Emerging Evidence -
Findings from the four stroke theme
projects.
Chair: Prof Marion Walker
A partnership between
Nottingh...
Leading Change in
Early Supported Discharge
Dr Rebecca Fisher & Professor Marion Walker
A partnership between
Nottinghamsh...
• Overview of the Stroke Early Supported
Discharge research programme
• Are the benefits of ESD still evident in
practice?...
Thanks to the Team
Collaboration for Leadership in Applied Health Research and Care for
Nottinghamshire, Derbyshire and Li...
• UK Policy context: National Stroke Strategy 2007, Royal
College Physicians Clinical Guideline for Stroke
• Clinical tria...
• “In performing the research we aim to (a) gain
clarity around how an ESD service might be
organised (b) test methods to ...
• Stroke Rehabilitation Implementation Research
• (A) What is the evidence?: Consensus on the core components of
evidence ...
A partnership between
Nottinghamshire Healthcare NHS Trust
and the University of Nottingham
Collaboration for Leadership i...
• Participants admitted to SU at NUH & SFH: Nov’10- Feb’12
• Eligibility criteria informed by international ESD Consensus
...
• Baseline & scheduled follow-up home visits (6, 26, 52 wk F/U)
• Choice determined by previous trials & meta-analyses inv...
• LOS used to calculate associated hospital based costs patient
by patient basis
• Using HRG & Trim-points translated LOS ...
Flow of participants
through study
Baseline Characteristics of Participants
Collaboration for Leadership in Applied Health Research and Care for
Nottinghamsh...
Clinical Hospital Data
Collaboration for Leadership in Applied Health Research and Care for
Nottinghamshire, Derbyshire an...
• ESD group significantly more knowledgeable
– Risk & practical help at 6 weeks (P<0.05)
– Community services & emotional ...
Comparison of patient outcomes:
Within Group Comparison
Collaboration for Leadership in Applied Health Research and Care f...
Collaboration for Leadership in Applied Health Research and Care for
Nottinghamshire, Derbyshire and Lincolnshire
CLAHRC N...
• Interaction Model: explore between group differences whilst adjusting for
possible covariates
– Descriptive analyses age...
Collaboration for Leadership in Applied Health Research and Care for
Nottinghamshire, Derbyshire and Lincolnshire
CLAHRC N...
Collaboration for Leadership in Applied Health Research and Care for
Nottinghamshire, Derbyshire and Lincolnshire
CLAHRC N...
Collaboration for Leadership in Applied Health Research and Care for
Nottinghamshire, Derbyshire and Lincolnshire
CLAHRC N...
Collaboration for Leadership in Applied Health Research and Care for
Nottinghamshire, Derbyshire and Lincolnshire
CLAHRC N...
Collaboration for Leadership in Applied Health Research and Care for
Nottinghamshire, Derbyshire and Lincolnshire
CLAHRC N...
Thank you for listening
rebecca.fisher@nottingham.ac.uk
www.clahrc-ndl.nihr.ac.uk
Twitter: @CLAHRC_NDL
Collaboration for L...
Concern that it would be
unethical to withdraw such
an established and accepted
treatment.
Concern that it would be
unethical to withdraw such
an established and accepted
treatment.
A pilot study of home visits
in...
1. National survey
 184 questionnaire posted
2. Opinions and perceptions
 42 interviews;
 17 with patients/staff involv...
1. National survey of practice
What is routine occupational therapy
practice when conducting pre-discharge
home visits for...
How many visits?
 Pre discharge assessment visit
April and May 2011 mean 7 (sd 6.93) 0- 27
 Access visit
April and May 2...
Reason for home visit
Reason Frequency Percentage
Assess/practice activities of daily living
in home environment
79 96%
Id...
Time on visits
 Time at home on visits. Range 10-135 mins
Mean 63 mins (SD 20) i.e. just over an hour
 Time on travel. R...
Time on…
 Time to organise visits.
Range 10-240 mins
Mean 50 mins (SD 34.58)
 Time writing up report.
Range 2-210 mins
M...
Overall time
Mean time 223 minutes
i.e. almost 3 ¾ hours
to undertake the „average‟ home visit
What is in your visiting bag?
Summary
 National picture of home visits
 Reasons for visits
 Time/workload involved
 National links for interviews/fu...
2. Opinions and perceptions;
experts, OTs, patients.
2. Opinions and perceptions;
experts, OTs, patients.
 Differing purposes of visits
 Effective use of resources
 „Entren...
2. Opinions and perceptions;
experts, OTs, patients.
 Differing purposes of visits
 Effective use of resources
 „Entren...
Should it be an OT?
YES
„Unique still to OT … should be protected … and
not become generic‟ (042).
Should it be an OT?
YES
„Unique still to OT … should be protected … and
not become generic‟ (042).
NO
„It is always assume...
Visiting
 There are often requests for visits which I feel
are inappropriate(127).
Visiting
 There are often requests for visits which I feel
are inappropriate(127).
 I don‟t think they [home visits] nee...
Visiting
 There are often requests for visits which I feel
are inappropriate(127).
 I don‟t think they [home visits] nee...
Resource issues
 They are popular with patient and staff however
they lack some understanding of how much time
and effort...
Resource issues
 They are popular with patient and staff however
they lack some understanding of how much time
and effort...
“…..they do not cost a lot, compared to a lot of
other interventions… if they then are reducing the
hospital stay by even ...
Realistic?
„They get observed in a very artificial situation for
an hour and then the occupational therapist makes
a judgm...
Realistic?
„They get observed in a very artificial situation for
an hour and then the occupational therapist makes
a judgm...
Patients
“I was quite happy in as much as I know that the
fact I‟d got a home visit they were considering me,
releasing me...
“Without a doubt, it was things that I haven‟t even
thought about, the height of the bed the amount
of steps from the stai...
3. Feasibility RCT
 Worked with clinical
colleagues to agree the
methodology
 Clinicians had power as
gate keepers in pr...
3. Feasibility RCT
 Worked with clinical
colleagues to agree the
methodology
 Clinicians had power as
gate keepers in pr...
3. Feasibility RCT
 RCT- 93 patients
randomly allocated;
 47 to intervention arm
(home visit) and
 46 to control (inter...
Feasibility RCT
 RCT -93 patients
randomly allocated;
 47 to intervention arm
46 to control
 Parallel -33
Recruitment
Systematic collection of data
 Mean cost of home visit £208 (SD £107).
 Mean cost of a hospital interview £75 (SD£40).
Trial Issues for future
 Measures
 Protocol adherence
 Safety- more falls in in home visit arm- more
confident? Chance?...
Relevant?
 Data shows interesting differences /RCT
feasible
 Main paper was 10th most read article in Clinical
Rehabilit...
HOVIS 2?
Thanks to…
TEAM HOVIS
Phillip Whitehead
Karen Fellows
Nikki Sprigg
Claire Edwards
STEERING GROUP
Prof Nadina Lincoln
Chris...
Wii STAR: Wii Stroke Therapy for
Arm Rehabilitation
PJ Standen, Kate Threapleton, Louise Connell,
Andy Richardson, David B...
Background
Collaboration for Leadership in Applied Health Research and Care for
Nottinghamshire, Derbyshire and Lincolnshi...
Background
Collaboration for Leadership in Applied Health Research and Care for
Nottinghamshire, Derbyshire and Lincolnshi...
Development of equipment
Collaboration for Leadership in Applied Health Research and Care for
Nottinghamshire, Derbyshire ...
Development of games
Collaboration for Leadership in Applied Health Research and Care for
Nottinghamshire, Derbyshire and ...
Feasibility trial
Collaboration for Leadership in Applied Health Research and Care for
Nottinghamshire, Derbyshire and Lin...
Feasibility trial
Collaboration for Leadership in Applied Health Research and Care for
Nottinghamshire, Derbyshire and Lin...
Feasibility trial
Collaboration for Leadership in Applied Health Research and Care for
Nottinghamshire, Derbyshire and Lin...
Adherence Data
Collaboration for Leadership in Applied Health Research and Care for
Nottinghamshire, Derbyshire and Lincol...
Barriers to use
Collaboration for Leadership in Applied Health Research and Care for
Nottinghamshire, Derbyshire and Linco...
