Jenni Murray

Frequency of anxiety after stroke: a systematic review and meta‐analysis of observational studies

Background and purpose Negative psychological outcomes occur frequently after stroke; however, there is uncertainty regarding the occurrence of anxiety disorders and anxiety symptoms after stroke. A systematic review of observational studies was conducted that assessed the frequency of anxiety in stroke patients using a diagnostic or screening tool. Summary of review Databases were searched up to March 2011. A random effects model was used to summarize the pooled estimate. Statistical heterogeneity was assessed using the I2 statistic. Forty-four published studies comprising 5760 stroke patients were included. The overall pooled estimate of anxiety disorders assessed by clinical interview was 18% (95%confidence interval 8–29%, I2 = 97%) and was 25% (95% confidence interval 21–28%, I2 = 90%) for anxiety assessed by rating scale. The Hospital Anxiety and Depression Scale-Anxiety subscale ‘probable’ and ‘possible’ cutoff scores were the most widely used assessment criteria. The combined rate of anxiety by time after stroke was: 20% (95% confidence interval 13–27%, I2 = 96%) within one-month of stroke; 23% (95% confidence interval 19–27%, I2 = 84%) one to five-months after stroke; and 24% (95% confidence interval 19–29%, I2 = 89%) six-months or more after stroke. Conclusion Anxiety after stroke occurs frequently although methodological limitations in the primary studies may limit generalizability. Given the association between prevalence rates and the Hospital Anxiety and Depression Scale-Anxiety cutoff used in studies, reported rates could in fact underrepresent the extent of the problem. Additionally, risk factors for anxiety, its impact on patient outcomes, and effects in tangent with depression remain unclear.

A systematic review of patient reported factors associated with uptake and completion of cardiovascular lifestyle behaviour change

BackgroundHealthy lifestyles are an important facet of cardiovascular risk management. Unfortunately many individuals fail to engage with lifestyle change programmes. There are many factors that patients report as influencing their decisions about initiating lifestyle change. This is challenging for health care professionals who may lack the skills and time to address a broad range of barriers to lifestyle behaviour. Guidance on which factors to focus on during lifestyle consultations may assist healthcare professionals to hone their skills and knowledge leading to more productive patient interactions with ultimately better uptake of lifestyle behaviour change support. The aim of our study was to clarify which influences reported by patients predict uptake and completion of formal lifestyle change programmes.MethodsA systematic narrative review of quantitative observational studies reporting factors (influences) associated with uptake and completion of lifestyle behaviour change programmes. Quantitative observational studies involving patients at high risk of cardiovascular events were identified through electronic searching and screened against pre-defined selection criteria. Factors were extracted and organised into an existing qualitative framework.Results374 factors were extracted from 32 studies. Factors most consistently associated with uptake of lifestyle change related to support from family and friends, transport and other costs, and beliefs about the causes of illness and lifestyle change. Depression and anxiety also appear to influence uptake as well as completion. Many factors show inconsistent patterns with respect to uptake and completion of lifestyle change programmes.ConclusionThere are a small number of factors that consistently appear to influence uptake and completion of cardiovascular lifestyle behaviour change. These factors could be considered during patient consultations to promote a tailored approach to decision making about the most suitable type and level lifestyle behaviour change support.

Review of longer-term problems after disabling stroke

Acute stroke is a commonly-used term in clinical practice and in standard texts, but tends to reinforce a widely-held perception of stroke as a short-term condition. Arguably, this brief, time-limited approach to stroke care has become more dominant, with the reliable evidence that hospital-based stroke care, using the model of a stroke rehabilitation unit, confers improved patient outcomes. For patients disabled by stroke, however, the substrate for longer-term problems is obvious, and stroke as a chronic condition is a more helpful and user-centred health care paradigm.

