Julie Luker

Efficient clinical evaluation of guideline quality: development and testing of a new tool

BackgroundEvaluating the methodological quality of clinical practice guidelines is essential before deciding which ones which could best inform policy or practice. One current method of evaluating clinical guideline quality is the research-focused AGREE II instrument. This uses 23 questions scored 1–7, arranged in six domains, which requires at least two independent testers, and uses a formulaic weighted domain scoring system. Following feedback from time-poor clinicians, policy-makers and managers that this instrument did not suit clinical need, we developed and tested a simpler, shorter, binary scored instrument (the iCAHE Guideline Quality Checklist) designed for single users.MethodsContent and construct validity, inter-tester reliability and clinical utility were tested by comparing the new iCAHE Guideline Quality Checklist with the AGREE II instrument. Firstly the questions and domains in both instruments were compared. Six randomly-selected guidelines on a similar theme were then assessed by three independent testers with different experience in guideline quality assessment, using both instruments. Per guideline, weighted domain and total AGREE II scores were calculated, using the scoring rubric for three testers. Total iCAHE scores were calculated per guideline, per tester. The linear relationship between iCAHE and AGREE II scores was assessed using Pearson r correlation coefficients. Score differences between testers were assessed for the iCAHE Guideline Quality Checklist.ResultsThere were congruent questions in each instrument in four domains (Scope & Purpose, Stakeholder involvement, Underlying evidence/Rigour, Clarity). The iCAHE and AGREE II scores were moderate to strongly correlated for the six guidelines. There was generally good agreement between testers for iCAHE scores, irrespective of their experience. The iCAHE instrument was preferred by all testers, and took significantly less time to administer than the AGREE II instrument. However, the use of only three testers and six guidelines compromised study power, rendering this research as pilot investigations of the psychometric properties of the iCAHE instrument.ConclusionThe iCAHE Guideline Quality Checklist has promising psychometric properties and clinical utility.

The diagnostic validity of musculoskeletal ultrasound in lateral epicondylalgia: a systematic review

BackgroundUltrasound is considered a reliable, widely available, non-invasive and inexpensive imaging technique for assessing soft tissue involvement in Lateral epicondylalgia. Despite the number of diagnostic studies for Lateral Epicondylalgia, there is no consensus in the current literature on the best abnormal ultrasound findings that confirm lateral epicondylalgia.MethodsEligible studies identified by searching electronic databases, scanning reference lists of articles and chapters on ultrasound in reference books, and consultation of experts in sonography. Three reviewers (VCDIII, KP, KW) independently searched the databases using the agreed search strategy, and independently conducted all stages of article selection. Two reviewers (VCDIII, KP) then screened titles and abstracts to remove obvious irrelevance. Potentially relevant full text publications which met the inclusion criteria were reviewed by the primary investigator (VCDIII) and another reviewer (CGS).ResultsAmong the 15 included diagnostic studies in this review, seven were Level II diagnostic accuracy studies for chronic lateral epicondylalgia based on the National Health and Medical Research Council Hierarchy of Evidence. Based from the pooled sensitivity of abnormal ultrasound findings with homogenous results (p > 0.05), the hypoechogenicity of the common extensor origin has the best combination of diagnostic sensitivity and specificity. It is moderately sensitive [Sensitivity: 0.64 (0.56-0.72)] and highly specific [Specificity: 0.82 (0.72-0.90)] in determining elbows with lateral epicondylalgia. Additionally, bone changes on the lateral epicondyle [Sensitivity: 0.56 (0.50-0.62)] were moderately sensitive to chronic LE. Conversely, neovascularity [Specificity: 1.00 (0.97-1.00)], calcifications [Specificity: 0.97 (0.94-0.99)] and cortical irregularities [Specificity: 0.96 (0.88-0.99)] have strong specificity for chronic lateral epicondylalgia. There is insufficient evidence supporting the use of Power Doppler Ultrasonogrophy, Real-time Sonoelastography and sonographic probe-induced tenderness in diagnosing LE.ConclusionsThe use of Gray-scale Ultrasonography is recommended in objectively diagnosing lateral epicondylalgia. The presence of hypoechogenicity and bone changes indicates presence of a stressed common extensor origin-lateral epicondyle complex in elbows with lateral epicondylalgia. In addition to diagnosis, detection of these abnormal ultrasound findings allows localization of pathologies to tendon or bone that would assist in designing an appropriate treatment suited to patient’s condition.

