attributed to events, representing an expenditure of €5550 per event. The adverse event rate varied substantially (8.6%–17.0%) when applying different published adverse event eligibility criteria. Conclusions This first study of adverse events in Ireland reports similar rates to other countries. In a time of austerity, adverse events in adult inpatients were estimated to cost over €194 million. These results provide important baseline data on the adverse event burden and, alongside web-based chart review, provide an incentive and methodology to monitor future patient-safety initiatives.
- Jan 2016
Background and purpose Revascularisation treatment with thrombolysis must be initiated within 4.5 h following ischaemic stroke symptom onset. Despite its proven benefits, thrombolysis therapy is underused, with patient delay in presenting to hospital with symptoms identified as the leading barrier. This study aimed to examine help-seeking behaviour at stroke onset, in order to understand delays in accessing acute medical care for stroke symptoms. Methods 149 consecutive patients hospitalised with ischaemic stroke were interviewed at 72 h poststroke with the Stroke Awareness Questionnaire and the Response to Symptoms Questionnaire. Results Sixty per cent of stroke cases presented to the ED within 3.5 h of stroke onset. Knowledge of stroke symptoms and risk factors was poor, with 40% unable to correctly define a stroke. Bystander recognition of symptoms (p=0.03) and bystander initiation of Emergency Medical Services was associated with ED presentation within 3.5 h (p=0.03). Conclusions This study provides insights into patient response when a stroke occurs, with the presence and action of others highlighted as critical in fast response to stroke symptoms. Knowledge of stroke warning signs and risk factors was low among stroke survivors. Findings highlight the complexity of changing help-seeking behaviour during stroke onset, and provide directions for public education efforts to reduce prehospital delay.
Cognitive impairment commonly occurs in the acute phase post-stroke, but may persist with over half of all stroke survivors experiencing some form of long-term cognitive deficit. Recent evidence suggests that optimising secondary prevention adherence is a critical factor in preventing recurrent stroke and the incidence of stroke-related cognitive impairment and dementia. The aim of this study was to profile cognitive impairment of stroke survivors at six months, and to identify factors associated with cognitive impairment post-stroke, focusing on indicators of adequate secondary prevention and psychological function. Participants were assessed at six months following an ischaemic stroke as part of the Action on Secondary Prevention Interventions and Rehabilitation in Stroke study (ASPIRE-S), which examined the secondary preventive and rehabilitative profile of patients in the community post-stroke. Cognitive impairment was measured using the Montreal Cognitive Assessment (MoCA). Two-hundred and fifty-six stroke patients were assessed at six months. Over half of the sample (56.6%) were found to have cognitive impairment, with significant associations between cognitive impairment and female sex (odds ratio (OR) = 1.6, 95% CI 1.01-2.57) and history of cerebrovascular disease (OR = 2.22, 95% CI 1.38-3.59). Treatment with antihypertensive medications (OR = .65, 95% CI .44-.96) and prescription of anticoagulant therapy (OR = .41, 95% CI .26-.68) were associated with reduced likelihood of cognitive impairment, however increasing number of total prescribed medications was moderately associated with poorer cognitive impairment (OR = 1.12, 95% CI 1.04-1.19). Findings reveal levels of cognitive impairment at 6 months post-stroke that are concerning. Encouragingly, aspects of secondary prevention were identified that may be protective in reducing the incidence of cognitive impairment post-stroke. Neuropsychological rehabilitation post-stroke is also required as part of stroke rehabilitation models to meet the burden of post-stroke cognitive impairment.
- Nov 2015
Mechanical guides in total knee arthroplasty are divided into intramedullary and extramedullary systems, designed to give accurate reference, to enable the surgeon to perform a tibial cut which is perpendicular to the mechanical axis. We conducted a systematic review and meta-analysis of levels 1 and 2 published data which directly compares the two methods of alignment, with outcomes of interest being the mean tibial component angle to the mechanical axis and the number of outliers from the optimal range. The PRISMA (preferred reporting items for systematic reviews and meta-analysis) guidance was followed. A search was conducted of online databases Medline PubMed; EMBASE; ISI Web of Science, and the Cochrane library, using the Boolean search string ([intramedullary OR extramedullary] AND knee AND [arthroplasty OR replacement]). Numerical data pertaining to tibial component alignment (TCA), the mechanical tibiofemoral angle, the tibial slope, and the number of outliers from optimal TCA were collated, and used to establish pooled results. No constraints on the search in terms of year of publication or language were instituted. Intrastudy bias was assessed using the Jadad score for randomized controlled trials and the Newcastle Ottawa score for prospective cohort studies. A total of 1,896 titles were reviewed. Following abstract review and full review of relevant articles, 10 publications were included for analysis, of which 8 were suitable to include for meta-analysis. No trials showed a significant difference in the mean TCA. Two trials showed an increased number of outliers in the extramedullary group and two studies showed an increased number of outliers in the intramedullary group. Pooled data from studies which included these outcomes showed no advantage for either system in limiting the number of outliers from the optimal TCA (relative risk, 0.99; 95% confidence interval [CI], 0.87-1.14; p = 0.004), and no significant difference in mean TCA (standardized mean difference, -0.07; 95% CI, -0.22 to 0.08; p = 0.000). Based on our results, no advantage can be attributed to the type of mechanical guide used in obtaining an adequate tibial cut. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.
