Lisa Mellon

Objective Assessment of Adherence to Inhalers by COPD Patients.

Rationale: Objective adherence to inhaled therapy by patients with chronic obstructive pulmonary disease (COPD) has not been reported. Objectives: To objectively quantify adherence to preventer Diskus inhaler therapy by patients with COPD with an electronic audio recording device (INCA). Methods: This was a prospective observational study. On discharge from hospital patients were given a salmeterol/fluticasone inhaler with an INCA device attached. Analysis of this audio quantified the frequency and proficiency of inhaler use. Measurements and Main Results: Patients with COPD (n = 244) were recruited. The mean age was 71 years, mean FEV1 was 1.3 L, and 59% had evidence of mild/moderate cognitive impairment. By combining time of use, interval between doses, and critical technique errors, thus incorporating both intentional and unintentional nonadherence, a measure “actual adherence” was calculated. Mean actual adherence was 22.6% of that expected if the doses were taken correctly and on time. Six percent had an actual adherence greater than 80%. Hierarchical clustering found three equally sized well‐separated clusters corresponding to distinct patterns. Cluster 1 (34%) had low inhaler use and high error rates. Cluster 2 (25%) had high inhaler use and high error rates. Cluster 3 (36%) had overall good adherence. Poor lung function and comorbidities were predictive of poor technique, whereas age and cognition with poor lung function distinguished those with poor adherence and frequent errors in technique. Conclusions: These data may inform clinicians in understanding why a prescribed inhaler is not effective and to devise strategies to promote adherence in COPD.

Can a media campaign change health service use in a population with stroke symptoms? Examination of the first Irish stroke awareness campaign

Background Mass media campaigns for stroke awareness encourage the public to recognise stroke symptoms and respond to stroke in a timely manner. However, there is little evidence to suggest that media messages can influence behaviour after stroke onset. The F.A.S.T. (Face Arm Speech Time) test is a common stroke recognition tool used in public education campaigns. Objective To assess the impact of the F.A.S.T. campaign on health service use in Ireland, which has had no previous exposure to a F.A.S.T. media campaign. Methods An interrupted time series design was used to detect behaviour change after the introduction of the first Irish F.A.S.T. campaign in presentations of patients with suspected stroke to two emergency departments (EDs), serving a population of about 580 000. Results There was a significant change in ED attendance of patients with reported stroke symptoms after the introduction of the F.A.S.T. campaign (β=0.84, 95% CI 0.43 to 1.24; p<0.001), although this was not sustained. ED presentation within 3.5 h was associated with emergency medical services activation (OR=3.1, p<0.001) and self-referral to the ED (OR=2.67, p<0.001). Conclusions This first Irish F.A.S.T. campaign had an initial impact on ED attendance of patients with stroke symptoms. However, the campaign effects were not sustained in the long term. Results indicate that prehospital delay in accessing acute stroke services is a complex process with involvement of factors other than stroke knowledge and intention to call 911.

Stroke warning campaigns: delivering better patient outcomes? A systematic review

Background Patient delay in presenting to hospital with stroke symptoms remains one of the major barriers to thrombolysis treatment, leading to its suboptimal use internationally. Educational interventions such as mass media campaigns and community initiatives aim to reduce patient delays by promoting the signs and symptoms of a stroke, but no consistent evidence exists to show that such interventions result in appropriate behavioral responses to stroke symptoms. Methods A systematic literature search and narrative synthesis were conducted to examine whether public educational interventions were successful in the reduction of patient delay to hospital presentation with stroke symptoms. Three databases, MEDLINE, CINAHL, and PsycINFO, were searched to identify quantitative studies with measurable behavioral end points, including time to hospital presentation, thrombolysis rates, ambulance use, and emergency department (ED) presentations with stroke. Results Fifteen studies met the inclusion criteria: one randomized controlled trial, two time series analyses, three controlled before and after studies, five uncontrolled before and after studies, two retrospective observational studies, and two prospective observational studies. Studies were heterogeneous in quality; thus, meta-analysis was not feasible. Thirteen studies examined prehospital delay, with ten studies reporting a significant reduction in delay times, with a varied magnitude of effect. Eight studies examined thrombolysis rates, with only three studies reporting a statistically significant increase in thrombolysis administration. Five studies examined ambulance usage, and four reported a statistically significant increase in ambulance transports following the intervention. Three studies examining ED presentations reported significantly increased ED presentations following intervention. Public educational interventions varied widely on type, duration, and content, with description of intervention development largely absent from studies, limiting the potential replication of successful interventions. Conclusions Positive intervention effects were reported in the majority of studies; however, methodological weaknesses evident in a number of studies limited the generalizability of the observed effects. Reporting of specific intervention design was suboptimal and impeded the identification of key intervention components for reducing patient delay. The parallel delivery of public and professional interventions further limited the identification of successful intervention components. A lack of studies of sound methodological quality using, at a minimum, a controlled before and after design was identified in this review, and thus studies incorporating a rigorous study design are required to strengthen the evidence for public interventions to reduce patient delay in stroke. The potential clinical benefits of public interventions are far-reaching, and the challenge remains in translating knowledge improvements and correct behavioral intentions to appropriate behavior when stroke occurs.

