507 research outputs found
Supplemental material for Functional and emotional outcomes after transient ischemic attack: A 12-month prospective controlled cohort study
No full textSupplemental Material for Functional and emotional outcomes after transient ischemic attack: A 12-month prospective controlled cohort study by Catherine M Sackley, Jonathan Mant, Richard J McManus, Glyn Humphreys, Leslie Sharp, Kathryn Mares George M Savva in International Journal of Stroke</p
Comparing processes of stroke care in high- and low-mortality hospitals in the West Midlands, UK
No full textObjective: There are wide variations in hospital-specific mortality for stroke. The aim of this study was to investigate whether there were differences in quality of care when a group of hospitals with high standardized mortality ratios (SMRs) in nationally published league tables were compared with a group with low SMRs.Design: Retrospective case note review of a random sample of patients from hospitals with high and low mortality according to published league tables.Setting: Eight hospitals in the West Midlands, UK.Participants: 702 patients admitted to hospital with acute stroke during the year 2000–2001.Main outcome measures: Process measures derived from the Intercollegiate Stroke Audit Package.Results: Crude 30 day mortality was 25% (99/402) in ‘top’ ranking hospitals and 38% (113/300) in ‘bottom’ ranking hospitals (P < 0.001). Bottom hospitals performed significantly (P < 0.001) less well on four out of seven indicators of process of care relating to the patients’ first 24 hours in hospital—assessment of eye movements and visual fields, screening for swallowing disorders and sensory testing. However, analysis at the individual hospital level showed that this was largely due to poor performance in one hospital with high mortality. If this outlier was omitted, there was little relationship between process of care and SMR. No significant differences were found in care provided after 24 hours. Nevertheless even in ‘top’ ranking hospitals only 47% of stroke patients had at least 50% of their hospital stay in a stroke/rehabilitation unit and only 40% were on aspirin within 48 hours.Conclusions: Our results show that there is scope for improving the quality of stroke care irrespective of where a hospital ranks in terms of mortality. The lack of association between SMR and quality of care as assessed by process measures casts some doubt over the value of ranking hospitals in terms of stroke SMR
Should we screen for atrial fibrillation?
No full textNo country has yet established a national screening programme (NSP) for atrial fibrillation (AF), including the UK. However, there is an increasing body of evidence suggesting screening may be beneficial, prompting recommendations from prominent expert bodies to screen for AF.1 Despite these data, the UK National Screening Committee (NSC) has not recommended systematic population screening. The review in 2014 concluded ‘… it is not clear that those identified as at risk through screening would benefit from early diagnosis’.2 The NSC also identified a need to improve clinical management and standardise the treatment services currently available to those with diagnosed AF. The British Cardiovascular Society issued a subsequent statement in response to the decision questioning the interpretation of the evidence and suggesting that it would be in the public interest to reconsider their decision.3 A further review by the UK NSC is scheduled for 2017/2018
What underlies the difference between self-reported health and disability after stroke? A qualitative study in the UK
No full textAbstract: Background: Levels of self-reported health do not always correlate with levels of physical disability in stroke survivors. We aimed to explore what underlies the difference between subjective self-reported health and objectively measured disability among stroke survivors. Methods: Face to face semi-structured interviews were conducted with stroke survivors recruited from a stroke clinic or rehabilitation ward in the UK. Fifteen stroke survivors purposively sampled from the clinic who had discordant self-rated health and levels of disability i.e. reported health as ‘excellent’ or ‘good’ despite significant physical disability (eight), or as ‘fair’ or ‘poor’ despite minimal disability (seven) were compared to each other, and to a control group of 13 stroke survivors with concordant self-rated health and disability levels. Interviews were conducted 4 to 6 months after stroke and data analysed using the constant comparative method informed by Albrecht and Devlieger’s concept of ‘disability paradox’. Results: Individuals with ‘excellent’ or ‘good’ self-rated health reported a sense of self-reliance and control over their bodies, focussed on