Facilitators
Collaboration for Leadership in Applied Health Research and Care for
Nottinghamshire, Derbyshire and Lincolns...
Outcome measures
Collaboration for Leadership in Applied Health Research and Care for
Nottinghamshire, Derbyshire and Linc...
Therapist Time - Participant Visits
Collaboration for Leadership in Applied Health Research and Care for
Nottinghamshire, ...
Therapist Time – Duration of Visits
Collaboration for Leadership in Applied Health Research and Care for
Nottinghamshire, ...
Therapist time - conclusions
Collaboration for Leadership in Applied Health Research and Care for
Nottinghamshire, Derbysh...
What we have learnt
Collaboration for Leadership in Applied Health Research and Care for
Nottinghamshire, Derbyshire and L...
Thank you for listening
p.standen@nottingham.ac.uk
kate.threaplrton@nottingham.ac.uk
www.clahrc-ndl.nihr.ac.uk
Twitter: @C...
Return to Work after Stroke:
A Feasibility Randomised Controlled Trial
Mary Grant
On behalf of:
KA Radford, EJ Sinclair, J...
Collaboration for Leadership in Applied Health Research and
Care for Nottinghamshire, Derbyshire and Lincolnshire
CLAHRC N...
• Vocational Rehabilitation: a process whereby those
disadvantaged by illness or disability can access, maintain
or return...
Collaboration for Leadership in Applied Health Research and
Care for Nottinghamshire, Derbyshire and Lincolnshire
CLAHRC N...
Aim of study
To test the feasibility of designing and delivering
occupational therapy-led stroke-specific
vocational rehab...
Method
Stroke survivors recruited from
acute and stroke rehab stroke wards
OT-led stroke-specific
vocational rehabilitatio...
Intervention
• Best practice guidelines (Tyerman and Meehan, 2004)
• Mapping work (Sinclair et al., 2013)
• Assessment, in...
Inclusion Criteria
• Confirmed stroke diagnosis
• Aged 16+
• In paid/voluntary work, education, >1 hour per week
Exclusion...
Participants
Gender: n (%)
Male
Female
17 (73.9%)
6 (26.1%)
19 (82.6%)
4 (17.4%)
Age
Mean (SD)
Range
58.3 (12.7)
24-78
53....
0
5
10
15
20
25
30
35
Minor
Moderate
Moderate/Seve
re
Severe
Missing
NIHSS; Stroke Severity (%) SSVR
Control
0
5
10
15
20
...
Participants
0
1
2
3
4
5
6 Visual Impairments (n)
SSVR
Control
0
5
10
15
20
25
30
35
40
45
Not affected Aphasia Dysarthria...
Primary Outcome
• Returned to work: yes/no
Secondary Outcomes
• Mood: Hospital Anxiety and Depression Scale (HADS)
• Work ...
Results: Participants
Collaboration for Leadership in Applied Health Research and
Care for Nottinghamshire, Derbyshire and...
Feasibility
0
20
40
60
80
100
3m 6m 12m
Questionnaire Response Rates (%)
SSVR
Control
Collaboration for Leadership in Appl...
Primary Outcome
0
20
40
60
80
100
3m 6m 12m
Participants in Work (%) SSVR
Control
Collaboration for Leadership in Applied ...
0
2
4
6
8
10
12
14
16
18
20
22
3m 6m 12m
Nottingham Extended Activities of Daily
Living: Median Score SSVR
Control
0
2
4
6...
Secondary Outcomes
-2
3
8
3m 6m 12m
WLQ: % Productivity Loss SSVR
Control
Collaboration for Leadership in Applied Health R...
Secondary Outcomes
0
15
30
45
60
3m 6m 12m
Sydney Psychosocial Reintegration
Scale: Median Score SSVR
Control
.00
.20
.40
...
Discussion
• Primary outcome: More intervention group participants
were in work at 12 months
• Secondary outcomes: Relativ...
Limitations
• More information known about the intervention
group
• Fixed time period
• Descriptive comparisons
Collaborat...
Conclusions
• Early OT-led SSVR can be effectively delivered and
measured using standardised and bespoke
questionnaires
• ...
References
• Daniel K, Wolfe CDA, Busch MA, McKevitt C (2009) What are the social
consequences of stroke in working aged a...
References
• Saka O, McGuire A, Wolfe C (2009) Cost of stroke in the United Kingdom.
Age and Ageing, 38(1), 27–32
• Sincla...
Thank you for listening
Collaboration for Leadership in Applied Health Research and Care for
Nottinghamshire, Derbyshire a...
Stroke Event 13 Sep  - First morning presentations
Stroke Event 13 Sep  - First morning presentations
Stroke Event 13 Sep  - First morning presentations
Stroke Event 13 Sep  - First morning presentations
Stroke Event 13 Sep  - First morning presentations
Stroke Event 13 Sep  - First morning presentations
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Stroke Event 13 Sep - First morning presentations

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  • Reasons for failure to complete measures included:
  • This table shows the demographic characteristics of the groups at baseline.The groups were similar with regard to Barthel scores, ethnic and sex variables and number of days between stroke onset and baseline assessment. The only demographic variable where groups differed was age, with the ESD group being slightly younger than the nonESD group.
  • We found no significant differences between groups in mortality or number of readmissions to a stroke unit or general ward within 28days and 1 year of baseline assessment. Patients referred to ESD had significantly shorter initial rehabilitation and total length of hospital stay.
  • Within group analysis were used to explore changes over time and indicated that both ESD and Non ESD patients improved significantly: changes were shown in the Barthel Index (increase), GHQ-28 (decrease), mental subcomponent score (MSC) of the SF-36 and EuroQol perceived health status (increases) across the three time points in both groups (Table 3). For the non ESD group there was also a significant increase over time on the NEADL (P=0.037). For the ESD group only, there were statistically significant increases in quality of life as indicated by the EuroQol Index (P=0.001) and the physical subcomponent summary scores (PSC) of the SF36 (P=0.010).
  • This table shows β (SE) and P values determined by modelling the combined within and between groups effects over time (baseline to 52 weeks) using the primary outcome measure, the Barthel Index, as the dependent variable.
  • In the model, for patients whose length of hospital stay exceeded 9 days (average length of stay for ESD patients in our study) we modelled that the hospital was awarded the full tariff. For patients whose length of hospital stay was up to 3 days, the model awarded the hospital was awarded part of the tariff (£1,500; Table 6) and for patients whose length of hospital stay was 4 to 9 days, the hospital was awarded £2,654 (AA22Z) or £2,588 (AA23Z). In both cases in our model, the procurer or commissioner could then retain part of the tariff as ‘savings’. For patients who exceeded the trim point, the additional payment was made to the hospital in the form of excess bed day costs (in line with the Payments by Results scheme). Of our study sample, 237 participants were assigned HRG codes AA22z or AA23z. A total saving of £245,217 was calculated based on total hospital length of stay for each patient and using the proposed tariff unbundling model. The average annual cost of the ESD services involved in our study, based on their team composition, was £350,000.
  • Of our study sample, 237 participants were assigned HRG codes AA22z or AA23z. A total saving of £245,217 was calculated based on total hospital length of stay for each patient and using the proposed tariff unbundling model. The average annual cost of the ESD services involved in our study, based on their team composition, was £350,000.
  • Includes 3 pilot – non randomised WithdrawalsAfter consent – 1 health reasons, 1 changed their mindIntervention withdrawals After baseline – 1 family issues (07/JW); 1 intervention ‘wasn’t his thing’ (16/DL); 1 could not complete training due to arm pain (19/CE; 1 had seizures (AP/27); 1 arm pain and severe aphasia (JR/28)After midpoint - 1 illness (pilot 02/PB); 1 family member ill (26/LS); 1 going on long holiday so only had 4 week intervention (CP/09)Control – found the measures onerous,
  • (3 depended on someone else to set it up for them).
  • 04 and 13 Received &gt; 15 visits.They both experienced technical problems and other issues
  • 04 and 13 Received &gt; 15 visits.They both experienced technical problems and other issues
  • My name is Mary Grant and I was employed as the research OT on the return to work after stroke study over the last three years.I am presenting today on behalf of all the people on the slide and would like to say a big thank you to all those who have helped with or participated in this project some of whom are here today – its great to see you!