Background Survivors of ischaemic stroke (IS) are at high-risk for future vascular events. Comprehensive information on the adequacy of secondary prevention after IS is lacking despite the knowledge that appropriate secondary prevention improves long-term patient outcomes. ASPIRE-S (Action on Secondary Prevention Interventions and Rehabilitation in Stroke) aimed to prospectively assess secondary prevention in patients 6 months following IS. Methods Consenting patients admitted with IS to three Dublin hospitals were recruited over 1 year, from October 2011. At 6 months post IS a comprehensive assessment was completed, modelled on the EUROASPIRE protocol for evaluation of the adequacy of secondary prevention in post-discharge cardiac patients. This assessment included measurements of blood pressure, body mass index and fasting lipid and glucose profiles. Secondary preventive medications and smoking status were also documented. Results Three hundred two patients (58 % male) participated, of whom 256 (85 %) were followed-up at 6 months. Mean age was 69 years (range 22–95). At follow-up, 68 % of patients had a BMI >25 kg/m2 and 16.4 % were still smoking. Almost two-thirds (63.4 %) had a blood pressure >140/90 and 23 % had low-density-lipoprotein >2.5 mmol/L. 28 % of diabetic patients had HbA1c ≥7 %. Ninety seven percent of patients were on anti-platelet and/or anticoagulant therapy. Of those with atrial fibrillation, 82 % were anti-coagulated (mean INR of 2.4). Ninety-five percent were on lipid-lowering therapy and three-quarters were on anti-hypertensive therapy. Conclusion This prospective multi-centre survey of IS patients demonstrated a high prevalence of remaining modifiable risk factors at 6 months post stroke, despite the widespread prescription of secondary preventive medications. There is scope to improve preventive measures after IS (in particular blood pressure) by incorporating evidence-based guidelines into quality assurance cycles in stroke care.
Aims This paper aims to examine the extent to which social context (supportive relationships, social participation and church attendance) and personal characteristics (personality and personal religiosity) modify the negative effects of disability on quality of life (QoL) in older people. Methods We used data from the Irish Longitudinal Study of Ageing (TILDA), a general-population sample of adults aged 50+ (n=2,700). QoL was measured with the two dimensions of the CASP-R12 – control/autonomy and self-realisation/pleasure. Disability was measured as the number of body function and activity deficits. We used conditional change regression analysis to test the effect of change in disability on change in QoL over two years, with interaction terms to examine moderating effects of supportive relationships (partner, relatives, and friends), social participation, church attendance, personality (neuroticism and extraversion) and personal religiosity (importance of religion to the person). Effects of age, sex, education, personality, retirement status and having a low income were adjusted for. Results Having a supportive partner significantly reduced the negative effect of increased disability on control/autonomy (interaction effect = 0.11, p=0.01), while the moderating effect of supportive relatives trended towards significance (0.08, p=0.05). Personal religiosity reduced the negative effect of increased disability on meaning and enjoyment in life (0.15, p<0.01). Social participation, church attendance and personality did not modify effects of increased disability on either QoL dimension. Conclusions Social context matters for maintaining QoL in poor physical health. Family relationships may provide key instrumental support, allowing older people to maintain independence as health declines. Social participation and church attendance may have direct benefits for QoL, but not buffer the negative effects of disability. However, effects of disability on QoL also depend on characteristics on the older person themselves - among those for whom religion is very important, physical health may be less important for living a fulfilling and enjoyable life.