Implications of stroke for caregiver outcomes: findings from the ASPIRE-S study

Background Informal caregivers are vital to the long-term care and rehabilitation of stroke survivors worldwide. However, caregiving has been associated with negative psychological outcomes such as anxiety and depression, which leads to concerns about caregiver as well as stroke survivor well-being. Furthermore, caregivers may not receive the support and service provision they require from the hospitals and community. Aims This study examines caregiver psychological well-being and satisfaction with service provision in the context of stroke. Methods Caregiver data were collected as part of the ASPIRE-S study, a prospective study of secondary prevention and rehabilitation which assessed stroke patients and their carers at six-months post stroke. Carer assessment included measurement of demographics, satisfaction with care (UK Healthcare Commission National Patient Survey of Stroke Care), psychological distress (Hospital Anxiety and Depression Scale), and vulnerability (Vulnerable Elders Scale). Logistic regression analyses and chi-squared tests were performed using STATA version 12. Results Analyses from 162 carers showed substantial levels of dissatisfaction (37·9%) with community and hospital services, as well as notable levels of anxiety (31·3%) and depressive symptoms (18·8%) among caregivers. Caregiver anxiety was predicted by stroke survivor anxiety (OR = 3·47, 95% CI 1·35–8·93), depression (OR = 5·17, 95% CI 1·83–14·58), and stroke survivor cognitive impairment (OR 2·35, 95% CI 1·00–5·31). Caregiver depression was predicted by stroke survivor anxiety (OR = 4·41, 95% CI 1·53–12·72) and stroke survivor depression (OR = 6·91, 95% CI 2·26–21·17). Conclusion Findings indicate that caregiver and stroke survivor well-being are interdependent. Thus, early interventions, including increased training and support programs that include caregivers, are likely to reduce the risk of negative emotional outcomes.

Factors influencing adherence among Irish haemodialysis patients

OBJECTIVE Adherence to dietary and fluid restrictions among haemodialysis patients with end stage renal failure (ESRD) is a multi-factorial concept. This study seeks to assess the predictive value of demographic and psychological variables in non-adherence. METHODS A multi-centre cross sectional design assessed 50 haemodialysis patients on self reported adherence, attitudes towards dietary restrictions, quality of life, depression and anxiety. Adherence to fluid and dietary restrictions was measured objectively using potassium (K), phosphorus (PO4) and inter-dialytic weight gain (IDWG) parameters. RESULTS 62% of patients were non-adherent with at least one aspect of the treatment regime. Regression analysis revealed age as significantly associated with adherence, in particular IDWG, with younger patients displaying poorer adherence. CONCLUSION Younger patients may experience greater difficulty integrating complex treatment demands into their lifestyles, and non-adherence may be a consequence of the severe lifestyle limitations imposed by the haemodialysis treatment regime. PRACTICE IMPLICATIONS Individualised interventions may be more effective than traditional methods of adherence monitoring in reducing the non-adherent behaviour.

The INCATM (Inhaler Compliance AssessmentTM): A comparison with established measures of adherence.

Objective: To compare the Inhaler Compliance AssessmentTM (INCATM), a novel audio-recording device objectively measuring timing and proficiency of inhaler use, against established adherence measures, and explore its discriminant and predictive validity. Design: Prospective observational study; 184 chronic obstructive pulmonary disease (COPD) patients used an INCATM-enabled salmeterol/fluticasone inhaler for one-month post-hospital discharge. Main outcome measures: INCATM (Attempted, Attempted Interval, Actual) adherence correlated with Doses Used Rate, self-reported adherence and prescription refill for concurrent validity. Discriminant validity for reason for admission, cognition and lung function; predictive validity for health status and quality-of-life. Results: Rates of Attempted, Attempted Interval and Actual adherence were 59, 47 and 23%, respectively. Only 7% of participants had Actual adherence >80%. INCATM variables significantly correlated with Doses Used Rate but not with self-report; Attempted and Attempted Interval were weakly associated with prescription refill. Higher cognitive and lung functioning groups had better INCATM adherence. Attempted and Attempted Interval predicted health status, while Doses Used Rate predicted quality-of-life. Conclusion: INCATM did not strongly correlate with self-report or prescription refill data. Discriminant and predictive validity demonstrated by INCATM suggests the potential utility of the INCATM as a method to identify intentional and unintentional adherence to inhaled medication and facilitate targeted intervention.