  • So a bit of background then - 110,000 strokes occur in the UK each year, and despite common misconceptions, a significant number of these occur in young adults of working age. Returning to work is a primary goal for many, however, less than half of stroke survivors are able to resume work. Worklessness has been linked to reduced physical and mental health and has been equated to smoking 10 packets of cigarettes a day. Not only does this have an effect on the stroke survivors quality of life, it also has an impact on society - the estimated costs associated with social care, informal care giving and lost productivity are estimated at £8.9 billion a year in the UK.
  • Vocational rehabilitation is defined as a process whereby those disadvantaged by illness or disability can ‘access, maintain or return to employment’Despite the growing political and social awareness of the importance of supporting those with disabilities back into work, only 37% of what were previous known as primary care trusts addressed work needs, less than 10% of the estimated requirementThere is a dearth of evidence supporting the clinical and cost-effectiveness of stroke specific vocational rehabilitation which is needed to prompt a change in service provision
  • This has been a four stage project as you can see on the slide.We started with an interview and mapping study of local provision in Derbyshire to support people back into work after a stroke. We found out what key stakeholders (stroke survivors, employers and providers from different sectors) thought the gaps in existing services were and what they wanted from stroke specific vocational rehabilitation.We used this information to design the intervention and tested it out on two case study participants in the development stage.We then carried out the feasibility trial (which is the main focus of my talk today) alongside economic and intervention analysis.Finally a number of stroke survivors and employers who received the intervention were interviewed to explore whether it was useful and acceptable (poster about this displayed today).
  • So this study aimed to assess the feasibility of designing and delivering an occupational therapy-led stroke-specific vocational rehabilitation intervention and measuring it’s effectiveness in a pilot randomised controlled trial.
  • Participants were identified from the Royal Derby Hospital. Ward staff identified potential participants and passed on the patient information sheet. Potential participants were given a minimum of 24 hours to consider participating, at which point they were visited by a researcher on the ward or at home if they had already been discharged. The researcher obtained consent and collected baseline data. Participants were then followed up postally at 3, 6 and 12 months post-randomisation
  • The intervention was designed using best practice guidelines and mapping work in Derbyshire. It involved assessment of the individual and their job and workplace, the provision of information and education, work preparation and the facilitation of a phased return. It was based on a case coordination model identified by Fadyl and McPherson where intervention is provided prior to and following work return alongside liaison with and referral to other services where appropriate.
  • Stroke participants were eligible if they were aged 16 or over and they were in paid or voluntary work or education for a minimum of 1 hour per week. Those not intending to RTW and those lacking capacity to give informed consent were also excluded.
  • The demographics of participants were generally comparable across the two groups. As you’d expect we had higher numbers of males both groups. The average age in both groups was in the 50s. Most participants were white British.We used the Standard Occupation Classification to determine job type; there were more participants with professional or managerial jobs in the intervention group whereas there were higher levels of unskilled and semi-skilled workers in the control group. This was the only statistically significant difference between groups and so has to be taken into account when looking at results.
  • There were relatively similar levels of stroke severity across the two groups as measured by the NIHSS, the majority of participants had mild to moderate strokes. We did have some missing data relating to stroke severity due to this information not being recorded the hospital notes. There were slightly higher numbers of participants in the intervention group with lacunar or partial anterior strokes, whereas more participants in the control group had total anterior or posterior circulation strokes.
  • Most participants in both groups didn’t have any speech and language impairments, but the percentages of participants who presented with aphasia or dysarthria were relatively comparable across the two groups. Slightly more participants in the intervention group had hemianopias but there were slightly higher levels of other visual disorders in the control group.
  • The primary outcome was whether the participant was in work at 12 monthsThe secondary outcomes were mood; measured by the HADS, work productivity; measured by two scales the WPAI and the WLQ; social participation; as measured by the SPRS, activities of daily living, as measured by the NEADL and finally, health status as measured by the EQ-5D
  • On average, 693 participants are admitted to the Royal Derby Hospital each year with stroke*.Of the 126 stroke survivors who met the inclusion criteria, 40 declined to take part (various reasons – missed on ward and did not respond to letters sent out, mild stroke did not feel they needed help, severe stroke or significant speech and/ or cognitive difficulties which meant they felt it was too early to think about work). 38 participants failed to meet the inclusion criteria for various reasons (diagnosed with TIA or migraine not stroke, decided not to return to work or planned to retire as a result of the stroke).46 recruited and 23 randomised to each arm of the trial). So 46 people were recruited and 23 randomised to each group.(*works out about 800 over 15 months but actually 1098 over our16 months recruitment period – should have been 15 months but due to staff changes – extended by a month).
  • This slide shows the response rates of the two groups at all three time points i.e. the percentage of participants who returned their questionnaires. There was relatively little variation across the two groups however the greatest difference was at 12 months; 78% of the intervention group returned their 12 month questionnaire in comparison to 61% of the control group. Acrossboth groups and all three time points, there was an average response rate of 73.9%
  • At 12 months, 57% of participants in the intervention group reported they were in work compared to 26% of participants in the control group (note there were more participants lost to follow up in the control group so we were unable to determine their vocational status)
  • The higher the scores on the NEADL demonstrate higher levels of ADLs, and a perfect score would be 22. As would be expected with mainly mild to moderate strokes, ADLS were relatively high throughout the course of the project, and there was very little variation between the two groups. In terms of anxiety and depression as measured by the HADS, there were also similar scores between the two groups. A higher score demonstrates higher levels of anxiety or depression.
  • Top graph shows the percentage of work productivity loss using the Work Limitations Questionnaire. There appears to be a greater % loss in the control group, especially at 6 and 12 months. The bottom graph demonstrates the percentage overall work impairment as measured by the Work Productivity and Activity Impairment Instrument. As you can see the control group has slightly higher levels of impairment throughout the project. Both groups seem to have the highest overall work impairment at 6 months, which is interesting as 6 months is the stage at which we have the highest number of participants in work in both groups.
  • Disability (as measured by the EQ-5D) was relatively stable throughout the course of the study, again, likely due to the relatively mild to moderate stroke patients enrolled onto the study. A perfect score would be 1, which would mean participants responded they had no problems in the 5 domain areas of mobility, self care, usual activities, pain and mental health. The SPRS measures reintegration into society, a perfect score would be 48. As you can see from the graph, the intervention group had slightly higher scores at 6 and 12 months.
  • So in relation to the primary outcome - more intervention group participants were in work at 12m. There was relatively little variation between the two groups on the secondary outcome measures – surprising as you would assume higher rates of work return would to improve mood and social reintegration, yet there weren’t obvious differences between the two groups. The overall response rate of 73.9% and completion rates of the questionnaires in addition to the fact that only one person withdrew from the intervention indicates the methodology we adopted was feasible. There are issues of timeliness as we recruited people with mainly minor to moderate strokes and it would appear that those with severe strokes need intervention at a later stage.
  • Limitations of the study.Fewer participants were lost to follow up in the intervention group compared to the control group and we were able to use my clinical knowledge of the participants in the intervention group to determine primary outcome data. This meant we had more information about this group in comparison to the control; this could possibly bias the results in favour of the intervention group. We had a fixed follow-up period of 12 months and so this limits knowledge about longer term outcomes.This was only a small scale feasibility trial and the lack of statistical power means any significance testing is not possible, therefore our findings are only descriptive.
  • So in conclusion, this study suggests early OT led stroke specific vocational rehabilitation can be effectively delivered and measured using standardised and bespoke questionnaires. It appears that this type of intervention can potentially influence return to work rates.Larger scale studies are warranted with sample sizes sufficient to demonstrate statistical significance between groups. The impact of this study has been the dissemination of new knowledge through conference presentations, paper publications and CLAHRC Bites (you have the latter in your packs). A very exciting and concrete impact has been the commissioning of a new OT post to deliver vocational rehabilitation in Nottingham based on the model which was used in the trial. This is being evaluated by the University of Nottingham led by Kate Radford and Jane Terry – our diffusion fellow will tell you more about this later today.Thanks for your attention.References on next two slides.