Background and purpose: In-hospital stroke is associated with slower access to thrombolysis than community-occurring stroke. It has been suggested that lack of knowledge regarding appropriate stroke response among hospital staff may contribute to delays in referral, assessment, and treatment of in-hospital stroke. Method: A survey was conducted among hospital ward staff members using the Stroke Awareness Questionnaire, which was adapted for use among hospital staff to assess their knowledge of stroke symptoms, acute treatments, and hospital protocols for treatment of stroke. Results: Ninety-six staff members were interviewed, 81% of whom were clinical staff (medical, nursing, allied health professionals). Ninety-two percent of staff could name ≥3 stroke symptoms. Only 49% of staff were aware of thrombolysis treatment, and only 48% could identify the time window for thrombolysis administration, with staff from stroke-related specialties likely to name thrombolysis as an acute treatment for stroke (71%; odds ratio =3.36, 95% confidence interval 1.17-9.61) and identify the correct treatment window (71%; odds ratio =3.55, 95% confidence interval 1.24-10.16). Only 52% of staff on general wards were aware of an in-hospital stroke protocol. Conclusions: Hospital staff had adequate knowledge of stroke signs and symptoms; however, there was low awareness of thrombolysis therapy and its correct treatment time window among hospital staff. Targeted educational programmes among hospital staff regarding stroke are required to optimize acute stroke care.
- Jun 2015
Informal caregivers are vital to the long-term care and rehabilitation of stroke survivors worldwide. However, caregiving has been associated with negative psychological outcomes such as anxiety and depression, which leads to concerns about caregiver as well as stroke survivor well-being. Furthermore, caregivers may not receive the support and service provision they require from the hospitals and community. This study examines caregiver psychological well-being and satisfaction with service provision in the context of stroke. Caregiver data were collected as part of the ASPIRE-S study, a prospective study of secondary prevention and rehabilitation which assessed stroke patients and their carers at six-months post stroke. Carer assessment included measurement of demographics, satisfaction with care (UK Healthcare Commission National Patient Survey of Stroke Care), psychological distress (Hospital Anxiety and Depression Scale), and vulnerability (Vulnerable Elders Scale). Logistic regression analyses and chi-squared tests were performed using stata version 12. Analyses from 162 carers showed substantial levels of dissatisfaction (37·9%) with community and hospital services, as well as notable levels of anxiety (31·3%) and depressive symptoms (18·8%) among caregivers. Caregiver anxiety was predicted by stroke survivor anxiety (OR = 3·47, 95% CI 1·35-8·93), depression (OR = 5·17, 95% CI 1·83-14·58), and stroke survivor cognitive impairment (OR 2·35, 95% CI 1·00-5·31). Caregiver depression was predicted by stroke survivor anxiety (OR = 4·41, 95% CI 1·53-12·72) and stroke survivor depression (OR = 6·91, 95% CI 2·26-21·17). Findings indicate that caregiver and stroke survivor well-being are interdependent. Thus, early interventions, including increased training and support programs that include caregivers, are likely to reduce the risk of negative emotional outcomes. © 2015 World Stroke Organization.
Background: In the caregiving literature there is a common assertion that a higher level of carer stress is a critical determinant of premature ending of homecare. However, this contention has not been systematically assessed. We therefore systematically reviewed and meta-analysed the prospective association between various forms of carer stress and subsequent institutionalisation of community-dwelling older people. Methods: Systematic literature search of prospective studies measuring carer stress at baseline and institutionalisation at follow-up. Given substantial interchangeability in the measurement of carer stress, we included a wide number of exposure measures, namely: carer stress, burden, depression, distress, anxiety, burnout, and strain. Institutionalisation included both acute and long-term care utilisation. The standardised mean difference between stressed and non-stressed carers was the primary measure of effect. We assessed study quality with the Crowe Critical Appraisal Tool (CCAT). Pre-planned sensitivity analysis included examination of estimates according to study size; decade published; study quality according to quartiles of CCAT scores; population; follow-up period; study design and impact of adjusted or unadjusted estimates. Results: The search yielded 6,963 articles. After exclusions, we analysed data from 54 datasets. The meta-analysis found that while carer stress has a significant effect on subsequent institutionalisation of care recipients, the overall effect size was negligible (SMD = 0 · 05, 95% CI = 0 · 04-0 · 07). Sensitivity analyses found that, the effect size was higher for measurements of stress than for other measures, though still relatively small (SMD = 0 · 23, 95% CI = 0 · 09-0 · 38). Thus, whether analysing the association between carer stress, burden, distress, or depression with either acute or long-term care, the effect size remains small to negligible. Concurrently, we found estimates reduce over time and were smaller with larger studies and those of higher quality, according to the CCAT scores. Conclusion: Despite strong statements to the contrary, it appears that the effect of carer stress on subsequent care recipient institutionalisation is small to negligible. The current findings point to a biased literature, with significant small study effects. The results suggest a need to re-evaluate the degree to which carer stress predicts premature ending of home care. Concurrently, other factors may be more crucial in institutional placement than carer stress and should be investigated.