A qualitative exploration of discharge destination as an outcome or a driver of acute stroke care

BackgroundMany patients with acute stroke do not receive recommended care in tertiary hospital settings. Allied health professionals have important roles within multidisciplinary stroke teams and influence the quality of care patients receive. Studies examining the role of allied health professionals in acute stroke management are scarce, and very little is known about the clinical decision making of these stroke clinicians. In this study we aimed to describe factors that influence the complex clinical decision making of these professionals as they prioritise acute stroke patients for recommended care. This qualitative study was part of a larger mixed methods study.MethodsThe qualitative methodology applied was a constructivist grounded theory approach.Fifteen allied health professionals working with acute stroke patients at three metropolitan tertiary care hospitals in South Australia were purposively sampled.Semi-structured interviews were conducted face to face using a question guide, and digital recording. Interviews were transcribed and analysed by two researchers using rigorous grounded theory processes.ResultsOur analysis highlighted ‘predicted discharge destination’ as a powerful driver of care decisions and clinical prioritisation for this professional group. We found that complex clinical decision making to predict discharge destination required professionals to concurrently consider patient’s pre-stroke status, the nature and severity of their stroke, the course of their recovery and multiple factors from within the healthcare system. The consequences of these decisions had potentially profound consequences for patients and sometimes led to professionals experiencing considerable uncertainty and stress.ConclusionsOur qualitative enquiry provided new insights into the way allied health professionals make important clinical decisions for patients with acute stroke. This is the first known study to demonstrate that the subjective prediction of discharge destination made early in an acute admission by allied health professionals, has a powerful influence over the care and rehabilitation provided, and the ultimate outcomes for stroke patients.

Measuring the quality of dysphagia management practices following stroke: a systematic review

Adherence to recommended clinical practices improves stroke outcomes. As a result, stroke clinicians are increasingly expected to evaluate the quality of the care they provide so that areas for improvement can be targeted. Finding the best method to evaluate the quality of dysphagia management can be challenging. Aim To systematically review process indicators used to assess the quality of care provided to patients with dysphagia following acute stroke and examine the level of evidence underpinning these indicators. Methods Databases were systematically searched to identify publications (January 2006–April 2009) that describe process indicators relating to the clinical management of acute stroke-related dysphagia. Relevant process indicators were extracted from the reviewed publications for detailed post hoc analysis including supporting evidence and alignment to the current Australian and English stroke guidelines. Results Title and abstract review found 150 potential studies. Full-text review resulted in 25 publications that met the studys inclusion criteria. Thirteen process indicators were identified in the literature that related to the initial assessment, clinical management, rehabilitation and discharge planning for patients with acute stroke-related dysphagia. These processes were supported by levels of evidence ranging from high ‘level 1’ (8%) down to ‘expert opinion’ evidence (46%). Two process indicators did not align to recommendations in the clinical guidelines. This systematic review underpins informed selection of process indicators for evaluating the quality of dysphagia management following stroke. The selection of quality indicators is complicated by equivocal supporting evidence; however, indicators should reflect expected local practices, align with national stroke guidelines and be feasible for clinical auditing.