  • Stroke Event 13 Sep - First morning presentations

    1. 1. Emerging Evidence - Findings from the four stroke theme projects. Chair: Prof Marion Walker A partnership between Nottinghamshire Healthcare NHS Trust and the University of Nottingham Collaboration for Leadership in Applied Health Research and Care for Nottinghamshire, Derbyshire and Lincolnshire CLAHRC NDL
    2. 2. Leading Change in Early Supported Discharge Dr Rebecca Fisher & Professor Marion Walker A partnership between Nottinghamshire Healthcare NHS Trust and the University of Nottingham Collaboration for Leadership in Applied Health Research and Care for Nottinghamshire, Derbyshire and Lincolnshire CLAHRC NDL
    3. 3. • Overview of the Stroke Early Supported Discharge research programme • Are the benefits of ESD still evident in practice? Results from a 3 year evaluation – Christine Cobley, Research Associate What to expect Collaboration for Leadership in Applied Health Research and Care for Nottinghamshire, Derbyshire and Lincolnshire CLAHRC NDL
    4. 4. Thanks to the Team Collaboration for Leadership in Applied Health Research and Care for Nottinghamshire, Derbyshire and Lincolnshire CLAHRC NDL • Marion Walker • Christine Cobley • Fiona Nouri • Nikki Chouliara • Iskra Potgieter • Amy Moody • Brian Crosbie • Meghan Thurston • Catherine Gaynor • Jo James • Rebecca Larder
    5. 5. • UK Policy context: National Stroke Strategy 2007, Royal College Physicians Clinical Guideline for Stroke • Clinical trial data: demonstrated effectiveness of Early Supported Discharge • Large variation in quality of service provision across the UK (Care quality commission 2011) Why ESD? Collaboration for Leadership in Applied Health Research and Care for Nottinghamshire, Derbyshire and Lincolnshire CLAHRC NDL Rehab Support Hospital Home Acute Rehab Rehab Support ESD
    6. 6. • “In performing the research we aim to (a) gain clarity around how an ESD service might be organised (b) test methods to facilitate the implementation of ESD services and report on successes and challenges associated with implementation (c) test methods to measure the effectiveness of ESD services” Our Remit Collaboration for Leadership in Applied Health Research and Care for Nottinghamshire, Derbyshire and Lincolnshire CLAHRC NDL
    7. 7. • Stroke Rehabilitation Implementation Research • (A) What is the evidence?: Consensus on the core components of evidence based Early Supported Discharge services • (B) What is the context?: qualitative mapping used to describe models of services operating in practice (how & why?) • (C) Implementing change: facilitate evidence based practice Educational programme: measuring effectiveness & team working • (D) Evaluation: Are the benefits of ESD still evident in practice? ESD research programme Collaboration for Leadership in Applied Health Research and Care for Nottinghamshire, Derbyshire and Lincolnshire CLAHRC NDL
    8. 8. A partnership between Nottinghamshire Healthcare NHS Trust and the University of Nottingham Collaboration for Leadership in Applied Health Research and Care for Nottinghamshire, Derbyshire and Lincolnshire CLAHRC NDL Are the benefits of stroke Early Supported Discharge still evident in practice?
    9. 9. • Participants admitted to SU at NUH & SFH: Nov’10- Feb’12 • Eligibility criteria informed by international ESD Consensus • Study differs to original trials: Evaluating ESD operating in real world practice • Both patients and carers eligible for ESD (whether or not they were referred to service) • Formation of Non-ESD cohort • Baseline assessment within 14days stroke onset; participants followed period of 12 months Methods : Participants & Intervention Collaboration for Leadership in Applied Health Research and Care for Nottinghamshire, Derbyshire and Lincolnshire CLAHRC NDL
    10. 10. • Baseline & scheduled follow-up home visits (6, 26, 52 wk F/U) • Choice determined by previous trials & meta-analyses investigating ESD • Primary: BI • Secondary:SF36; EQ5D;*NEADL;GHQ-28; Satisfaction Qu* • Carer Outcomes: *GHQ-28; *SF-36; *Satisfaction Qu *Assessments not completed at baseline, but 6w, 6m & 12m f/u stages • Hospital data from Hospital Trust, Primary Care Trust & Local Authority databases – Admission & discharge to SU – Place of residence on admission & discharge – Service discharge to (if any) – BI admission & discharge – HRG code – LOS on acute & rehab wards – Readmissions at 28days & 1yr post baseline assessment Methods : Data Collected Collaboration for Leadership in Applied Health Research and Care for Nottinghamshire, Derbyshire and Lincolnshire CLAHRC NDL
    11. 11. • LOS used to calculate associated hospital based costs patient by patient basis • Using HRG & Trim-points translated LOS into associated costs • Used model of tariff unbundling that could be used to generate savings from ESD related reduction LOS to fund ESD services • To compare with annual staffing of ESD services information used: – ESD Team Structure – Banding & Whole Time Equivalent figures Methods : Statistical Analysis Collaboration for Leadership in Applied Health Research and Care for Nottinghamshire, Derbyshire and Lincolnshire CLAHRC NDL
    12. 12. Flow of participants through study
    13. 13. Baseline Characteristics of Participants Collaboration for Leadership in Applied Health Research and Care for Nottinghamshire, Derbyshire and Lincolnshire CLAHRC NDL Variable ESD (n=135) Non ESD (n=158) Comparison P Age, median (IQR) ††† 71(62-79) 76(65.75-82) 0.005* N days between stroke onset & baseline assessment, mean (SD) †† 7(7) 6(6) 0.503 Gender † Women, N (%) 45(33.3%) 56 (35.4%) 0.705 Male, N (%) 90(66.6%) 102(64.6%) Baseline BI, median (IQR) ††† 80 (65-95) 85 (70-95) 0.174 Ethnicity† White, N(%) 127(94%) 155 (98.1%) 0.068 Other, N(%) 8 (6%) 3 (1.9%) †Groups were compared using χ2 for Ethnicity & Gender. ††Groups were compared using t-test for N days between stroke onset and baseline assessment. †††Groups were compared using Mann Whitney U Test for Age and Baseline Barthel score. *Significant at P<0.05.
    14. 14. Clinical Hospital Data Collaboration for Leadership in Applied Health Research and Care for Nottinghamshire, Derbyshire and Lincolnshire CLAHRC NDL Variable ESD (n=135) NESD (n=158) Comparison* P BI adm, mean (SD) 11.4 (5.5) 10.7 (5.6) 0.326 BI disch, mean (SD) 18 (6) 18 (4.75) 0.749 Total LOS acute, median (IQR) 4(2-7) 3(2-5.75) 0.061 Total LOS rehab, median (IQR) 0(0-12) 6.5(0-15.75) 0.018* Total LOS (rehab + acute stay), median (IQR) 9(4-18.25) 11(5-21.0) 0.029* Readmitted to SU within 28 days hospital discharge N (%) 2(1.5%) 1(0.7%) 0.606 Readmitted to Gen ward within 28 days of hospital discharge, N (%) 12(9.2%) 11(7.7%) 0.669 Readmitted to SU within 1 year baseline assessment, N (%) 18(13.8%) 10 (7.0%) 0.073 Readmitted to Gen ward within 1 year baseline assessment, N (%) 47 (36.0%) 62 (43.4%) 0.266 Case fatality, N (%) 11 (8.5%) 16 (11.2%) 0.544 †Groups were compared using χ2 for Readmissions and Case Fatality. †† t-test for BI †††Mann Whitney U Test for LOS. *Significant at P<0.05.