- May 2015
Background: Breast cancer is the most common cancer affecting women worldwide. It is a distressing diagnosis and, as a result, considerable research has examined the psychological sequelae of being diagnosed and treated for breast cancer. Breast cancer is associated with increased rates of depression and anxiety and reduced quality of life. As a consequence, multiple studies have explored the impact of psychological interventions on the psychological distress experienced after a diagnosis of breast cancer. Objectives: To assess the effects of psychological interventions on psychological morbidities, quality of life and survival among women with non-metastatic breast cancer. Search methods: We searched the following databases up to 16 May 2013: the Cochrane Breast Cancer Group Specialised Register, CENTRAL, MEDLINE, EMBASE, CINAHL and PsycINFO; and reference lists of articles. We also searched the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) search portal and ClinicalTrials.gov for ongoing trials in addition to handsearching. Selection criteria: Randomised controlled trials that assessed the effectiveness of psychological interventions for non-metastatic breast cancer in women. Data collection and analysis: Two review authors independently appraised and extracted data from eligible trials. Any disagreement was resolved by discussion. Extracted data included information about participants, methods, the intervention and outcome. Main results: Twenty-eight randomised controlled trials comprising 3940 participants were included. The most frequent reasons for exclusion were non-randomised trials and the inclusion of women with metastatic disease. A wide range of interventions were evaluated, with 24 trials investigating a cognitive behavioural therapy and four trials investigating psychotherapy compared to control. Pooled standardised mean differences (SMD) from baseline indicated less depression (SMD -1.01, 95% confidence interval (CI) -1.83 to -0.18; P = 0.02; 7 studies, 637 participants, I(2) = 95%, low quality evidence), anxiety (SMD -0.48, 95% CI -0.76 to -0.21; P = 0.0006; 8 studies, 776 participants, I(2) = 64%, low quality evidence) and mood disturbance (SMD -0.28, 95% CI -0.43 to -0.13; P = 0.0003; 8 studies, 1536 participants, I(2) = 47%, moderate quality evidence) for the cognitive behavioural therapy group than the control group. For quality of life, only an individually-delivered cognitive behavioural intervention showed significantly better quality of life than the control with an SMD of 0.65 (95% CI 0.07 to 1.23; P = 0.03; 3 studies, 141 participants, I(2) = 41%, very low quality evidence). Pooled data from two group-delivered studies showed a non-significant overall survival benefit favouring cognitive behavioural therapy compared to control (pooled hazard ratio (HR) 0.76, 95% CI 0.25 to 2.32; P = 0.63; 530 participants, I(2) = 84%, low quality evidence). Four studies compared psychotherapy to control with one to two studies reporting on each outcome. The four studies were assessed as high risk of bias and provided limited evidence of the efficacy of psychotherapy. Adverse events were not reported in any of the included studies. Authors' conclusions: A psychological intervention, namely cognitive behavioural therapy, produced favourable effects on some psychological outcomes, in particular anxiety, depression and mood disturbance. However, the evidence for survival improvement is still lacking. These findings are open to criticism because of the notable heterogeneity across the included studies and the shortcomings of the included studies.