Screening for Fragile X Syndrome: Information Needs for Health Planners

1 SUMMARY OF FINDINGS 61 9.7 Measurement of FMRP 75 2 BACKGROUND 62 9.8 Alternatives to standard PCR 75 2.1 Molecular genetics 63 9.8.1 Repeat expansion detection 75 2.2 Improved diagnosis 63 9.8.2 Ligase chain reaction 75 2.3 Routine screening 63 9.8.3 Hybrids 75 2.4 Screening policy 63 9.9 Testing protocols 75 3 SYSTEMATIC REVIEW 63 9.9.1 Screening 75 4 NATURAL HISTORY 64 9.9.2 Prenatal diagnosis 76 4.1 Physical features 64 9.9.3 Pre-implantation diagnosis 76 4.2 Cognitive profile 64 10 PRACTICAL EXPERIENCE OF 4.3 Behavioural features 64 SCREENING AND DIAGNOSIS 76 4.3.1 Autism 64 10.1 Antenatal screening 76 4.3.2 Attention deficit disorders 65 10.1.1 Fairfax 76 4.4 Treatment 65 10.1.2 New York 76 5 GENETICS 65 10.2 Pre-conceptual screening 76 5.1 Population genetics 66 10.3 Active cascade screening 76 5.2 Cytogenetics 66 10.3.1 New South Wales 76 5.3 Molecular genetics 66 10.3.2 New York 76 5.4 Fragile X mental retardation-1 66 10.3.3 Murcia 77 5.5 Normal alleles 67 10.3.4 Kuopio 77 5.5.1 Distribution of repeat sizes 67 10.4 Prenatal diagnosis and termination of 5.5.2 Female alleles 67 pregnancy 77 5.6 Mutated alleles 67 10.5 Paediatric screening 77 5.6.1 Full mutation 67 10.5.1 Referral 77 5.6.2 Pre-mutation 67 10.5.2 Active 77 5.6.3 Mosaics 67 11 MODELLING ALLELE DYNAMICS 78 5.6.4 Other mutations 68 5.7 Grey zone 68 11.1 A simple model 78

A qualitative synthesis of factors influencing maintenance of lifestyle behaviour change in individuals with high cardiovascular risk

BackgroundManagement of cardiovascular risk factors includes commitment from patients to adhere to prescribed medications and adopt healthy lifestyles. Unfortunately many fail to take up and maintain the four key healthy behaviours (not smoking, having a balanced diet, limiting alcohol consumption and being more active). Five factors (beliefs, knowledge, transport and other costs, emotions, and friends and family support) are known to predict uptake of lifestyle behaviour change. The key factors influencing maintenance of healthy lifestyles are not known but would be helpful to support the development of relapse prevention programmes for this population. Our review aimed to clarify the main patient perceived factors thought to influence maintenance of changed healthy lifestyles.MethodsWe performed a systematic review of qualitative observational studies and applied the principles of content synthesis and thematic analysis to extract reported factors (barriers and facilitators) considered by individuals to be influential in maintaining changed healthy lifestyle behaviours. Factors were then organised into an existing framework of higher order categories which was followed by an analysis of the interrelationships between factors to identify key themes.ResultsTwenty two studies met our inclusion criteria. Participants reported barriers and facilitators within 13 categories, the majority of which were facilitators. The most commonly reported influences were those relating to social support (whether provided formally or informally), beliefs (about the self or the causes and management of poor health, and the value of maintaining lifestyle behaviours), and other psychological factors (including attitude, thinking and coping styles, and problem solving skills). Physical activity was the most commonly investigated behaviour in four categories, but overall, the main barriers and facilitators were related to a range of behaviours. Through analysis of the interrelationships between factors within categories, ‘social support’, ‘education and knowledge’, and ‘beliefs and emotions’ were all considered key themes.ConclusionsOur review suggests that for the most part, factors that influence lifestyle change are also important for maintaining healthy behaviours. This indicates that addressing these barriers and facilitators within lifestyle support programmes would also be of value in the longer-term.

