Stroke liaison workers for patients and carers.
MD thesis, University of Glasgow.
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This thesis has developed to explore a specific intervention in a core context. That context is the transition of stroke from hospital to home and from acute illnesses to chronic disease. This includes the change from a rehabilitation focus on the physical effects and complications of stroke (during in-patient stroke unit care) to the psychological, emotional and social consequences of stroke as well as the risk of recurrence.
Specifically it focuses on an intervention in two key problem areas. The first is the risk of stroke or transient ischaemic attack (TIA) recurrence and risk factor modification through lifestyle change. The second is the area of psychosocial problems post stroke. Both these areas may be addressed by a single intervention, and it is that potential intervention that is evaluated in detail in this thesis. Other problem areas such as functional recovery and interventions to affect this are set in context, but not specifically covered here.
Chapter One highlights the association in the literature between the well documented social and psychological consequences of stroke and longer term health outcomes for patients. We can see from the literature that there is a strong association between depression and worse outcomes in terms of rehabilitation, reduced cognitive functioning and increased mortality. In addition patients with poor social support or poor family functioning are recognised to have a longer length of hospital stay and poorer rehabilitation profile. Patients who have a poor understanding of their illness are less likely to comply with treatment advice or re-attend for further treatment. There is therefore a setting for evaluating an intervention that might seek to impact the emotional, informational and social needs of patients post stroke.
Chapter Two describes a randomised controlled trial of a Stroke Nurse Specialist intervention in a behaviour modification programme. This trial was intended to address the risk of Transient Ischaemic Attack (TIA) or Stroke recurrence by aiming to improve the information needs of post stroke and TIA patients, hoping to improve their compliance, lifestyle modification and ultimately risk factor control. The primary outcome was the proportion of patients who achieved control of all their modifiable risk factors (e.g. smoking, hypertension, diabetes and hypercholesterolaemia) according to predetermined criteria. No significant difference was seen between the groups for the primary outcome (proportion achieving risk factor control: Experiment 46.4% Vs Control 41.7%, p=0.34). Differences were seen between the groups in the reduction in systolic blood pressure (Experiment -9.2mmHg, SD 23.3 Vs Control -1.0mmHg, SD 22.4, p=0.04). In addition patients in the experimental group were more likely to express satisfaction with aspects of liaison and information provision.
Chapter Three evaluates the effects of the short term behaviour modification intervention (detailed in Chapter Two) at over three years after initial enrolment. Rates of follow up of the initial cohort were lower than the initial study (50% compared to 94%). No significant difference exists at three years between the intervention and control groups for the primary outcome of risk factor control. Differences were observed between the groups for the rates of admission to nursing homes (Experiment 0 Vs Control 5, p=0.02), however the small size of this follow up sample limits the conclusions that can be drawn from this result.
Chapter Four attempts to set the randomised controlled trial evaluated in Chapters Two and Three in the context of other outpatient rehabilitation interventions and tries to establish if there is comparability between the interventions and even combinability for subsequent meta-analysis. This process identifies several core themes:
• Physical fitness training after stroke,
• Occupational therapy after stroke,
• Multidisciplinary rehabilitation post stroke,
• Information provision and education post stroke and
• Psychological and social support.
In addition, several trials targeting intervention aimed at carers only were identified.
Chapter Five describes a systematic review and meta-analysis of Stroke Liaison Worker trials – that is trials that evaluated a healthcare worker or volunteer who provided social support, information and liaison with the patient after discharge. This includes the trial described in Chapter Two. Individual patient data meta-analysis was conducted of 16 trials evaluating 18 interventions. Meta-analysis did not demonstrate any benefit of Stroke Liaison Workers compared to usual care for the primary outcomes of subjective health status or extended activities of daily living. In addition there was no benefit from Stroke Liaison Worker on the outcomes of death, institutionalisation, mental health or dependence. Patients were more satisfied that someone had really listened to them. Carers were more satisfied that they had received enough information about the causes of stroke, that they had enough information about recovery, that someone had really listened, and that they did not feel neglected. Subgroup analysis by patient dependence at recruitment revealed that patients with mild to moderate dependence had reduced dependence in the intervention group (OR 0.60, 0.44 – 0.83, p=0.002) as well as a reduction in death or dependence (OR 0.55, 0.39 – 0.78, p=0.0008).
In Chapter Six I was keen to evaluate whether the interventions in the literature and the framework for combining and evaluating them could be mapped onto existing services in Scotland. This was done through a questionnaire of the Scottish Stroke Nurses Forum. This identified 58 Stroke Liaison Workers from around Scotland who identified themselves as providing the services described using the review criteria in Chapter Five. These nurses identified that their commonest requests for help relate to psychological or emotional issues. 62% of respondents believed that their role was effective for all their patients.
In conclusion, Stroke Liaison Workers result in greater satisfaction with certain aspects of service provision but do not appear to result in changes to patient subjective health, extended ADL or carer subjective health. Subgroup analysis suggests that patients with mild to moderate dependence may benefit. Overall there does not appear to be evidence of effectiveness for this complex intervention when applied to all patients or carers.
||Ellis G, Rodger J, McAlpine C, Langhorne P. The impact of stroke nurse specialist input
on risk factor modification: a randomised
controlled trial. Age and Ageing 2005; 34(4):389-392
||Stroke, Interventions, Outpatient, Nurse, Social Worker, Volunteer, Depression, Anxiety, Quality of Life, Psychological Problems, Social Support, Recurrence.
||R Medicine > R Medicine (General)
||College of Medical Veterinary and Life Sciences > Institute of Cardiovascular and Medical Sciences
||Langhorne, Prof. Peter
|Date of Award:
Dr Graham Ellis
||Copyright of this thesis is held by the author.
||25 Aug 2008
||10 Dec 2012 13:17
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