Background: Patient delay in presenting to hospital with stroke symptoms remains one of the major barriers to thrombolysis treatment, leading to its suboptimal use internationally. Educational interventions such as mass media campaigns and community initiatives aim to reduce patient delays by promoting the signs and symptoms of a stroke, but no consistent evidence exists to show that such interventions result in appropriate behavioral responses to stroke symptoms. Methods: A systematic literature search and narrative synthesis were conducted to examine whether public educational interventions were successful in the reduction of patient delay to hospital presentation with stroke symptoms. Three databases, MEDLINE, CINAHL, and PsycINFO, were searched to identify quantitative studies with measurable behavioral end points, including time to hospital presentation, thrombolysis rates, ambulance use, and emergency department (ED) presentations with stroke. Results: Fifteen studies met the inclusion criteria: one randomized controlled trial, two time series analyses, three controlled before and after studies, five uncontrolled before and after studies, two retrospective observational studies, and two prospective observational studies. Studies were heterogeneous in quality; thus, meta-analysis was not feasible. Thirteen studies examined prehospital delay, with ten studies reporting a significant reduction in delay times, with a varied magnitude of effect. Eight studies examined thrombolysis rates, with only three studies reporting a statistically significant increase in thrombolysis administration. Five studies examined ambulance usage, and four reported a statistically significant increase in ambulance transports following the intervention. Three studies examining ED presentations reported significantly increased ED presentations following intervention. Public educational interventions varied widely on type, duration, and content, with description of intervention development largely absent from studies, limiting the potential replication of successful interventions. Conclusions: Positive intervention effects were reported in the majority of studies; however, methodological weaknesses evident in a number of studies limited the generalizability of the observed effects. Reporting of specific intervention design was suboptimal and impeded the identification of key intervention components for reducing patient delay. The parallel delivery of public and professional interventions further limited the identification of successful intervention components. A lack of studies of sound methodological quality using, at a minimum, a controlled before and after design was identified in this review, and thus studies incorporating a rigorous study design are required to strengthen the evidence for public interventions to reduce patient delay in stroke. The potential clinical benefits of public interventions are far-reaching, and the challenge remains in translating knowledge improvements and correct behavioral intentions to appropriate behavior when stroke occurs.
Background: Hospitalisation is an ideal time to implement smoking cessation interventions. However, little is known about the extent to which inpatients receive such advice, or the impact it has on motivation to quit and quitting behaviours post-hospitalisation. Aims: This study aimed to determine the prevalence of smoking and cessation advice received by inpatients in two teaching hospitals in Ireland, and the impact of cessation advice on smoking at 3 months post discharge. Methods: We surveyed 1001 inpatients across two hospital sites, over a six-month period. Demographic details, clinical history, smoking history, motivation to quit, cigarette dependence, and recent quitting history were assessed. Results: Prevalence of smoking within the sample was 23.4% (235/1001). Only 32% (75/235) of smokers reported that smoking cessation was discussed during admission. Smokers' mean Fagerström nicotine-dependence score was 3.7 (SD = 2.7), indicating low dependence levels. At 3 months, 17% (25/146) of smokers reported smoking cessation. Provision of smoking cessation advice during hospitalisation was associated with higher motivation to quit (OR = 2.79, 95% CI 2.12–3.68), and successful quit behaviour for confirmed (OR = 1.98, 95% CI 1.55–2.53) and self-reported quitters (OR = 1.47, 95% CI 1.3–1.66) Conclusions: This observational study finds that provision of brief cessation advice and smoking status documentation was suboptimal. Where advice was given, it was associated with enhanced motivation to quit and increased quit rates. These findings, along with low dependence scores, suggest that systematic provision of low-intensity cessation interventions could significantly enhance quit rates in hospitalised smokers.
- Sep 2014
Objectives: The effect of chronic disease status on quality of life (QoL) has been well established. However, less is known about how chronic diseases affect QoL. This article examines impairment in three domains of the WHO International Classification of Functioning, Health and Disability (ICF) - body function, activity and participation, as well as affective well-being, - as potential mediators of the relationship between chronic disease and QoL. Method: A cross-sectional sample (n = 4961) of the general Irish community-dwelling population aged 50+ years was obtained from the Irish Longitudinal Study of Ageing (TILDA). The CASP measure of QoL was examined as two dimensions - control/autonomy and self-realisation/pleasure. Structural equation modelling was used to test the direct and indirect effects of chronic disease on QoL, via variables capturing body function, activity, participation and positive affect. Results: A factor analysis showed that indicators of body function and activity loaded onto a single overall physical impairment factor. This physical impairment factor fully mediated the effect of chronic disease on positive affect and QoL. The total effect of chronic disease on control/autonomy (-0.160) was primarily composed of an indirect effect via physical impairment (-0.86), and via physical impairment and positive affect (-0.45). The decomposition of effects on self-realisation/pleasure was similar, although the direct effect of physical impairment was weaker. The model fitted the data well (RMSEA = 0.02, TLI = 0.96, CFI = 0.96). Conclusion: Chronic disease affects QoL through increased deficits in physical body function and activity. This overall physical impairment affects QoL both directly and indirectly via reduced positive affect.