Quality of written information used in Down syndrome screening

A qualitative assessment was performed on 81 leaflets used in maternal serum Down syndrome screening from National Health Service (NHS) obstetric units and private screening services. Quality was assessed by factual content, presentation and reading ease and this was amalgamated into a single overall score expressed as a percentage of the maximum possible score. Eleven (14%) leaflets included all eight factual items recommended by the Royal College of Obstetricians and Gynaecologists (RCOG); only one included these and a further nine items recognised as important to the consumer. Three (4%) leaflets contained information that was incorrect and 17 (21%) that was misleading or inconsistent. Using published criteria six (7%) leaflets were well presented and ten (12%) were fairly easy to read. The average reading age was 13–14 years. The overall quality score showed that five leaflets had 80% or more of the total possible score. However a substantial number, 15 (19%), were totally unacceptable having scores of 40% or less. In general the quality of leaflets used in the UK is considered poor. A national peer‐reviewed leaflet should be prepared which can be modified to suit local policy. Copyright

Structured re-assessment system at 6 months after a disabling stroke: a randomised controlled trial with resource use and cost study

BACKGROUND national policy recommends routine re-assessment of disabled patients and their carers at 6 months after stroke onset. The clinical and resource outcomes of this policy were investigated. DESIGN prospective, single-blind, randomised controlled trial in two centres. PARTICIPANTS a total of 265 patients with a disabling stroke and their carers. INTERVENTIONS a structured re-assessment system for patients and their carers at 6 months post-stroke or existing care. OUTCOME MEASURES primary: patient independence (Frenchay activities index) and carer stress (general health questionnaire 28). Secondary: activities of daily living, mood state, satisfaction with services, carer strain index, health and social service resource use and costs. RESULTS independence at 12 months post-stroke was similar in both groups (Frenchay activities index, adjusted mean difference 0.64; 95% confidence interval -0.74-2.02). Emotional distress in carers was similar in both groups (general health questionnaire 28, mean difference 0.02; 95% confidence interval -0.95-1.00). Results for the secondary outcome measures and total mean costs were similar for both groups. The intervention group patients used 301 fewer hospital bed days and 1,631 fewer care home bed days. CONCLUSIONS the structured, systematic re-assessment for patients and their carers was not associated with any clinically significant evidence of benefit at 12 months. Health and social care resource use and mean cost per patient were broadly similar in both groups. TRIAL REGISTRATION International Standard Randomised Controlled Trial Register; number: ISRCTN55412871.

Individual influences on lifestyle change to reduce vascular risk: a qualitative literature review

BACKGROUND Management of cardiovascular risk includes adoption of healthy lifestyles. Uptake and completion rates for lifestyle programmes are low and many barriers and facilitators to lifestyle behaviour change have been reported in the literature. Clarity on which barriers and facilitators to target during consultations in primary care may support a more systematic approach to lifestyle behaviour change in those at high risk of cardiovascular events. AIM To identify the main barriers and facilitators to lifestyle behaviour change in individuals at high risk of cardiovascular events. DESIGN A content synthesis of the qualitative literature reporting patient-level influences on lifestyle change. METHOD Qualitative studies involving patients at high risk of cardiovascular events were identified through electronic searching and screening against predefined selection criteria. Factors (reported influences) were extracted and, using a clustering technique, organised into categories that were then linked to key themes through relationship mapping. RESULTS A total of 348 factors were extracted from 33 studies. Factors were organised into 20 categories and from these categories five key themes were identified: emotions, beliefs, information and communication, friends and family support, and cost/transport. CONCLUSION It is possible to organise the large number of self-reported individual influences on lifestyle behaviours into a small number of themes. Further research is needed to clarify which of these patient-level barriers and facilitators are the best predictors of uptake and participation in programmes aimed at helping people to change lifestyle.