their physical rehabilitation and lifestyle changes and reported few bodily and post-stroke symptoms regardless of level of disability. They also frequently described a positive affect and optimism towards recovery. Some, especially those with ‘good’ self-rated health and significant disability also found meaning from their stroke, reporting a spiritual outlook including practicing daily gratitude and acceptance of limitations. Individuals with minimal disability reporting ‘fair’ or ‘poor’ self-rated health on the other hand frequently referred to their post-stroke physical symptoms and comorbidities and indicated anxiety about future recovery. These differences in psychological outlook clustered with differences in perception of relational and social context including support offered by family and healthcare professionals. Conclusions: The disability paradox may be illuminated by patterns of individual attributes and relational dynamics observed among stroke survivors. Harnessing these wider understandings can inform new models of post-stroke care for evaluation
Do patients actually do what we ask: patient fidelity and persistence to the targets and self-management for the control of blood pressure in stroke and at risk groups blood pressure self-management intervention
No full textObjective: Self-management of hypertension can reduce and control blood pressure (BP) compared with clinic monitoring. However, self-management relies on patients following an algorithm, which may be variably adhered to. This study reports fidelity of high-risk patients to the self-management algorithm set by the TASMIN-SR trial. Methods: Patients with hypertension, above target clinic BP and one or more of stroke, diabetes, coronary heart disease or chronic kidney disease, were invited to self-monitor following an individualized self-titration algorithm. Home BP readings and medication change details were submitted monthly for 12 months. Readings downloaded from patients' electronic monitors were compared with written submissions, and protocol fidelity was assessed. Results: Two hundred and seventy-six patients were randomized to self-management and 225 (82%) completed the required training sessions. Of these, 166 (74%) completed self-management. A total of 11385 (89.6%) submitted readings were accurate compared with corresponding downloaded monitor readings. Mean error rate was 5.2% per patient, which increased with age but not comorbidities. Patients made 475 of 683 (69.5%) algorithm-recommended medication changes, equating to nearly three medication changes per patient. Mean SBP for patients who completed training and made all recommended changes dropped from 141 mmHg (95% CI 138.26-144.46) to 121 mmHg (95% CI 118.30-124.17 mmHg) compared with 129 mmHg (95% CI 125.27-136.73 mmHg) for patients who made none. Conclusion: Most patients randomized to self-management completed training; however, 36% of these had dropped out by 12 months. Self-monitoring was largely undertaken properly and accurately recorded. Fidelity with self-management was associated with lower achieved SBP. Successful implementation of self-management into daily practice requires careful training and should be accompanied by monitoring of fidelity.</p
GPs' mindlines on deprescribing antihypertensives in older patients with multimorbidity: a qualitative study in English general practice
No full textBackground: optimal management of hypertension in older patients with multimorbidity is a cornerstone of primary care practice. Despite emphasis on personalised approaches to treatment in older patients, there is little guidance on how to achieve medication reduction when GPs are concerned that possible risks outweigh potential benefits of treatment. Mindlines - tacit, internalised guidelines developed over time from multiple sources - may be of particular importance in such situations. Aim: to explore GPs' decision-making on deprescribing antihypertensives in patients with multimorbidity aged ≥80 years, drawing on the concept of mindlines. Design and setting: qualitative interview study set in English general practice. Method: thematic analysis of face-to-face interviews with a sample of 15 GPs from seven practices in the East of England, using a chart-stimulated recall approach to explore approaches to treatment for older patients with multimorbidity with hypertension. Results: GPs are typically confident making decisions to deprescribe antihypertensive medication in older patients with multimorbidity when prompted by a trigger, such as a fall or adverse drug event. GPs are less confident to attempt deprescribing in response to generalised concerns about polypharmacy, and work hard to make sense of multiple sources (including available evidence, shared experiential knowledge, and non-clinical factors) to guide decision-making. Conclusion: in the absence of a clear evidence base on when and how to attempt medication reduction in response to concerns about polypharmacy, GPs develop 'mindlines' over time through practice-based experience. These tacit approaches to making complex decisions are critical to developing confidence to attempt deprescribing and may be strengthened through reflective practice.</p