    15. 15. • ESD group significantly more knowledgeable – Risk & practical help at 6 weeks (P<0.05) – Community services & emotional support at 6weeks, 6 & 12months (P<0.05) – Higher level overall satisfaction services received 6 weeks & 6 months (P<0.01) • No other differences on outcomes between groups at individual time points Comparison of patient outcomes: Between Group Comparison Collaboration for Leadership in Applied Health Research and Care for Nottinghamshire, Derbyshire and Lincolnshire CLAHRC NDL
    16. 16. Comparison of patient outcomes: Within Group Comparison Collaboration for Leadership in Applied Health Research and Care for Nottinghamshire, Derbyshire and Lincolnshire CLAHRC NDL ESD (n=110) Non ESD (n=109) Variable Baseline 6 Weeks 6 Months 12 Months P Baseline 6 Weeks 6 Months 12 Months P BI 80(65-91) 95(84-100) 95(80-100) 90(75-100) 0.000* 85(70-95) 90(80-100) 95(80-100) 95(75-100) 0.000* NEADL Q 35(24-49) 39(27-50) 31.5(18-46) 0.146 Q 35(24-52) 36(24.5-54) 36(20-50.5) 0.037 GHQ-28 25(18-35) 22(16-34) 19(12-30) 18.5(13-29) 0.000* 23(17-31) 22(16-29) 19.5(14-25) 20(13-26) 0.001* PCS 32.9(24.3- 39.9) 32.4(25.4- 42.4) 33.9(22.9- 47.1) 31.7(21.3- 43.1) 0.010* 35.1(28.3- 43.3) 34.5(26.3-42.9) 33.3(24.8- 43.9) 35.3(24.1- 45.8) 0.413 MCS 50.3(38.8- 58.7) 47.1(35.7- 55.3) 52.4(43.9- 58.1) 53.3(44.2- 60.2) 0.000* 51.3(43.6- 58.0) 47.9(34.4-57.1) 54.1(45.8- 58.5) 53.5(48.1- 59.1) 0.006* EuroQol Index 0.74(0.65- 0.84) 0.78(0.7-0.88) 0.77(0.68- 1.00) 0.77(0.65- 0.88) 0.001* 0.75(0.68- 0.88) 0.77(0.69-0.88) 0.77(0.68- 0.88) 0.77(0.69- 0.88) 0.711 EuroQol Imaginable Health 55(45-70) 60(50-80) 65(50-80) 70(50-80) 0.000* 60(50-80) 65(50-80) 70(50-80) 75(50-85) 0.002* †Median (interquartile range in parentheses). Groups were compared using Friedman Test. *Significant at P<0.05.
    17. 17. Collaboration for Leadership in Applied Health Research and Care for Nottinghamshire, Derbyshire and Lincolnshire CLAHRC NDL Parameter β Std. Error P value Model A: Main Effects Gender 0.206 0.2015 0.306 Ethnicity 0.170 0.4322 0.695 Age -0.661 0.1974 0.001* ESD -0.065 0.1910 0.734 Time6Weeks 1.103 0.1492 0.000* Time26Weeks 1.202 0.1575 0.000* Time52Weeks 0.918 0.1556 0.000* Model B: Interaction Effects ESD*Gender -0.035 0.2730 0.898 ESD*Ethnicity -0.590 0.3127 0.059 ESD*Age -0.587 0.3030 0.053 ESD*Time6Weeks 1.569 0.2270 0.000* ESD*Time26Weeks 1.500 0.2262 0.000* ESD*Time52Weeks 1.057 0.2183 0.000* *Significant at P<0.05 Generalised Estimating Equations analysis of Barthel Index scores at 6, 26, and 52 weeks
    18. 18. • Interaction Model: explore between group differences whilst adjusting for possible covariates – Descriptive analyses age significantly different, model age insignificant in relation to BI performance over time – No differences between groups ethnic & sex variables – Findings favoured ESD group: at 6weeks: 4.7 times likely BI ≥ 90 – Findings favoured ESD group: at 6months: 4.5 times likely BI ≥ 90 – Findings favoured ESD group: at 12 months: 2.9 times likely BI ≥ 90 • Sensitivity Analyses: Robustness of model explored adjusting BI threshold values (85, 93, and 95) Findings remained consistent Results: GEE Modelling findings Collaboration for Leadership in Applied Health Research and Care for Nottinghamshire, Derbyshire and Lincolnshire CLAHRC NDL
    19. 19. Collaboration for Leadership in Applied Health Research and Care for Nottinghamshire, Derbyshire and Lincolnshire CLAHRC NDL Results: Carer Outcomes • No Between Group differences – Physical, mental & psychological well-being – Satisfaction & knowledge stroke related services • Within Group differences – Significant improvement in mental health of carers receiving ESD (χ2(2)=13.000, p = 0.002) – Post-hoc analysis showed difference between 6weeks & 6 months (Z=-3.646, p=0.000)
    20. 20. Collaboration for Leadership in Applied Health Research and Care for Nottinghamshire, Derbyshire and Lincolnshire CLAHRC NDL Results: Unbundling National Stroke Tariff • Using Payment by Results scheme & stroke tariffs for each patient, associated hospital based care costs calculated • Used proposed model of unbundling National Stroke Tariff to calculate potential savings could be associated with ESD • Unbundling model involved splitting total LOS into discrete segments attributing appropriate amounts of tariff to each HRG Code Best Practice tariff (£) Trim- point (days) Day 0 to 3 Day 4 to 9 Day 10 to Trim- point Daily cost exceedi ng trim- point LOS Hospital Receives Commissioner saving AA22z £4,570 57 £1,500 £1064 £2,006 £179 17 £4,570 £0.00 3 £1,500 £3,070 8 £2,564 £2,006 73 £4,570 + £2,864 -£2,864 AA23z £4,633 51 £1,500 £1088 £2,045 £181 17 £4,633 £0.00 3 £1,500 £3,133 8 £2,588 £2,045 73 £4,570 + £3,982 -£3,982
    21. 21. Collaboration for Leadership in Applied Health Research and Care for Nottinghamshire, Derbyshire and Lincolnshire CLAHRC NDL Results: Unbundling National Stroke Tariff • Of Study Sample, 237 assigned HRG AA22z or AA23z • Total saving of £245,217 calculated based on total LOS • Average Annual cost of ESD service involved in study based on team composition: £350,000
    22. 22. Collaboration for Leadership in Applied Health Research and Care for Nottinghamshire, Derbyshire and Lincolnshire CLAHRC NDL Summary of Findings & Concluding Remarks • Study has measured effectiveness ESD in practice, for 1st time • When adopting evidence based model, ESD services can – Significantly reduce LOS – Result in equivalent or better outcomes for patients & their carers • Presented quantitative methodology: evaluating effectiveness of ESD services, using BI as measure of patient recovery • Distinction to trials important – Participants not randomised, groups compared formed naturally – ESD intervention investigated are services operating outside strict, protocol driven trial environment
    23. 23. Collaboration for Leadership in Applied Health Research and Care for Nottinghamshire, Derbyshire and Lincolnshire CLAHRC NDL Summary of Findings & Concluding Remarks • Present model of tariff unbundling for use within English Payment by Results Scheme, would ensure ESD related cost savings associated with reduction in LOS were realised • Findings in addition to policy & national guideline recommendations, difficult to believe why ESD services are not accessible to all eligible
    24. 24. Thank you for listening rebecca.fisher@nottingham.ac.uk www.clahrc-ndl.nihr.ac.uk Twitter: @CLAHRC_NDL Collaboration for Leadership in Applied Health Research and Care for Nottinghamshire, Derbyshire and Lincolnshire CLAHRC NDL
    25. 25. Concern that it would be unethical to withdraw such an established and accepted treatment.
    26. 26. Concern that it would be unethical to withdraw such an established and accepted treatment. A pilot study of home visits in Australia recruited only ten participants in 3m despite admission records suggesting more people should have been available.
    27. 27. 1. National survey  184 questionnaire posted 2. Opinions and perceptions  42 interviews;  17 with patients/staff involved in trial  20 senior OT interviews;  6 expert interviews 3. Feasibility RCT  126 trial patients recruited
    28. 28. 1. National survey of practice What is routine occupational therapy practice when conducting pre-discharge home visits for patients with a stroke?
    29. 29. How many visits?  Pre discharge assessment visit April and May 2011 mean 7 (sd 6.93) 0- 27  Access visit April and May 2011 mean 7 (sd 8.39) 0- 38 74% knew number of visits; 26% did not 87% policy to have 2 members of staff attending
    30. 30. Reason for home visit Reason Frequency Percentage Assess/practice activities of daily living in home environment 79 96% Identify/address safety issues 78 95% Assess/practice mobility/transfers in home environment 75 92% As part of discharge planning 66 81% Carer concerns 63 77% Assess access to and within property 63 76% Increase patient’s confidence and mood 59 72%
    31. 31. Time on visits  Time at home on visits. Range 10-135 mins Mean 63 mins (SD 20) i.e. just over an hour  Time on travel. Range 15-180 mins Mean 49 mins (SD 25.41)
    32. 32. Time on…  Time to organise visits. Range 10-240 mins Mean 50 mins (SD 34.58)  Time writing up report. Range 2-210 mins Mean 61 mins (SD 33.13)
    33. 33. Overall time Mean time 223 minutes i.e. almost 3 ¾ hours to undertake the „average‟ home visit
    34. 34. What is in your visiting bag?