Patient behaviour at the time of stroke onset: a cross-sectional survey of patient response to stroke symptoms

Background and purpose Revascularisation treatment with thrombolysis must be initiated within 4.5 h following ischaemic stroke symptom onset. Despite its proven benefits, thrombolysis therapy is underused, with patient delay in presenting to hospital with symptoms identified as the leading barrier. This study aimed to examine help-seeking behaviour at stroke onset, in order to understand delays in accessing acute medical care for stroke symptoms. Methods 149 consecutive patients hospitalised with ischaemic stroke were interviewed at 72 h poststroke with the Stroke Awareness Questionnaire and the Response to Symptoms Questionnaire. Results Sixty per cent of stroke cases presented to the ED within 3.5 h of stroke onset. Knowledge of stroke symptoms and risk factors was poor, with 40% unable to correctly define a stroke. Bystander recognition of symptoms (p=0.03) and bystander initiation of Emergency Medical Services was associated with ED presentation within 3.5 h (p=0.03). Conclusions This study provides insights into patient response when a stroke occurs, with the presence and action of others highlighted as critical in fast response to stroke symptoms. Knowledge of stroke warning signs and risk factors was low among stroke survivors. Findings highlight the complexity of changing help-seeking behaviour during stroke onset, and provide directions for public education efforts to reduce prehospital delay.

Knowledge of Thrombolytic Therapy Amongst Hospital Staff Preliminary Results and Treatment Implications

Background and Purpose— In-hospital stroke is associated with slower access to thrombolysis than community-occurring stroke. It has been suggested that lack of knowledge regarding appropriate stroke response among hospital staff may contribute to delays in referral, assessment, and treatment of in-hospital stroke. Method— A survey was conducted among hospital ward staff members using the Stroke Awareness Questionnaire, which was adapted for use among hospital staff to assess their knowledge of stroke symptoms, acute treatments, and hospital protocols for treatment of stroke. Results— Ninety-six staff members were interviewed, 81% of whom were clinical staff (medical, nursing, allied health professionals). Ninety-two percent of staff could name ≥3 stroke symptoms. Only 49% of staff were aware of thrombolysis treatment, and only 48% could identify the time window for thrombolysis administration, with staff from stroke-related specialties likely to name thrombolysis as an acute treatment for stroke (71%; odds ratio =3.36, 95% confidence interval 1.17–9.61) and identify the correct treatment window (71%; odds ratio =3.55, 95% confidence interval 1.24–10.16). Only 52% of staff on general wards were aware of an in-hospital stroke protocol. Conclusions— Hospital staff had adequate knowledge of stroke signs and symptoms; however, there was low awareness of thrombolysis therapy and its correct treatment time window among hospital staff. Targeted educational programmes among hospital staff regarding stroke are required to optimize acute stroke care.

STROKOG (stroke and cognition consortium): An international consortium to examine the epidemiology, diagnosis, and treatment of neurocognitive disorders in relation to cerebrovascular disease

The Stroke and Cognition consortium (STROKOG) aims to facilitate a better understanding of the determinants of vascular contributions to cognitive disorders and help improve the diagnosis and treatment of vascular cognitive disorders (VCD).

Determining rates of smoking cessation advice delivered during hospitalisation and smoking cessation rates 3 months post discharge: a two-hospital survey

ABSTRACT Background: Hospitalisation is an ideal time to implement smoking cessation interventions. However, little is known about the extent to which inpatients receive such advice, or the impact it has on motivation to quit and quitting behaviours post-hospitalisation. Aims: This study aimed to determine the prevalence of smoking and cessation advice received by inpatients in two teaching hospitals in Ireland, and the impact of cessation advice on smoking at 3 months post discharge. Methods: We surveyed 1001 inpatients across two hospital sites, over a six-month period. Demographic details, clinical history, smoking history, motivation to quit, cigarette dependence, and recent quitting history were assessed. Results: Prevalence of smoking within the sample was 23.4% (235/1001). Only 32% (75/235) of smokers reported that smoking cessation was discussed during admission. Smokers’ mean Fagerström nicotine-dependence score was 3.7 (SD = 2.7), indicating low dependence levels. At 3 months, 17% (25/146) of smokers reported smoking cessation. Provision of smoking cessation advice during hospitalisation was associated with higher motivation to quit (OR = 2.79, 95% CI 2.12–3.68), and successful quit behaviour for confirmed (OR = 1.98, 95% CI 1.55–2.53) and self-reported quitters (OR = 1.47, 95% CI 1.3–1.66) Conclusions: This observational study finds that provision of brief cessation advice and smoking status documentation was suboptimal. Where advice was given, it was associated with enhanced motivation to quit and increased quit rates. These findings, along with low dependence scores, suggest that systematic provision of low-intensity cessation interventions could significantly enhance quit rates in hospitalised smokers.