Measuring outcomes in the longer term after a stroke

The immediate and early outcomes after a stroke are relatively easy to define and measure. Mortality, medical complications, returning home and residual physical disability are well-established measures of interest to patients, clinicians and researchers. However, outcome measurement in the longer term is more complex and there is no consensus about the type of approach to adopt. We, and others, have demonstrated that the problems faced by stroke patients and their supporters in the longer term are numerous, diverse and complex, encompassing aspects of physical, social and mental well-being. Currently there is no single available measure that provides a ‘good fit’ across all these outcome domains in the special context of longer term stroke care. This raises problematic questions for clinical service monitoring (is the local stroke population recovering well?) and for research studies (which outcome domain should be applied?). In research, measures such as the Frenchay Activities Index (that assesses extended activities of daily living) or Homesat (that assesses satisfaction with care) are commonly used in stroke studies investigating longer term outcomes. However, these measures only deal with limited aspects of the longer term stroke experience. Greater coverage has been attempted using a combination of measures, each addressing a different component of stroke outcome. However, in routine clinical practice such an approach is impractical, expensive and time-consuming. Yet the need remains to develop reliable systems of measurement that will aid policy and decision-making regarding effective provision of resources to meet the longer term needs of stroke patients. The development of a clinical monitoring tool that would identify patient needs and highlight where services might be developed or improved would be of benefit to patients, practitioners and service commissioners. Several solutions to the issue of longer term stroke outcome measurement have been proposed. One statistical solution has been to combine the differences between treatment groups for several clinically related outcomes and then assess the significance of the combined summary statistic. This global hypothesis testing method neatly addresses the issue of type I errors that can occur as a result of multiple statistical tests. In a study of postdischarge care for stroke and transient ischaemic attack, five separate outcome domains were statistically combined to form a three-month ‘health profile’. A highly statistically significant result was reported but the summary statistic and between group differences are difficult to interpret as a patient-related value. Furthermore, this complex approach is not amenable to routine clinical monitoring. A second approach has been to develop a stroke-specific, multidimensional outcome measure such as the Stroke Impact Scale. Developed in the USA, this is a 60-item multi-domain Address for correspondence: Jenni Murray, School of Healthcare, University of Leeds, Leeds LS2 9JT, UK. e-mail: j.y.murray@leeds.ac.uk

Cluster Randomized Controlled Trial: Clinical and Cost-Effectiveness of a System of Longer-Term Stroke Care

Background and Purpose— We developed a new postdischarge system of care comprising a structured assessment covering longer-term problems experienced by patients with stroke and their carers, linked to evidence-based treatment algorithms and reference guides (the longer-term stroke care system of care) to address the poor longer-term recovery experienced by many patients with stroke. Methods— A pragmatic, multicentre, cluster randomized controlled trial of this system of care. Eligible patients referred to community-based Stroke Care Coordinators were randomized to receive the new system of care or usual practice. The primary outcome was improved patient psychological well-being (General Health Questionnaire-12) at 6 months; secondary outcomes included functional outcomes for patients, carer outcomes, and cost-effectiveness. Follow-up was through self-completed postal questionnaires at 6 and 12 months. Results— Thirty-two stroke services were randomized (29 participated); 800 patients (399 control; 401 intervention) and 208 carers (100 control; 108 intervention) were recruited. In intention to treat analysis, the adjusted difference in patient General Health Questionnaire-12 mean scores at 6 months was −0.6 points (95% confidence interval, −1.8 to 0.7; P=0.394) indicating no evidence of statistically significant difference between the groups. Costs of Stroke Care Coordinator inputs, total health and social care costs, and quality-adjusted life year gains at 6 months, 12 months, and over the year were similar between the groups. Conclusions— This robust trial demonstrated no benefit in clinical or cost-effectiveness outcomes associated with the new system of care compared with usual Stroke Care Coordinator practice. Clinical Trial Registration— URL: http://www.controlled-trials.com. Unique identifier: ISRCTN 67932305.