    35. 35. Summary  National picture of home visits  Reasons for visits  Time/workload involved  National links for interviews/further research
    36. 36. 2. Opinions and perceptions; experts, OTs, patients.
    37. 37. 2. Opinions and perceptions; experts, OTs, patients.  Differing purposes of visits  Effective use of resources  „Entrenched practice‟  Perceptions of patients  Implementation aspects
    38. 38. 2. Opinions and perceptions; experts, OTs, patients.  Differing purposes of visits  Effective use of resources  „Entrenched practice‟  Perceptions of patients  Implementation aspects
    39. 39. Should it be an OT? YES „Unique still to OT … should be protected … and not become generic‟ (042).
    40. 40. Should it be an OT? YES „Unique still to OT … should be protected … and not become generic‟ (042). NO „It is always assumed to be an OT role … there may be some instances when it could be more appropriate for another profession to lead the visit‟ (039).
    41. 41. Visiting  There are often requests for visits which I feel are inappropriate(127).
    42. 42. Visiting  There are often requests for visits which I feel are inappropriate(127).  I don‟t think they [home visits] need to be carried out as a routine task (106).
    43. 43. Visiting  There are often requests for visits which I feel are inappropriate(127).  I don‟t think they [home visits] need to be carried out as a routine task (106).  I believe it should be made a policy that all patients that have had a stroke have a pre- discharge OT home visit (132).
    44. 44. Resource issues  They are popular with patient and staff however they lack some understanding of how much time and effort they take (088).
    45. 45. Resource issues  They are popular with patient and staff however they lack some understanding of how much time and effort they take (088).  They‟re extraordinarily expensive in terms of time and resource ….‟(Expert 1)
    46. 46. “…..they do not cost a lot, compared to a lot of other interventions… if they then are reducing the hospital stay by even one or two nights... OT time isn't that expensive compared to a lot of things, to a lot of other interventions…that go on in hospital” (Expert 4)
    47. 47. Realistic? „They get observed in a very artificial situation for an hour and then the occupational therapist makes a judgment on the basis of that as to whether somebody‟s going to be able to manage, you know, safely or not. And I think that that is unrealistic‟ (Expert 1)
    48. 48. Realistic? „They get observed in a very artificial situation for an hour and then the occupational therapist makes a judgment on the basis of that as to whether somebody‟s going to be able to manage, you know, safely or not. And I think that that is unrealistic‟ (Expert 1) „Home visits are an essential part of practice as patients can present very differently in their own environment‟ (039).
    49. 49. Patients “I was quite happy in as much as I know that the fact I‟d got a home visit they were considering me, releasing me from hospital so I was quite happy to conform with anything that would encourage them to say, you can go home” (Patient 1)
    50. 50. “Without a doubt, it was things that I haven‟t even thought about, the height of the bed the amount of steps from the stairs…would I be able to use the stair lift…if there hadn‟t been a home visit things could have gone disastrously wrong” (Patient 5)
    51. 51. 3. Feasibility RCT  Worked with clinical colleagues to agree the methodology  Clinicians had power as gate keepers in process
    52. 52. 3. Feasibility RCT  Worked with clinical colleagues to agree the methodology  Clinicians had power as gate keepers in process  „New‟ methodology in rehab research;  RCT arm (clinical uncertainty)  Cohort arm („Sure‟)- but asked to define
    53. 53. 3. Feasibility RCT  RCT- 93 patients randomly allocated;  47 to intervention arm (home visit) and  46 to control (interview) arm.  Cohort -33
    54. 54. Feasibility RCT  RCT -93 patients randomly allocated;  47 to intervention arm 46 to control  Parallel -33
    55. 55. Recruitment
    56. 56. Systematic collection of data  Mean cost of home visit £208 (SD £107).  Mean cost of a hospital interview £75 (SD£40).
    57. 57. Trial Issues for future  Measures  Protocol adherence  Safety- more falls in in home visit arm- more confident? Chance?  Control group- too much intervention?
    58. 58. Relevant?  Data shows interesting differences /RCT feasible  Main paper was 10th most read article in Clinical Rehabilitation  Pump Priming award from NUH for virtual reality project based on interviews→  The Senior Stroke Association Fellowship.
    59. 59. HOVIS 2?
    60. 60. Thanks to… TEAM HOVIS Phillip Whitehead Karen Fellows Nikki Sprigg Claire Edwards STEERING GROUP Prof Nadina Lincoln Chris Sampson Cecily Palmer Oswald Newold Dr Nicola Brain Dr Guo Boliang Dr Daniel Simpkins Dr Lyn Legg Prof Marion Walker Dr Kate Radford Dr Annie McCluskey Prof Marilyn James Dr Amanda Crompton Prof Cath Sackley Dr Ruth Parry Dr Karen Stainer Dr Tracy Sach and of course the Ward Staff and Patients
    61. 61. Wii STAR: Wii Stroke Therapy for Arm Rehabilitation PJ Standen, Kate Threapleton, Louise Connell, Andy Richardson, David Brown, Steven Battersby, Fran Platts A partnership between Nottinghamshire Healthcare NHS Trust and the University of Nottingham Collaboration for Leadership in Applied Health Research and Care for Nottinghamshire, Derbyshire and Lincolnshire CLAHRC NDL
    62. 62. Background Collaboration for Leadership in Applied Health Research and Care for Nottinghamshire, Derbyshire and Lincolnshire CLAHRC NDL • Need new approach to provide the necessary rehabilitation of upper limb following stroke. • Patients have decreasing access to appropriate therapy and even if sent home with exercises, adherence to treatment is poor. • Exercise plans can appear rigid and inflexible. Their effectiveness is irrelevant if they exhaust patients’ capabilities and motivation (Clay and Hopps, 2003). • Adherence could be improved if treatments are designed that are amenable or adaptable to more appropriately fit into the lifestyles and limitations of patients and their families.
    63. 63. Background Collaboration for Leadership in Applied Health Research and Care for Nottinghamshire, Derbyshire and Lincolnshire CLAHRC NDL • Virtual reality and interactive video gaming have emerged as new treatment approaches in stroke rehabilitation (Laver et al, 2011). • Commercial gaming consoles already used in clinical settings (eg Saposnik et al 2010): advantages of being widely acceptable, providing easily perceived feedback and their low cost facilitates unrestricted home use. • But games not designed for therapeutic use and current systems do not capture movement of fingers.
    64. 64. Development of equipment Collaboration for Leadership in Applied Health Research and Care for Nottinghamshire, Derbyshire and Lincolnshire CLAHRC NDL • In conjunction with users we developed a low cost intervention for home use that was flexible and motivating in order to improve adherence. • After several iterations we produced the virtual glove which allows capture of position of thumb and three fingers and translates into game play. • Designed to facilitate practice of movements that underlie everyday tasks such as grasp and release.
    65. 65. Development of games Collaboration for Leadership in Applied Health Research and Care for Nottinghamshire, Derbyshire and Lincolnshire CLAHRC NDL • Four games each with different levels of challenge to keep the participants motivated to continue to use the system, but to ensure that they can achieve some success. • Scores displayed on the screen at the end of a game. • A log of when the system is in use is collected by the computer as well as what games are being played and what scores the user obtains.
    66. 66. Feasibility trial Collaboration for Leadership in Applied Health Research and Care for Nottinghamshire, Derbyshire and Lincolnshire CLAHRC NDL We approached patients who • were aged 18 or over who • were recovering from a stroke • were no longer receiving any other intensive rehabilitation • still experiencing problems with their upper limb • Recruited from stroke wards City Hospital, ESD and Community Support Team and Stroke Outreach Service. • Randomly allocated to either the intervention (virtual glove) group or the control group (usual care). • Intervention group had the virtual glove, games and a PC in their homes for a period of 8 weeks. • They were advised to use the system for 20 mins 3x day (max 56 hours).
