Janet Prvu-Bettger

Sex differences in quality of life after ischemic stroke

Objective: We aimed to compare quality of life (QOL) in women and men after ischemic stroke or TIA, and to determine the incremental impact of demographic, socioeconomic, clinical, and stroke-specific effects on longitudinal QOL. Methods: We assessed QOL in patients with ischemic stroke or TIA at 3 and 12 months postdischarge in the Adherence eValuation After Ischemic stroke–Longitudinal Registry using the European Quality of Life–5 Dimensions (EQ-5D) instrument. We generated multivariable linear regression models to evaluate the association between sex and EQ-5D while sequentially adjusting for sociodemographic, clinical, and stroke-related variables. We also used a proportional odds model to assess sex differences in the change in EQ-5D scores from 3 to 12 months. Results: A total of 1,370 patients were included, 53.7% male, median age 65 years (interquartile range 56–77 years). Women had significantly lower QOL at 3 months (unadjusted EQ-5D 0.81 in women vs 0.84 in men; p < 0.001) and 12 months (0.83 vs men 0.84; p < 0.001) poststroke. After multivariable adjustment for sociodemographic, clinical, and stroke-related factors, women continued to have lower QOL at 3 months (mean difference −0.036; p = 0.003) and at 12 months (mean difference −0.022; p = 0.046). Women fared worse in the dimensions of mobility, pain/discomfort, and anxiety/depression at 3 and 12 months. There were no sex differences in change in EQ-5D score from 3 to 12 months. Conclusion: Women have worse QOL than men up to 12 months after stroke, even after adjusting for important sociodemographic variables, stroke severity, and disability.

Measuring Community Participation of Adults With Psychiatric Disabilities: Reliability of Two Modes of Data Collection

PURPOSE/OBJECTIVE The Americans with Disabilities Act set in motion a series of policies and actions to promote community integration and participation, including for those individuals with psychiatric disabilities. Measuring participation in this population is in its infancy. This study examines the test-retest reliability of two modes of administration of a measure that assesses participation in four social life domains and the extent to which participation is viewed as sufficient and important. RESEARCH METHOD/DESIGN One hundred and 19 individuals with a diagnosis of schizophrenia, bipolar disorder, or major depression were randomly assigned to either an interviewer- or self-administered method of completing the measure, and filled out the measure again in the same format within 48-72 hr. RESULTS Correlations at the individual participation item and scale levels between the two time points were nearly all in the r = .6-.9 range. Agreement on the importance and sufficiency of their participation was also consistently high. The importance of participation in each area ranged from 36% to 95%, and among these individuals, between 18% and 71% indicated they were not participating as much as desired. CONCLUSIONS/IMPLICATIONS Community participation of individuals with psychiatric disabilities can be reliably measured using 2 methods of administration as an outcome in rehabilitation research and evaluation studies with this population. These individuals are engaged to varying degrees in a wide-range of participation areas in the community that are important, but most not to the degree that they desire. More intervention efforts are needed to increase the sufficiency of community participation.

Factors Associated With Discharge to Home Versus Discharge to Institutional Care After Inpatient Stroke Rehabilitation

OBJECTIVE To examine sociodemographic and clinical characteristics independently associated with discharge home compared with discharge to a skilled nursing facility (SNF) after acute inpatient rehabilitation. DESIGN Retrospective cohort study. SETTING Three tertiary accredited acute care rehabilitation facilities. PARTICIPANTS Adult patients with stroke (N=2085). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Not applicable. RESULTS Of 2085 patients with stroke treated at 3 centers over a 4-year period, 78.2% (n=1631) were discharged home and 21.8% (n=454) discharged to an SNF. Findings from a multivariable logistic regression analysis indicated that patients were less likely to be discharged home if they were older (odds ratio [OR], .98; 95% confidence interval [CI], .96-.99), separated or divorced (compared with married; OR, .61; 95% CI, .48-.79), or with Medicare health insurance (compared with private insurance; OR, .69; 95% CI, .55-.88), or had dysphagia (OR, .83; 95% CI, .71-.98) or cognitive deficits (OR, .79; 95% CI, .77-.81). The odds of being discharged home were higher for those admitted with a higher motor FIM score (OR, 1.10; 95% CI, 1.09-1.11). The following were not associated with discharge disposition: sex, race, prestroke vocational status, availability of secondary health insurance, number of days from stroke onset to rehabilitation facility admission, stroke type, impairment group, cognitive FIM on admission, other stroke deficits (aphasia, ataxia, neglect, or speech disturbance), stroke complications of hyponatremia or urinary tract infection, or comorbid conditions. CONCLUSIONS One in 5 patients with stroke were discharged to an SNF after inpatient rehabilitation. On admission, several sociodemographic and clinical characteristics were identified that could be considered as important factors in early discussions for discharge planning.

An academic-health service partnership in nursing: lessons from the field.