Inequities in access to rehabilitation: exploring how acute stroke unit clinicians decide who to refer to rehabilitation

Abstract Purpose: Less than half of the patients with stroke in Australian hospitals are assessed by rehabilitation specialists. We sought to explore how clinicians working in acute stroke units (ASUs) determine which patients to refer to rehabilitation services. Method: Qualitative descriptive study. Team meetings were observed and medical records were reviewed over four weeks at two ASUs. Focus groups were conducted with staff from eight ASUs in two states of Australia. Results: Rehabilitation was mentioned in team meetings for 50/64 patients (78%) during the observation period. Rehabilitation referrals were organised for 47 patients (94%) for whom rehabilitation was discussed (74% of the sample); and for no patients when rehabilitation was not discussed. Factors identified that influenced whether referrals were organised included the anticipated discharge destination; severity of stroke; staff expectations of the patient’s recovery; and if there was advocacy by families about rehabilitation. Clinicians tended to refer the patients they considered would be accepted by the rehabilitation service. Staff at two ASUs expressed concern that referring all patients with stroke-related deficits to rehabilitation would be unfavourable with rehabilitation providers. Conclusions: Decisions made by ASU staff regarding who to refer to stroke rehabilitation are often not solely based on patients’ rehabilitation requirements. Implications for Rehabilitation Not all patients on acute stroke units (ASUs) who may have benefited from rehabilitation were offered rehabilitation referrals. Criteria for rehabilitation referrals need to be made explicit and discussed openly with consumers, ASU clinicians and rehabilitation specialists. A change in rehabilitation assessment practices is required to provide data regarding the unmet rehabilitation needs of patients with stroke. New models of rehabilitation service delivery or increased rehabilitation services may be required to meet the rehabilitation needs of all patients with stroke.

Implementing a complex rehabilitation intervention in a stroke trial: a qualitative process evaluation of AVERT

BackgroundThe implementation of multidisciplinary stroke rehabilitation interventions is challenging, even when the intervention is evidence-based. Very little is known about the implementation of complex interventions in rehabilitation clinical trials.The aim of study was to better understand how the implementation of a rehabilitation intervention in a clinical trial within acute stroke units is experienced by the staff involved. This qualitative process evaluation was part of a large Phase III stroke rehabilitation trial (AVERT).MethodsA descriptive qualitative approach was used. We purposively sampled 53 allied health and nursing staff from 19 acute stroke units in Australia, New Zealand and Scotland. Semi-structured interviews were conducted by phone, voice-internet, or face to face. Digitally recorded interviews were transcribed and analysed by two researchers using rigorous thematic analysis.ResultsOur analysis uncovered ten important themes that provide insight into the challenges of implementing complex new rehabilitation practices within complex care settings, plus factors and strategies that assisted implementation. Themes were grouped into three main categories: staff experience of implementing the trial intervention, barriers to implementation, and overcoming the barriers. Participation in the trial was challenging but had personal rewards and improved teamwork at some sites. Over the years that the trial ran some staff perceived a change in usual care. Barriers to trial implementation at some sites included poor teamwork, inadequate staffing, various organisational barriers, staff attitudes and beliefs, and patient-related barriers. Participants described successful implementation strategies that were built on interdisciplinary teamwork, education and strong leadership to ‘get staff on board’, and developing different ways of working.ConclusionsThe AVERT stroke rehabilitation trial required commitment to deliver an intervention that needed strong collaboration between nurses and physiotherapists and was different to current care models. This qualitative process evaluation contributes unique insights into factors that may be critical to successful trials teams, and as AVERT was a pragmatic trial, success factors to delivering complex intervention in clinical practice.Trial registrationAVERT registered with Australian New Zealand Clinical Trials Registry ACTRN12606000185561.

Demographic and stroke-related factors as predictors of quality of acute stroke care provided by allied health professionals.