Large national reviews of patient charts estimate that approximately 10% of hospital admissions are associated with an adverse event (defined as an injury resulting in prolonged hospitalisation, disability or death, caused by healthcare management). Apart from having a significant impact on patient morbidity and mortality, adverse events also result in increased healthcare costs due to longer hospital stays. Furthermore, a substantial proportion of adverse events are preventable. Through identifying the nature and rate of adverse events, initiatives to improve care can be developed. A variety of methods exist to gather adverse event data both retrospectively and prospectively but these do not necessarily capture the same events and there is variability in the definition of an adverse event. For example, hospital incident reporting collects only a very small fraction of the adverse events found in retrospective chart reviews. Until there are systematic methods to identify adverse events, progress in patient safety cannot be reliably measured. This review aims to discuss the need for a safety culture that can learn from adverse events, describe ways to measure adverse events, and comment on why current adverse event monitoring is unable to demonstrate trends in patient safety.
Background. Depression is an increasing problem in older adults, which is exacerbated by under diagnosis and ineffective treatment options. Broadly speaking, as people age, their levels of regular physical activity (PA) decrease, while their experience of chronic pain increases. PA has been shown to be an effective, yet under-utilised, treatment for depression in this age-cohort although the influence of pain on the relationship between PA and depressive symptoms has not been considered. Methods. Secondary analysis of national data from The Irish Longitudinal Study on Ageing (TILDA, 2011) (n = 8163 participants aged 50 years and older) examined the mediating or moderating role of pain in the relationship between depressive symptoms and PA, and the impact of PA, pain and depressive symptoms on health-care utilisation. Results. Approximately 8.5% TILDA older adults were depressed. No mediating or moderating effects of pain were found in the association between PA and depressive symptoms. Higher levels of PA were found to be independently associated with lower depressive symptoms, while higher levels of pain significantly increased the likelihood of depressive symptoms supporting previous findings. Depressive symptoms and higher levels of pain were also found to significantly increase health-care utilisation. Conclusions. Consistent with previous findings in this field, both PA and pain were found to be independently associated with depressive symptoms in Irish older adults. Furthermore, pain does not play a mediating or moderating role in the relationship between PA and depressive symptoms. Continued support for ongoing initiatives in this area aimed at increasing PA in older adults as a means to improve both physical and mental well-being is advised. The absence of any synergistic effect between PA and pain suggests that clinicians and health service providers should continue to promote PA as a treatment for depression, irrespective of the pain levels of their patients.
Health psychology is the study of psychological and behavioural processes in health, illness and health care. Health psychology emerged in Ireland with the establishment of the Psychological Society of Ireland (PSI) Health Psychology Special Interest Group in the mid-1980s, which in 2003 became the Division of Health Psychology (DHP). The DHP has grown quickly and has established itself as an active and engaged PSI Division. This paper outlines the history of health psychology in Ireland. Current opportunities and challenges for both the discipline and profession of Health Psychology are considered, and future directions are highlighted.
Background: Survivors of ischaemic stroke (IS) are at high-risk for future vascular events. Comprehensive information on the adequacy of secondary prevention after IS is lacking despite the knowledge that appropriate secondary prevention improves long-term patient outcomes. ASPIRES (Action on Secondary Prevention Interventions and Rehabilitation in Stroke) aimed to prospectively assess secondary prevention in patients 6 months following IS. Methods: Consenting patients admitted with IS to three Dublin hospitals were recruited over 1 year, from October 2011. At 6 months post IS a comprehensive assessment was completed, modelled on the EUROASPIRE protocol for evaluation of the adequacy of secondary prevention in post-discharge cardiac patients. This assessment included measurements of blood pressure, body mass index and fasting lipid and glucose profiles. Secondary preventive medications and smoking status were also documented. Results: Three hundred two patients (58 % male) participated, of whom 256 (85 %) were followed-up at 6 months. Mean age was 69 years (range 22–95). At follow-up, 68 % of patients had a BMI >25 kg/m 2 and 16.4 % were still smoking. Almost two-thirds (63.4 %) had a blood pressure >140/90 and 23 % had low-density-lipoprotein >2.5 mmol/L. 28 % of diabetic patients had HbA1c ≥7 %. Ninety seven percent of patients were on anti-platelet and/or anticoagulant therapy. Of those with atrial fibrillation, 82 % were anti-coagulated (mean INR of 2.4). Ninety-five percent were on lipid-lowering therapy and three-quarters were on anti-hypertensive therapy. Conclusion: This prospective multi-centre survey of IS patients demonstrated a high prevalence of remaining modifiable risk factors at 6 months post stroke, despite the widespread prescription of secondary preventive medications. There is scope to improve preventive measures after IS (in particular blood pressure) by incorporating evidence-based guidelines into quality assurance cycles in stroke care.