PURPOSE To describe the development of an academic-health services partnership undertaken to improve use of evidence in clinical practice. APPROACH Academic health science schools and health service settings share common elements of their missions: to educate, participate in research, and excel in healthcare delivery, but differences in the business models, incentives, and approaches to problem solving can lead to differences in priorities. Thus, academic and health service settings do not naturally align their leadership structures or work processes. We established a common commitment to accelerate the appropriate use of evidence in clinical practice and created an organizational structure to optimize opportunities for partnering that would leverage shared resources to achieve our goal. FINDINGS A jointly governed and funded institute integrated existing activities from the academic and service sectors. Additional resources included clinical staff and student training and mentoring, a pilot research grant-funding program, and support to access existing data. Emergent developments include an appreciation for a wider range of investigative methodologies and cross-disciplinary teams with skills to integrate research in daily practice and improve patient outcomes. CONCLUSIONS By developing an integrated leadership structure and commitment to shared goals, we developed a framework for integrating academic and health service resources, leveraging additional resources, and forming a mutually beneficial partnership to improve clinical outcomes for patients. CLINICAL RELEVANCE Structurally integrated academic-health service partnerships result in improved evidence-based patient care delivery and in a stronger foundation for generating new clinical knowledge, thus improving patient outcomes.

Geographic Access to and Availability of Community Resources for Persons Diagnosed with Severe Mental Illness in Philadelphia USA

This study assesses whether there are differences in geographic access to and availability of a range of different amenities for a large group of persons diagnosed with severe mental illness (SMI) in Philadelphia (USA) when compared to a more general set of residential addresses. The 15,246 persons who comprised the study group had better outcomes than an equal number of geographical points representative of the general Philadelphia population on measures of geographic proximity and availability for resources considered important by people diagnosed with SMI. These findings provide support for the presence of geographic prerequisites for attaining meaningful levels of community integration.

Is self or caregiver report comparable to Medicare claims indicators of healthcare utilization after stroke

Abstract Background: Claims data from Medicare or other payers might not generalize to other populations regarding service use after stroke especially among younger patients. However, high agreement between self-report and Medicare claims data would support the use of self-reported healthcare utilization data in these populations. Methods: A population-based sample of 147 stroke participants with traditional fee-for service Medicare and their family caregivers was examined. Concordance with Medicare claims was examined for stroke participant self-report for Emergency Room visits, hospitalizations, and physician visits for a six-month period after stroke, and for both stroke participant and caregiver reports of receipt of Physical Therapy (PT), Speech and Language Pathology (SLP), or Home Health Agency (HHA) visits. Results: Agreement was good for Emergency Room visits (kappa 0.75), hospitalization (kappa 0.70), and physician visits (Prevalence Adjusted Bias Adjusted Kappa [PABAK] 0.69) but more moderate for physical therapy, speech and language therapy, and home health agency visits (kappa 0.56–0.63). Caregiver agreement with Medicare claims was similar to stroke participant agreement. African Americans were less likely to self-report therapy compared to whites (OR 0.32 PT, 0.38 SLP, 0.29 HHA, p < 0.03). Younger stroke participants reported lower levels of Emergency Room visits than claims (OR 0.81, p = 0.001). Conclusion: Healthcare utilization after stroke can be reliably assessed from Medicare claims, Stroke participant, or Caregiver report for salient events such as hospitalizations and Emergency Room visits. Self-report and caregiver report appear to be less reliable for identifying use of therapy or home health services. Caution should be used when interpreting disparities based on self-report data alone in these areas.

A Person-Centered Approach to Poststroke Care: The COMprehensive Post-Acute Stroke Services Model: The COMPASS Care Model

Many individuals who have had a stroke leave the hospital without postacute care services in place. Despite high risks of complications and readmission, there is no standard in the United States for postacute stroke care after discharge home. We describe the rationale and methods for the development of the COMprehensive Post‐Acute Stroke Services (COMPASS) care model and the structure and quality metrics used for implementation. COMPASS, an innovative, comprehensive extension of the TRAnsition Coaching for Stroke (TRACS) program, is a clinician‐led quality improvement model providing early supported discharge and transitional care for individuals who have had a stroke and have been discharged home. The effectiveness of the COMPASS model is being assessed in a cluster‐randomized pragmatic trial in 41 sites across North Carolina, with a recruitment goal of 6,000 participants. The COMPASS model is evidence based, person centered, and stakeholder driven. It involves identification and education of eligible individuals in the hospital; telephone follow‐up 2, 30, and 60 days after discharge; and a clinic visit within 14 days conducted by a nurse and advanced practice provider. Patient and caregiver self‐reported assessments of functional and social determinants of health are captured during the clinic visit using a web‐based application. Embedded algorithms immediately construct an individualized care plan. The COMPASS models pragmatic design and quality metrics may support measurable best practices for postacute stroke care.