    67. 67. Feasibility trial Collaboration for Leadership in Applied Health Research and Care for Nottinghamshire, Derbyshire and Lincolnshire CLAHRC NDL Measures of upper limb function were taken at baseline, 4 weeks and 8 weeks • Wolf Motor Functions Test - a measure of upper limb functioning • 9 Hole Peg Test - a test of fine motor co-ordination • Nottingham Extended Activities of Daily Living • Motor Activity Log - how well and how much they use their more impaired arm to accomplish each of a range of ADL • For intervention group only: frequency and type of requests for help; duration and type of support provided; frequency of using the equipment
    68. 68. Feasibility trial Collaboration for Leadership in Applied Health Research and Care for Nottinghamshire, Derbyshire and Lincolnshire CLAHRC NDL Three sets of results • Adherence: did participants use the equipment as frequently as we had recommended? • Did the outcome measures show any difference between the groups? • How much time did the research team spend supporting home use of the intervention?
    69. 69. Adherence Data Collaboration for Leadership in Applied Health Research and Care for Nottinghamshire, Derbyshire and Lincolnshire CLAHRC NDL 0 10 20 30 40 50 60 70 80 90 100 1 2 3 4 8 9 13 17 22 23 24 26 % Participant ID Percentage of Recommended Use Recommended time used % Recommended days used %
    70. 70. Barriers to use Collaboration for Leadership in Applied Health Research and Care for Nottinghamshire, Derbyshire and Lincolnshire CLAHRC NDL • Equipment outages. • Needing someone to help them set up equipment or put on the glove. • If the participant is computer literate the games are likely to become boring: “I would say the first few weeks was brilliant. But as I say, then as it got going longer on, it was sort of, well, some days I couldn't be bothered and then some days, if you've got something else to do, it was just sort of missing it out. But at first, yes, it was really good.” (P8). • Other health problems and fatigue • Competing commitments: “And what time the family came, if the family came just when I had started it – I had to then leave it” (P4) , and more passive pastimes: “I admit it depended what was on the telly” (P4). • Getting back to pre stroke life especially once mobile
    71. 71. Facilitators Collaboration for Leadership in Applied Health Research and Care for Nottinghamshire, Derbyshire and Lincolnshire CLAHRC NDL • Flexibility: “Whereas with a computer, you could say four o'clock/five o'clock, if you felt all right, you could do it sort of any time you wanted to. You're not set to a time all the time, which was quite good.” (P8) • Immersion in games: “You just forget what – you sort of look at the time and, say it was ten o'clock, you're playing and then the next time you look up you think, crikey, it's half-past eleven, sort of thing.” (P8) • Belief in its therapeutic nature: “Oh yeah, of course, because it helps – well, it helps you a lot in your movement. First and fore, with the position, you know, then you enjoy the games.” (P9) • Support and encouragement from relatives
    72. 72. Outcome measures Collaboration for Leadership in Applied Health Research and Care for Nottinghamshire, Derbyshire and Lincolnshire CLAHRC NDL • 22 participants completed outcome measures at 4 weeks and 18 at 8 weeks. • The only significant (p<0.05) difference was a higher reported use in the intervention group of the affected limb on the MAL at 8 weeks when compared to the control group . • The lack of differences between the two groups was probably due to the considerable variation in how much the equipment was used. – Looking at the intervention group only, there was a significantly (p<0.05) higher change from baseline on WOLF grip strength in those with a higher use of the equipment, when compared to those with a lower use.
    73. 73. Therapist Time - Participant Visits Collaboration for Leadership in Applied Health Research and Care for Nottinghamshire, Derbyshire and Lincolnshire CLAHRC NDL • Intervention group only – Total number of visits = 118 (mean = 9.83; SD = 3.97) – Includes visits to complete baselines, outcome measures and all visits related to delivering the intervention 0 2 4 6 8 10 12 14 16 18 1 2 3 4 8 9 13 17 22 23 24 26 Visits Participant ID Total Number of Visits
    74. 74. Therapist Time – Duration of Visits Collaboration for Leadership in Applied Health Research and Care for Nottinghamshire, Derbyshire and Lincolnshire CLAHRC NDL • 146 hours was spent delivering the intervention in total 19 22 14 52 21 15 3 0 5 10 15 20 25 30 35 40 45 50 55 Baseline Midpoint OM Final OM Int Training Technical Other Comms Other Research Hours Research Activity Total Hours Delivering Intervention
    75. 75. Therapist time - conclusions Collaboration for Leadership in Applied Health Research and Care for Nottinghamshire, Derbyshire and Lincolnshire CLAHRC NDL • Mean number of visits (9.83) over approximately 8 weeks, duration is not extraordinary. • The complexities of delivering a novel intervention in a community setting probably account for above average amount of visits. • Some participants with complex stroke pathology (cognitive issues, profound sensory disturbance) demanded more ‘one to one’ therapy time. • After an initial OT/PT assessment, there may be an argument for trained support staff to deliver this intervention which could have cost-benefits to a service.
    76. 76. What we have learnt Collaboration for Leadership in Applied Health Research and Care for Nottinghamshire, Derbyshire and Lincolnshire CLAHRC NDL • Identifying potential participants difficult and time consuming. • Once identified, recruitment reasonable (62% of 47 consented). • Huge variation in adherence and outcomes but inclusion criteria deliberately wide. • Adherence low but it’s low for other unsupervised rehabilitation. • Eight weeks is a long time to ask people to use kit especially if they are trying to return to their pre stroke life. • No reason to drop any of the outcome measures if going for definitive trial, although baseline measures sometimes required two visits. • We provided a high level of support perhaps because it was a novel intervention in a community setting.
    77. 77. Thank you for listening p.standen@nottingham.ac.uk kate.threaplrton@nottingham.ac.uk www.clahrc-ndl.nihr.ac.uk Twitter: @CLAHRC_NDL Collaboration for Leadership in Applied Health Research and Care for Nottinghamshire, Derbyshire and Lincolnshire CLAHRC NDL
    78. 78. Return to Work after Stroke: A Feasibility Randomised Controlled Trial Mary Grant On behalf of: KA Radford, EJ Sinclair, J Terry, MF Walker, NB Lincoln, A Drummond, J Phillips, C Coole, L Watkins, E Rowley, B Guo, N Brain, K Muhiddin, M Jarvis, M Jenkinson, C Sampson, C Edwards A partnership between Nottinghamshire Healthcare NHS Trust and the University of Nottingham Collaboration for Leadership in Applied Health Research and Care for Nottinghamshire, Derbyshire and Lincolnshire CLAHRC NDL
    79. 79. Collaboration for Leadership in Applied Health Research and Care for Nottinghamshire, Derbyshire and Lincolnshire CLAHRC NDL • 110,000 strokes annually a quarter of which occur in working age adults, less than half of stroke survivors resume work (Daniel et al., 2009) • Health risks - greater than heart disease (Waddell and Aylwood, 2005) • Reduced quality of life • Dramatic societal costs of £8.9 billion a year (Saka et al., 2009) Background
    80. 80. • Vocational Rehabilitation: a process whereby those disadvantaged by illness or disability can access, maintain or return to employment (Tyerman and Meehan, 2004) • Work is a recognised health outcome (NHS Outcomes Framework, 2010) • Rehabilitation frequently fails to address work needs (Playford et al., 2011) • Lack of evidence for stroke-specific vocational rehabilitation (SSVR) Background continued Collaboration for Leadership in Applied Health Research and Care for Nottinghamshire, Derbyshire and Lincolnshire CLAHRC NDL