Mass media campaigns for stroke awareness encourage the public to recognise stroke symptoms and respond to stroke in a timely manner. However, there is little evidence to suggest that media messages can influence behaviour after stroke onset. The F.A.S.T. (Face Arm Speech Time) test is a common stroke recognition tool used in public education campaigns. To assess the impact of the F.A.S.T. campaign on health service use in Ireland, which has had no previous exposure to a F.A.S.T. media campaign. An interrupted time series design was used to detect behaviour change after the introduction of the first Irish F.A.S.T. campaign in presentations of patients with suspected stroke to two emergency departments (EDs), serving a population of about 580 000. There was a significant change in ED attendance of patients with reported stroke symptoms after the introduction of the F.A.S.T. campaign (β=0.84, 95% CI 0.43 to 1.24; p<0.001), although this was not sustained. ED presentation within 3.5 h was associated with emergency medical services activation (OR=3.1, p<0.001) and self-referral to the ED (OR=2.67, p<0.001). This first Irish F.A.S.T. campaign had an initial impact on ED attendance of patients with stroke symptoms. However, the campaign effects were not sustained in the long term. Results indicate that prehospital delay in accessing acute stroke services is a complex process with involvement of factors other than stroke knowledge and intention to call 911.
- Mar 2013
Purpose: This study aims to evaluate the validity of current measurement models for the control, autonomy, self-realisation, and pleasure (CASP) measure of quality of life (QoL)-a second-order four-factor CASP-19 model and a second-order three-factor CASP-12 version-in a recent population survey. A previous large sample study did not report good fit for these measurement models. The study also aims to re-develop the model and propose a well-fitting alternative. Methods: To evaluate the current measurement models, confirmatory factor analysis (CFA) was used. A cross-sectional sample (n = 6,823) representative of the Irish community-dwelling population aged 50 and over was obtained from the Irish Longitudinal Study of Ageing (TILDA). Model revision was based on descriptive statistics, exploratory factor analysis and examination of fit diagnostic statistics. Revised models were tested using CFA. Results: The results of the CFA did not support the validity of the established measurement models. A reformulated 12-item, two-factor model comprising control/autonomy and self-realisation/pleasure, with residual covariances for negatively worded items, had excellent fit to the data (χ(2) 161.90, df = 44, p < 0.001; RMSEA = 0.03, 90 % CI 0.02-0.03), and a clearer conceptual rationale. The same model with one overall QoL factor had similar excellent fit. Conclusions: We recommend the use of the single-factor model (CASP-R12) when assessing overall quality of life. The dimensions of control/autonomy and self-realisation/pleasure can be examined separately by researchers interested in those constructs. Researchers using structural equation modelling can use the well-fitting measurement model outlined here including adjustment for residual covariances.
Background and purpose: this paper examines the impact of demographic change from 2007 to 2021 on the total cost of stroke in Ireland and analyses potential impacts of expanded access to stroke unit care and thrombolytic therapy on stroke outcomes and costs. Methods: total costs of stroke are estimated for the projected number of stroke cases in 2021 in Ireland. Analysis also estimates the potential number of deaths or institutionalised cases averted among incident stroke cases in Ireland in 2007 at different rates of access to stroke unit care and thrombolytic therapy. Drawing on these results, total stroke costs in Ireland in 2007 are recalculated on the basis of the revised numbers of incident stroke patients estimated to survive stroke, and of the numbers estimated to reside at home rather than in a nursing home in the context of expanded access to stroke units or thrombolytic therapy. Results: future costs of stroke in Ireland are estimated to increase by 52-57% between 2007 and 2021 on the basis of demographic change. The projected increase in aggregate stroke costs for all incident cases in 1 year in Ireland due to the delivery of stroke unit care and thrombolytic therapy can be offset to some extent by reductions in nursing home and other post-acute costs.
Quality of life (QoL) is a key outcome variable in determining the success of health and social policy. Often, QoL is assessed in a context where health or well-being are compromised. This study sought to explore individually defined QoL among older people living in the community in Ireland and to examine its determinants, including health and psychological well-being, and perceptions of ageing. A national randomly selected sample of community-dwelling older people (aged 65+) in the Republic of Ireland and Northern Ireland (N = 1,815) were interviewed in their homes. QoL, health and social status, and perceptions of ageing were assessed. The mean QoL score was high (78.5, SD = 18.1). Higher QoL was associated with higher social class, better self-assessed health, fewer functional impairments and lower levels of depression and loneliness (allp < .001). Higher QoL was also associated with more positive perceptions of ageing. While QoL for this older population was high, it was significantly negatively affected by lower socio-economic status and negative perceptions of ageing.