Background: We recently indicated that patient age on its own is not a determinant of quality of allied health care received after an acute stroke. It has not been tested whether other non-age variables influence care decisions made by allied health professionals. This paper explores demographic and stroke-related variables that are putatively associated with the quality of care provided to acute stroke patients by allied health professionals. Methods: Data were retrospectively audited from 300 acute stroke patient records regarding allied health care. Compliance with each of 20 indicators of allied health care quality was established. The influence of various demographic and stroke-related variables on each performance indicator was examined. We undertook a series of analyses using univariate logistic regression models to establish the influence of these variables on care quality. Results: Patient age had a significant correlation with only one process indicator (early mobilization). Seven variables, including stroke severity and level of dependence, were associated with patient age. The majority of these age proxies had significant associations with process indicator compliance. Correlations between non-age variables, in particular stroke severity and comorbidity, suggest the potential for complex confounding relationships between non-age variables and quality of allied health care. Conclusion: Compliance with individual indicators of allied health care was significantly associated with variables other than patient age, and included stroke severity, previous independence, comorbidities, day of admission, stroke unit admission, and length of stay. The inter-relationships between these non-age variables suggest that their influence on quality of care is complex.

Age and gender as predictors of allied health quality stroke care

Background: Improvement in acute stroke care requires the identification of variables which may influence care quality. The nature and impact of demographic and stroke-related variables on care quality provided by allied health (AH) professionals is unknown. Aims: Our research explores the association of age and gender on an index of acute stroke care quality provided by AH professionals. Methods: A retrospective clinical audit of 300 acute stroke patients extracted data on AH care, patients’ age and gender. AH care quality was determined by the summed compliance with 20 predetermined process indicators. Our analysis explored relationships between this index of quality, age, and gender. Age was considered in different ways (as a continuous variable, and in different categories). It was correlated with care quality, using gender-specific linear and logistic regression models. Gender was then considered as a confounder in an overall model. Results: No significant association was found for any treatment of age and the index of AH care quality. There were no differences in gender-specific models, and gender did not significantly adjust the age association with care quality. Conclusion: Age and gender were not predictors of the quality of care provided to acute stroke patients by AH professionals.

A holistic client-centred program for vulnerable frequent hospital attenders: cost efficiencies and changed practices

Objective: A small percentage of Australians frequently attend hospital emergency departments (ED) with potentially avoidable health crises. These individuals are termed ‘vulnerable’ due to their complex health and social needs. When these needs are unmanaged, unnecessary ED and hospital‐admission costs are incurred. A holistic community‐based program was developed to engage a cohort of vulnerable individuals in strategies to improve their health and health behaviours, and health service use.

A qualitative study using the Theoretical Domains Framework to investigate why patients were or were not assessed for rehabilitation after stroke

Objective: To explore the factors perceived to affect rehabilitation assessment and referral practices for patients with stroke. Design: Qualitative study using data from focus groups analysed thematically and then mapped to the Theoretical Domains Framework. Setting: Eight acute stroke units in two states of Australia. Subjects: Health professionals working in acute stroke units. Interventions: Health professionals at all sites had participated in interventions to improve rehabilitation assessment and referral practices, which included provision of copies of an evidence-based decision-making rehabilitation Assessment Tool and pathway. Results: Eight focus groups were conducted (32 total participants). Reported rehabilitation assessment and referral practices varied markedly between units. Continence and mood were not routinely assessed (4 units), and people with stroke symptoms were not consistently referred to rehabilitation (4 units). Key factors influencing practice were identified and included whether health professionals perceived that use of the Assessment Tool would improve rehabilitation assessment practices (theoretical domain ‘social and professional role’); beliefs about outcomes from changing practice such as increased equity for patients or conversely that changing rehabilitation referral patterns would not affect access to rehabilitation (‘belief about consequences’); the influence of the unit’s relationships with other groups including rehabilitation teams (‘social influences’ domain) and understanding within the acute stroke unit team of the purpose of changing assessment practices (‘knowledge’ domain). Conclusion: This study has identified that health professionals’ perceived roles, beliefs about consequences from changing practice and relationships with rehabilitation service providers were perceived to influence rehabilitation assessment and referral practices on Australian acute stroke units.