Home-based versus hospital-based cardiac rehabilitation after myocardial infarction or revascularisation: design and rationale of the Birmingham Rehabilitation Uptake Maximisation Study (BRUM): a randomised controlled trial [ISRCTN72884263]
No full textBackgroundCardiac rehabilitation following myocardial infarction reduces subsequent mortality, but uptake and adherence to rehabilitation programmes remains poor, particularly among women, the elderly and ethnic minority groups. Evidence of the effectiveness of home-based cardiac rehabilitation remains limited. This trial evaluates the effectiveness and cost-effectiveness of home-based compared to hospital-based cardiac rehabilitation.Methods/designA pragmatic randomised controlled trial of home-based compared with hospital-based cardiac rehabilitation in four hospitals serving a multi-ethnic inner city population in the United Kingdom was designed. The home programme is nurse-facilitated, manual-based using the Heart Manual. The hospital programmes offer comprehensive cardiac rehabilitation in an out-patient setting.PatientsWe will randomise 650 adult, English or Punjabi-speaking patients of low-medium risk following myocardial infarction, coronary angioplasty or coronary artery bypass graft who have been referred for cardiac rehabilitation.Main outcome measuresSerum cholesterol, smoking cessation, blood pressure, Hospital Anxiety and Depression Score, distance walked on Shuttle walk-test measured at 6, 12 and 24 months. Adherence to the programmes will be estimated using patient self-reports of activity.In-depth interviews with non-attendees and non-adherers will ascertain patient views and the acceptability of the programmes and provide insights about non-attendance and aims to generate a theory of attendance at cardiac rehabilitation. The economic analysis will measure National Health Service costs using resource inputs. Patient costs will be established from the qualitative research, in particular how they affect adherence.DiscussionMore data are needed on the role of home-based versus hospital-based cardiac rehabilitation for patients following myocardial infarction and revascularisation, which would be provided by the Birmingham Rehabilitation Uptake Maximisation Study (BRUM) study and has implications for the clinical management of these patients. A novel feature of this study is the inclusion of non-English Punjabi speakers
Cost-effectiveness of antihypertensive deprescribing in primary care: a Markov modelling study using data from the OPTiMISE trial
No full textBackground:
Deprescribing of antihypertensive medications for older patients with normal blood pressure is recommended by some clinical guidelines, where the potential harms of treatment may outweigh the benefits. This study aimed to assess the cost-effectiveness of this approach.
Methods:
A Markov patient-level simulation was undertaken to model the effect of withdrawing one antihypertensive compared with usual care, over a life-time horizon. Model population characteristics were estimated using data from the OPTiMISE antihypertensive deprescribing trial, and the effects of blood pressure changes on outcomes were derived from the literature. Health-related quality of life was modeled in Quality-Adjusted Life Years (QALYs) and presented as costs per QALY gained.
Results:
In the base-case analysis, medication reduction resulted in lower costs than usual care (mean difference £185), but also lower QALYs (mean difference 0.062) per patient over a life-time horizon. Usual care was cost-effective at £2975 per QALY gained (more costly, but more effective). Medication reduction resulted more heart failure and stroke/TIA events but fewer adverse events. Medication reduction may be the preferred strategy at a willingness-to-pay of £20 000/QALY, where the baseline absolute risk of serious drug-related adverse events was ≥7.7% a year (compared with 1.7% in the base-case).
Conclusions:
Although there was uncertainty around many of the assumptions underpinning this model, these findings suggest that antihypertensive medication reduction should not be attempted in many older patients with controlled systolic blood pressure. For populations at high risk of adverse effects, deprescribing may be beneficial, but a targeted approach would be required in routine practice
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