    81. 81. Collaboration for Leadership in Applied Health Research and Care for Nottinghamshire, Derbyshire and Lincolnshire CLAHRC NDL 1. Interview and mapping study of current provision 2. Intervention development phase (case study design) 3. Feasibility trial with economic and intervention analysis 4. Qualitative study with stroke survivors and employers to explore usefulness and acceptability of the intervention Four stage project
    82. 82. Aim of study To test the feasibility of designing and delivering occupational therapy-led stroke-specific vocational rehabilitation (SSVR) and measuring it’s effectiveness in a pilot randomised controlled trial (RCT) Collaboration for Leadership in Applied Health Research and Care for Nottinghamshire, Derbyshire and Lincolnshire CLAHRC NDL
    83. 83. Method Stroke survivors recruited from acute and stroke rehab stroke wards OT-led stroke-specific vocational rehabilitation (SSVR) Usual Care (UC) Postal follow-up: 3, 6 and 12 months Collaboration for Leadership in Applied Health Research and Care for Nottinghamshire, Derbyshire and Lincolnshire CLAHRC NDL
    84. 84. Intervention • Best practice guidelines (Tyerman and Meehan, 2004) • Mapping work (Sinclair et al., 2013) • Assessment, information, education, work preparation and phased return to work (Grant et al., 2012) • Case co-ordination model (Fadyl and McPherson, 2009) Collaboration for Leadership in Applied Health Research and Care for Nottinghamshire, Derbyshire and Lincolnshire CLAHRC NDL
    85. 85. Inclusion Criteria • Confirmed stroke diagnosis • Aged 16+ • In paid/voluntary work, education, >1 hour per week Exclusion Criteria • Not intending to RTW • Unable to give informed consent Collaboration for Leadership in Applied Health Research and Care for Nottinghamshire, Derbyshire and Lincolnshire CLAHRC NDL
    86. 86. Participants Gender: n (%) Male Female 17 (73.9%) 6 (26.1%) 19 (82.6%) 4 (17.4%) Age Mean (SD) Range 58.3 (12.7) 24-78 53.8 (12.6) 18-77 Length of Hospital Stay Mean days (SD) 19.6 (21.6) 27.1 (26.9) Occupation: n (%) Non-Professional Professional 4 (17.4%) 19 (82.6%) 12 (52.2%) 11 (47.8) Characteristic SSVR (n=23) Control (n=23) Collaboration for Leadership in Applied Health Research and Care for Nottinghamshire, Derbyshire and Lincolnshire CLAHRC NDL
    87. 87. 0 5 10 15 20 25 30 35 Minor Moderate Moderate/Seve re Severe Missing NIHSS; Stroke Severity (%) SSVR Control 0 5 10 15 20 25 30 35 LACS PACS TACS POCS Missing Bamford Classification (%) SSVR Control Collaboration for Leadership in Applied Health Research and Care for Nottinghamshire, Derbyshire and Lincolnshire CLAHRC NDL
    88. 88. Participants 0 1 2 3 4 5 6 Visual Impairments (n) SSVR Control 0 5 10 15 20 25 30 35 40 45 Not affected Aphasia Dysarthria Dysarthria and aphasia Speech and Language Impairments (%) SSVR Control Collaboration for Leadership in Applied Health Research and Care for Nottinghamshire, Derbyshire and Lincolnshire CLAHRC NDL
    89. 89. Primary Outcome • Returned to work: yes/no Secondary Outcomes • Mood: Hospital Anxiety and Depression Scale (HADS) • Work Productivity: Work Productivity and Activity Impairment Instrument (WPAI) and Work Limitations Questionnaire (WLQ) • Social Participation: Sydney Psychosocial Reintegration Scale (SPRS) • Activities of Daily Living: Nottingham Extended Activities of Daily Living (NEADL) • Health Status: EQ-5D Collaboration for Leadership in Applied Health Research and Care for Nottinghamshire, Derbyshire and Lincolnshire CLAHRC NDL
    90. 90. Results: Participants Collaboration for Leadership in Applied Health Research and Care for Nottinghamshire, Derbyshire and Lincolnshire CLAHRC NDL
    91. 91. Feasibility 0 20 40 60 80 100 3m 6m 12m Questionnaire Response Rates (%) SSVR Control Collaboration for Leadership in Applied Health Research and Care for Nottinghamshire, Derbyshire and Lincolnshire CLAHRC NDL
    92. 92. Primary Outcome 0 20 40 60 80 100 3m 6m 12m Participants in Work (%) SSVR Control Collaboration for Leadership in Applied Health Research and Care for Nottinghamshire, Derbyshire and Lincolnshire CLAHRC NDL
    93. 93. 0 2 4 6 8 10 12 14 16 18 20 22 3m 6m 12m Nottingham Extended Activities of Daily Living: Median Score SSVR Control 0 2 4 6 8 3m 6m 12m 3m 6m 12m Anxiety Depression Hospital Anxiety and Depression Scale: Median Scores SSVR Control Collaboration for Leadership in Applied Health Research and Care for Nottinghamshire, Derbyshire and Lincolnshire CLAHRC NDL
    94. 94. Secondary Outcomes -2 3 8 3m 6m 12m WLQ: % Productivity Loss SSVR Control Collaboration for Leadership in Applied Health Research and Care for Nottinghamshire, Derbyshire and Lincolnshire CLAHRC NDL
    95. 95. Secondary Outcomes 0 15 30 45 60 3m 6m 12m Sydney Psychosocial Reintegration Scale: Median Score SSVR Control .00 .20 .40 .60 .80 1.00 3m 6m 12m EQ5D: Average of Scaled Scores SSVR Control Collaboration for Leadership in Applied Health Research and Care for Nottinghamshire, Derbyshire and Lincolnshire CLAHRC NDL
    96. 96. Discussion • Primary outcome: More intervention group participants were in work at 12 months • Secondary outcomes: Relatively little variation between the two groups. • Feasibility: Feasible to recruit, deliver and measure early SSVR - overall response rate of 73.9% - only one person withdrew from intervention Collaboration for Leadership in Applied Health Research and Care for Nottinghamshire, Derbyshire and Lincolnshire CLAHRC NDL
    97. 97. Limitations • More information known about the intervention group • Fixed time period • Descriptive comparisons Collaboration for Leadership in Applied Health Research and Care for Nottinghamshire, Derbyshire and Lincolnshire CLAHRC NDL
    98. 98. Conclusions • Early OT-led SSVR can be effectively delivered and measured using standardised and bespoke questionnaires • SSVR can potentially influence return to work rates • Knowledge from this feasibility study useful in planning future research: larger scale studies needed to demonstrate effect • Impact of research: dissemination of new knowledge and new SSVR OT post commissioned in Nottingham Collaboration for Leadership in Applied Health Research and Care for Nottinghamshire, Derbyshire and Lincolnshire CLAHRC NDL
    99. 99. References • Daniel K, Wolfe CDA, Busch MA, McKevitt C (2009) What are the social consequences of stroke in working aged adults? A systematic review. Stroke, 40, 431-440 • Fadyl JK, McPherson KM (2009) Approaches to vocational rehabilitation after traumatic brain injury: a review of the evidence. Journal of Head Trauma Rehabilitation, 24(3), 195-212. • Grant M, Sinclair E, Walker MF, Radford KA. Vocational rehabilitation following stroke: describing intervention. International Journal of Stroke. 2012; 7 (Suppl 2):29. • Department of Health (2010) The NHS Outcomes Framework 2011/12, London: Department of Health. • Playford ED, Radford K, Burton C, Gibson A, Jellie B, Sweetland J, Watkins C. (2011) Mapping Vocational Rehabilitation Services for people with Long term neurological conditions: Summary report. Department of Health. Available at: http://www.ltnc.org.uk/ Accessed 10.12.12. Collaboration for Leadership in Applied Health Research and Care for Nottinghamshire, Derbyshire and Lincolnshire CLAHRC NDL
    100. 100. References • Saka O, McGuire A, Wolfe C (2009) Cost of stroke in the United Kingdom. Age and Ageing, 38(1), 27–32 • Sinclair E, Radford K, Grant M, Terry J (2013) Developing stroke specific vocational rehabilitation: a soft systems analysis of current service provision. Disability and Rehabilitation. Published online, May 2013. DOI:10.3109/09638288.2013.793410 • Tyerman A, Meehan M J (eds) (2004) Vocational assessment and rehabilitation after acquired brain injury: Interagency guidelines. London: British Society of Rehabilitation Medicine/ Job Centre Plus/ Royal College of Physicians • Wadell G, Aylward AK (2005) The scientific and conceptual basis of incapacity benefits. London: HMSO Collaboration for Leadership in Applied Health Research and Care for Nottinghamshire, Derbyshire and Lincolnshire CLAHRC NDL
    101. 101. Thank you for listening Collaboration for Leadership in Applied Health Research and Care for Nottinghamshire, Derbyshire and Lincolnshire CLAHRC NDL kate.radford@nottingham.ac.uk Mary Grant – mcxmig@nottingham.ac.uk www.clahrc-ndl.nihr.ac.uk

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