Despite advances in the acute management of stroke, a large proportion of stroke patients are left with significant impairments. Over the coming decades the prevalence of stroke-related disability is expected to increase worldwide and this will impact greatly on families, healthcare systems and economies. Effective neuro-rehabilitation is a key factor in reducing disability after stroke. In this review, we discuss the effects of stroke, principles of stroke rehabilitative care and predictors of recovery. We also discuss novel therapies in stroke rehabilitation, including non-invasive brain stimulation, robotics and pharmacological augmentation. Many trials are currently underway, which, in time, may impact on future rehabilitative practice.
Stroke is the second leading cause of death worldwide, and the leading cause of acquired disability in adults. An audit conducted by the Irish Heart Foundation revealed that there are inadequate services and facilities to prevent, assess and treat the yearly 10 000 stroke victims in Ireland. A national media campaign (FAST) was broadcast to educate people about the warning signs of stroke. This audit is to examine the effectiveness of the Beaumont Hospital Acute Stroke Unit and the FAST campaign.
Best practice communication between healthcare professionals and patients involves using quality patient information leaflets (PILs). We assessed medical and physiotherapy students' (N = 337) ability to appraise the readability, psychology theory content and quality of nine international smoking PILs. Flesch scores ranged from 52.8-79.7% (fairly difficult to fairly easy). Students identified components of the Health Belief Model (84-98%), Theory of Planned Behaviour (65-88%) and Transtheoretical Model (37-86%). Importantly, student-proposed additional theory-based content had no detrimental effect on readability scores. Overall quality scores indicated low-moderate quality. This assignment helped students critically evaluate the utility of PILs for communication.
Background The extent of stroke-related disability typically becomes most apparent after patient discharge to the community. As part of the Irish National Audit of Stroke Care (INASC), a national survey of community-based allied health professionals and public health nurses was conducted. The aim was to document the challenges to service availability for patients with stroke in the community and to identify priorities for service improvement. Methods The study was a cross-sectional tailored interview survey with key managerial and service delivery staff. As comprehensive listings of community-based health professionals involved in stroke care were not available, a cascade approach to information gathering was adopted. Representative regional managers for services incorporating stroke care (N = 7) and disciplinary allied health professional and public health nurse managers (N = 25) were interviewed (94% response rate). Results Results indicated a lack of formal, structured community-based services for stroke, with no designated clinical posts for stroke care across disciplines nationally. There was significant regional variation in availability of allied health professionals. Considerable inequity was identified in patient access to stroke services, with greater access, where available, for older patients (≥ 65 years). The absence of a stroke strategy and stroke prevalence statistics were identified as significant impediments to service planning, alongside organisational barriers limiting the recruitment of additional allied health professional staff, and lack of sharing of discipline-specific information on patients. Conclusions This study highlighted major gaps in the provision of inter-disciplinary team community-based services for people with stroke in one country. Where services existed, they were generic in nature, rarely inter-disciplinary in function and deficient in input from salient disciplines. Challenges to optimal care included the need for strategic planning; increased funding of healthcare staff; increased team resources and teamwork; and removal of service provision barriers based on age. There were notably many challenges beyond funding. Similar evaluations in other healthcare systems would serve to provide comparative lessons to serve to tackle this underserved aspect of care for patients with stroke and their families.
The process of adaptation to the physical and psychosocial consequences after stroke is a major challenge for many individuals affected. The aim of this study was to examine if stroke patients within 1 month of admission (n = 153) and followed up at 1 year (n = 107) engage in selection, optimization, and compensation (SOC) adaptive strategies and the relationship of these strategies with functional ability, health-related quality of life (HRQOL) and depression 1 year later. Adaptive strategies were measured using a 15-item SOC questionnaire. Internal and external resources were assessed including recovery locus of control, stroke severity, and socio-demographics. Outcome measures were the Stroke Specific Quality of Life Questionnaire (SS-QoL), the Nottingham Extended Activities of Daily Living Scale and the Depression Subscale of the Hospital Anxiety and Depression Scale. Findings indicated that stroke patients engaged in the use of SOC strategies but the use of these strategies were not predictive of HRQOL, functional ability or depression 1 year after stroke. The use of SOC strategies were not age specific and were consistent over time, with the exception of the compensation subscale. Results indicate that SOC strategies may potentially be used in response to loss regulation after stroke and that an individual's initial HRQOL functional ability, levels of depression and socio-economic status that are important factors in determining outcome 1 year after stroke. A stroke-specific measure of SOC may be warranted in order to detect significant differences in determining outcomes for a stroke population.